School of Nursing

5th Floor Fisher Hall
600 Forbes Avenue
Pittsburgh, PA 15282
Email: nursing@duq.edu
Phone: 412.396.6550
Fax: 412.396.6346

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Vital Signs and Measurements

Temperature - Range 36.5 to 37 axillary

Common variations:
  • Crying may elevate temperature
  • Stabilizes in 8 to 10 hours after delivery
Signs of potential distress or deviations from expected findings:
  • Temperature is not reliable indicator of infection
  • A temperature less than 36.5

Heart rate - Range 120 to 160 beats per minute

Common variations:
  • Heart rate range to 100 when sleeping to 180 when crying
  • Color pink with acrocyanosis
  • Heart rate may be irregular with crying
Signs of potential distress or deviations from expected findings:
  • Although murmurs may be due to transitional circulation-all murmurs
  • should be followed-up and referred for medical evaluation
  • Deviation from range
  • Faint sound

Respiration - Range 30 to 60 breaths per minute

Common variations:
  • Bilateral bronchial breath sounds
  • Moist breath sounds may be present shortly after birth
Signs of potential distress or deviations from expected findings:
  • Asymmetrical chest movements
  • Apnea >15 seconds
  • Diminished breath sounds
  • Seesaw respirations
  • Grunting
  • Nasal flaring
  • Retractions
  • Deep sighing
  • Tachypnea - respirations > 60
  • Persistent irregular breathing
  • Excessive mucus
  • Persistant fine crackles
  • Stridor (Crowing respiratory sound)

Blood Pressure - not done routinely

Factors to consider:
  • Varies with change in activity level
  • Appropriate cuff size important for accurate reading
  • Average newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower extremities
Sign of potential distress or deviations from expected findings:
  • Calf systolic pressure 6 to 9 mm Hg less than systolic pressure in upper extremities may be indicative of coarctation of the aorta

General Measurements

Head Circumference - 33 to 35 cm

Expected findings:
  • Head should be 2 to 3 cms larger than the chest

Chest circumference - 30.5 to 33 cm

Common variations:
  • Molding* of head may result in a lower head circumference measurement
  • Head and chest circumference may be equal for the first 24 to 48 hours of life
*Molding refers to the process by which the neonates head is shaped during labor as it passes through the birth canal. The head may become elongated due to the overlapping of the cranial bones at the suture lines.

Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.)

Length range - 48 to 53 cms (19 - 21 inches)