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Introduction   

A cardiac assessment of a newborn is critical to detect any serious cardiovascular abnormalities after birth such as a murmur or other abnormal findings. Newborns may be born with a congenital cardiac defect or develop acquired heart disease from teratogens or maternal infection. The purpose of this course is to educate learners about the process of a newborn cardiac assessment and why it is essential.  

Definition 

The newborn cardiac assessment may be performed in the postpartum unit, nursery, neonatal intensive care unit, outpatient settings, or other pediatric acute care units. Although most newborn cardiovascular assessments will be benign or without abnormalities, prompt identification of congenital heart defects or other acquired heart diseases is necessary [5]. The cardiovascular assessment will include techniques such as inspection, palpation, auscultation, and measurement of vital signs. 

Assessment 

General History 

The nurse should gather a detailed family history of any cardiovascular or related disorders, including any known genetic abnormalities [5]. The mother’s prenatal history should also be considered, including a history of diabetes, lupus, exposure to teratogens, infections, and alcohol and drug use. Other details that should be assessed are gestational age at birth, birth weight, poor weight gain, dysmorphic features, and feeding intolerance [5]. 

Cardiovascular System 

When assessing the cardiovascular system of a newborn, the nurse should consider the baby’s level of consciousness, such as muscle tone, activity level, and alertness [5].  

The nurse should also assess for the following: 

• Chest symmetry 

• Capillary refill (should be less than 3 seconds) 

• Pulses (brachial and femoral are common sites in newborns) 

• • Pulses should be equal between the left and right extremities and upper and lower extremities. 

• • Bounding pulses may indicate a patent ductus arteriosus or excessive fluid volume. 

• • Weak pulses may indicate shock or obstructive outflow lesions 

• Heart sounds: S1 and S2 should be present. S3 and S4 heart sounds are also considered normal in children.  

• Innocent murmurs are present in many children because of their thin chest walls. Diastolic and continuous murmurs are often pathological [5]. 

Respiratory System 

Newborns with cardiac disorders frequently have respiratory difficulties as well [5]. The nurse should closely monitor for any respiratory changes or abnormities, such as the following: 

• Rapid, shallow respirations 

• Increased work of breathing, including retractions, grunting, and nasal flaring 

• Sudden respiratory distress or cyanosis during feeding [5]. 

Dermatological System 

The nurse should assess for the following abnormalities during a newborn cardiac assessment: 

• Peripheral edema [5] 

• Diaphoresis 

• Extremity skin temperature (cold extremities may indicate poor perfusion) 

• Central cyanosis may indicate a cyanotic heart defect or severe anemia. 

• Peripheral cyanosis (acrocyanosis of the hands and feet is a normal finding for the first 48 hours of life) 

• Pallor or mottling of the skin may indicate poor perfusion or anemia. 

• Clubbing of fingernails 

• Erythema in fingers and toes  

Vital Signs 

Alterations in a newborn’s vital signs could be indicative of a cardiovascular disorder [5]. The nurse should assess the following: 

• Heart rate 

• May use a pulse oximeter or central monitor, palpate a peripheral pulse, auscultate the rate, or palpate via the pulsation of the umbilical cord. 

• The average heart rate range for newborns is 110 to 160 bpm. 

• Both sustained tachycardia and bradycardia may indicate a cardiovascular disorder.  

[5] 

• Respiratory rate 

• Newborn’s breathing pattern is normally irregular and should be counted for a full 60 seconds for accuracy [5] 

• The normal range for respiratory rate for newborns spans from 30 to 60 breaths per minute. 

• A respiratory rate above 60 breaths per minute warrants investigation. 

• Blood Pressure 

• Blood pressure is not a routine part of the newborn’s assessment. If a cardiovascular disorder is suspected, it should be performed using the correct cuff size for the size and age of the newborn. 

• Blood pressure can vary greatly depending on the newborn’s weight and gestational age; however, the baby’s mean arterial pressure is usually near the newborn’s completed gestational age in weeks. Normal blood pressures range from 30 to 45 mm Hg diastolic and 50 to 75 mm Hg systolic [5]. 

• Wide pulse pressures may indicate a patent ductus arteriosus. 

• Narrow pulse pressures may indicate poor cardiac output. 

• Four limb extremity blood pressures are warranted if cardiovascular disease is suspected. 

• Pulse Oximetry 

• A newborn’s pulse oximetry reading should be greater than 95% in most instances. Premature infants and full-term infants immediately after delivery may have lower saturations [5].  

Diagnostics 

Certain diagnostic tests may be ordered by the provider to aid in the newborn cardiovascular assessment. A common diagnostic test is the chest X-ray, which can show cardiac size and shape, lung vascular markings, pulmonary vascularity, and position of organs [2]. A blood gas can also be evaluated from arterial, venous, or capillary blood. The blood gas can show if the newborn has metabolic acidosis or base excess.  

An electrocardiogram (EKG) can be useful to determine any cardiovascular conduction problems [5]. An echocardiogram is another common test that takes ultrasound pictures of the heart. It can show cardiac size, position, blood flow patterns, function, and nearby vasculature [2]. The echocardiogram is especially useful for diagnosing congenital cardiac defects.  

Epidemiology 

In the United States, congenital heart defects (CHDs) are the most common birth defect, occurring in almost 1% of all births [1]. This equates to approximately 40,000 newborns a year who are born with CHD in the United States. Being able to perform a cardiovascular assessment and identify these types of disorders is important because approximately 25% of these babies born with CHDs will need treatment, including surgery or other procedures, to survive [1].  

Pathophysiology 

The heart is comprised of four chambers: right and left ventricles and right and left atria [5]. The left atrium collects oxygenated blood from the pulmonary veins and pumps the blood into the left ventricle. The left ventricle then pumps the oxygenated blood through the aorta to the rest of the body. The right atrium collects deoxygenated blood from the body via the vena cava and pumps it into the right ventricle. The right ventricle then pumps the deoxygenated blood to the lungs via the pulmonary artery.  

CHDs can have multiple effects on the newborn, including increased pulmonary blood flow, decreased pulmonary blood flow, totally or partially obstructed blood flow, or a combination of effects. Acquired heart disease can occur in a heart with structural defects or with a congenital defect [5].  

Clinical Signs and Symptoms 

Clinical signs and symptoms that would warrant a detailed cardiovascular assessment in a newborn include the following [4]: 

• Cyanosis (blue or gray color, especially to the lips or around the mouth) 

• Tachypnea and/or respiratory distress 

• Murmur 

• Activity intolerance during feedings 

• Edema in the extremities or around the eyes 

• Decreased oxygen saturation 

• Hypotension or extreme blood pressure variations from upper and lower extremities  

Etiology 

Genetic abnormalities are the most common cause of CHDs, accounting for about 25% of all defects [1]. The remainder have no known cause. Acquired heart disease in the newborn can result from infection, teratogens, maternal diabetes, autoimmune factors, or genetic abnormalities. A child’s risk of developing a CHD is increased by three times if a parent or sibling has a CHD [1]. Most are caused by a combination of genetic and environmental factors. 

Treatment 

Treatment of an abnormal newborn cardiac assessment will be dependent on the diagnosis of the specific disorder or problem that is occurring. Treatment options include medications such as diuretics, antiarrhythmics, beta-blockers, or ACE inhibitors [3]. More intensive procedures or surgeries could be warranted, such as cardiac catheterization, heart surgery, or even a heart transplant. 

Safety Considerations 

In a newborn with a suspected cardiovascular disorder, the nurse should allow for periods of rest and recovery [5]. Assessments, feedings, diaper changes, lab draws, and other procedures should be attempted to be completed at the same time, allowing for periods of rest in between activities. Oral intake, urinary output, and symptoms of lethargy and overexertion should be monitored. 

Bacterial endocarditis prevention is another critical safety measure that should be addressed in newborns with cardiovascular disease [5]. High-risk clients should be prescribed preventative antibiotics before all dental and surgical procedures. The caregivers should also alert all health-care providers of the child’s condition before any procedure [3]. 

Research Findings 

Current research recommends screening newborn infants in the hospital nursery or other acute units for critical congenital heart defects before discharge [2]. This screening method can help to identify newborns with cardiovascular disorders before signs and symptoms become evident. The screening is performed on infants greater than 24 hours of age using a pulse oximeter. The pulse oximetry screening may not detect all critical congenital heart defects, and an infant may still be later diagnosed with a disorder even with a passed screen [2].  

The person performing the screening should apply the pulse oximeter to the newborn’s right wrist, hand, or foot [2]. A pulse oximetry reading with a value greater than 95% in the right hand or foot with less than a 3% difference in the oxygen saturation value between the right foot and hand is considered a passed screen. If the pulse oximetry reading is less than 90%, less than 95% on three different measures, or there is a greater than 3% difference in pulse oximetry values between the right hand and the right food, the screening is considered failed. A failed screen should be reported to the attending provider, who will likely order further testing [2]. 

Conclusion

Cardiovascular assessment is a critical component of a newborn’s overall assessment. Performing a cardiac assessment on a newborn is critical to detect any serious cardiovascular abnormalities after birth such as a murmur or other abnormal findings. Newborns may be born with a congenital cardiac defect or develop acquired heart disease from teratogens or maternal infection, which may not be clinically apparent at birth.  

Nurses should be aware of the techniques in performing a newborn cardiovascular assessment, and what factors are abnormal or indicative of cardiovascular disease.  

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