Page 816 - Saunders Comprehensive Review For NCLEX-RN

d. Hymen tag may be visible.
e. First voiding should occur within 24
hours.
2. Male
a. Prepuce (foreskin) covers glans penis.
b. Scrotum may be edematous.
c. Verify meatus at tip of penis.
d. Testes are descended but may retract
with cold.
e. Assess for hernia or hydrocele.
f. First voiding should occur within 24
hours.
N. Spine
1. Straight
2. Posture flexed
3. Supportive of head momentarily when prone
4. Chin flexed on upper chest
5. Well-coordinated, sporadic movements
6. A degree of hypotonicity or hypertonicity may
indicate central nervous system damage.
7. Assess for hair tufts and dimples along the spinal
column (may be indicative of a possible opening).
O. Extremities
1. Flexed
2. Full range of motion; symmetrical movements
3. Fists clenched
4. Ten fingers and 10 toes, all separate
5. Legs bowed
6. Major gluteal folds even
7. Creases on soles of feet
8. Assess for fractures (especially clavicle) or dislocations
(hip).
9. Assist PHCP to assess for developmental dysplasia of
the hip; when thighs are rotated outward, no clicks
should be heard (Ortolani’s sign and Barlow’s sign
are the 2 assessment tools for developmental
dysplasia of the hip).
10. Pulses palpable (radial, brachial, femoral)

Slight tremors noted in the newborn may be a common finding

but could also be a sign of hypoglycemia, hypocalcemia, or drug
withdrawal.
III. Body Systems Assessment and Interventions

A. Cardiovascular system

1. Keep the newborn warm.

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