Arrange in the correct order the events that occur when a nurse measures the length of an infant

Learn how to assess vital signs on an infant!

As a pediatric nurse, you will be required to know how to assess vital signs on many different pediatric populations, such as the newborn (infant). This review will detail how to assess the respiratory rate, heart rate, temperature, weight, length, head circumference, and chest circumference.

Assessing Vital Signs on a Newborn (Infant)

When collecting vital signs on an infant you will want to keep the following in mind:

• Start with the most non-invasive vital sign first.
  • Sequence for assessing an infant’s vital signs:
    • Respirations, heart rate, temperature, weight, length, head circumference, chest circumference
  • Supplies needed:
    • Infant size stethoscope
    • Watch for counting
    • Thermometer
    • Scale
    • Measuring tape
  • Sanitize supplies before and after use, perform hand hygiene before and after assessment

Respirations

• Normal respiratory rate: 30-60 breaths per minute
• Assess for any signs of distress: nasal flaring, chest retractions, skin color, <30 or >60 breaths per minute
• Count for one full minute: at this age the rate is irregular so you need to count for 1 full minute. Infants have what is called periodic breathing (this is where the infant breathes and stops for a few seconds and then breathes again).
• Watch the rise and fall of the chest….one rise and one fall equals one breath
  • Tip: infants are abdominal breathers so watch this area or lightly place a hand on the area while counting
    
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Heart Rate:

• Use an appropriate size diaphragm and bell for the infant
• Normal heart rate
  • Less than a month old: 100 to 190 bpm (varies on if sleeping or crying)
  • One month to year old: 90-180 bpm
• Count the apical pulse by auscultating for 1 full minute
  • Infants can experience sinus arrhythmia which is associated with respirations….the heart rate speeds up and down with respirations.
  • The apical pulse on an infant is found at the 4th intercostal space (ICS), lateral to the midclavicular line….remember in the adult it was the 5th ICS.
    
    Credit: RegisteredNurseRN.com
• The heart rate is going to be fast so it will take you practice when learning how to count the heart rate on an infant.

Temperature

• Normal temperature range for an infant: 36.4-37.4 ‘C (97.5-99.3 ‘F)
• Route taken is via the armpit…axillary
  
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• Place the tip of the thermometer within the fold of the armpit and close the arm and wait for the thermometer to beep.

Weight

• Remove clothing and soiled diaper (can keep a dry diaper on the infant)
• Place infant on the scale and obtain weight
• Compare current weight to previous weights
  
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Length

• May need another person to help hold the infant still as you mark the length
• Measure from head to heel and place paper behind infant to mark length areas
• Lay baby back…keep head midline and extend a leg…mark these areas on the paper and measure with measuring tape.
• Normal length 18-22 inches
  
  Credit: RegisteredNurseRN.com

Head Circumference

• Use a measuring tape and measure in centimetres
• Measure the largest diameter of the head. This is found around the forehead (just above the eyebrows) and the prominent part of the back of the head.
• Normal: 33 cm to 38 cm
  
  Credit: RegisteredNurseRN.com

Chest Circumference

• Use a measuring tape and measure in centimetres
• Wrap the measuring tape around the infant’s chest and use the nipple line as a guide.
• The chest circumference should be about 1-2 cm less than the head circumference.
  
  Credit: RegisteredNurseRN.com

References:

Center for Disease Control and Prevention. (2016). Measuring Head Circumference [Ebook] (p. 1). Retrieved from https://www.cdc.gov/zika/pdfs/Microcephaly_measuring.pdf

Growth Charts – Clinical Growth Charts. Retrieved 3 August 2020, from https://www.cdc.gov/growthcharts/clinical_charts.htm

Infant Guidelines | Height & Weight Measurement. Retrieved 3 August 2020, from https://www.ihs.gov/hwm/infantguidelines/