Wertz
Newborn
Assessment
Newborn Physical Assessment Please use the following code:
+ = Present/normal
= Not present
NA = Not applicable
Bld glucose NA
____________________________________________________________________
Ilotycin: 2302 (time) Vit K: 2302 (time) Length: 49.5 cm Wt.: 6 lbs., 8.5 oz.
Nursed in L&D: YES
After you have read the infants chart and gathered the information, give your assessment of this infants status when it was 1 hour after birth
(give details, not good)
NIPS Score is 0; Mom was holding baby; Strong cry; Easily consoled; HR RRR; No respiratory distress noted; Capillary refill < 3;
Skin is pink and warm; Lung sounds clear bilaterally; Abdominal is soft, round and non-distended; Bowel sounds active; Moves all
extremeties equally bilaterally; Nursed in L&D.
NOW
YOU
ARE
READY
TO
DO
A
PHYSICAL
ASSESSMENT
ON
THIS
BABY
(to
be
completed
by
you
the
day
you
are
caring
for
the
baby):
Temp: 36.9oC (axillary)
Color: Pink
Jaundice
Skin: Clear
Pale
Stained
Resp: 42
Plethoric
Acrocyanosis
Mottles
Petechiae
Lanugo
Dry
Milia
Abrasions
Pressure marks
Ecchymosis
Rash
HR: 142
Vernix
Nevi
Respirations: Regular
Grunting
Shallow
Nasal flaring
Cry: Lusty
Weak
Head: Symmerty/shape
Molding
Mongolian spots
Abdominal
Sighing
Retracting
Other NA
Shrill
Cephalhematoma
Other NA
Full
Depressed
Full
Depressed
Sutures
Overriding
Separated
Approximated
Coronal
Sagittal
Lambdoidal
Ears: (describe exact location & how you determined if it was normal)
Position: Normal
Skin tags
Abnormal
Flaring
Describe normal position: Symmetrical; in line with outer canthi of eye bilaterally
Nose: Symmetry
Patent: Left
Right
Left
Subconjunctival hemorrhage
Nevi on lids
Edema
Red reflex
Other
NA
NA
Pale
Cyanotic
Teeth
Epsteins pearls
Abnormal NA
Abnormal NA
Symmetry +
Fracture NA
Engorgement
Other NA
Tuft of hair
Intact
Stool: Yes
Type: Meconium
Other NA
Left
Symmetry
Movement
Digits (number)
10
10
Flexion creases
Palmar creases
Sole creases
Hips:
Intact
Dislocated/subluxation
Right
Left
Lethargic
Rigid
Tremors
Reflexes:
Reflex: Describe what you observed
Placing a finger on the newborns sole by The newborn should grasp the finger placed in
the toes, the newborn should grasp the
sole of foot bilaterally.
finger with their soles bilaterally.
What is your overall assessment and prognosis for this infant (do not say good):
Baby Girl Xs physical assessment noted the anterior and posterior fontanels were soft and flat; the sutures were approximated.
The infant was alert, calm and cooperative after being breastfed, arousing to sound and tactile. The infants eyes and ears are
symmetrical bilaterally, and the nose and mouth are symmetrical also. The infants heart rate and respiratory rate is within normal
limits for a newborn. The infant displayed positive reflex and neuromuscular tone is normal. Bowel sounds are active in all four
quadrants bilaterally; patient passed her first meconium stool and I changed her diaper. The infant voided earlier in the morning. Two
birthmarks noted above eye lids bilaterally. Skin is pink and dry. No lesions or rashes noted.
On the basis of your assessment, list 2-3 nursing diagnoses for this baby and all the teaching
interventions you would use for each nursing diagnosis. Please include the rationale for your actions.
You must have at least two references besides your textbooks for your rationales. Be sure your
assessment and interventions correspond to your Nursing Diagnosis.
Nursing Diagnosis
1. Effective breastfeeding
related to basic
breastfeeding knowledge
Necessary
Assessments/Interventions
1. Provide infant contact with mother
skin-to-skin and have infant nurse
within first hour of birth
2. Instruct proper positioning
3. Nurse 8-10 times in 24-hour period
4. Monitor stools and voids
2. Disturbed sleeping
pattern related to new
environment
Rationale
Having the infant within the first hour of birth promotes
bonding and encourages milk production
Proper positioning is important for the infant to be able to
latch onto the breast and help to prevent nipple soreness
Nursing the infant 8-10 times in a 24-hour period
encourages milk production and provides adequate
nutrition for infant growth
Monitoring stools and voids allows parents and
physicians to ensure infant is getting enough nutrition
and fluids
Practice rooming-in by allowing mother and infant to
remain together for 24 hours a day (Shealy et. Al, 2005)
Follow a consistent bedtime routine
Bathe the baby at night
Read a book or sing lullabies
Keep a low-stimulation environment
Recognize signs the infant is tired such as rubbing eyes,
flicking the ears, or yawning and stretching often
(Davis, Parker & Montgomery, 2004)
3. Ineffective
thermoregulation related
to transition
References
About Skin-to-Skin Care (2014, August 20). In American Academy of Pediatrics. Retrieved November 27, 2014, from
http://www.healthychildren.org/English/ages-stages/baby/preemie/Pages/About-Skin-to-Skin-Care.aspx
Davis KF, Parker KP, Montgomery GL. 2004. Sleep in Infants and Young Children: Part One: Normal Sleep. Journal of Pediatric
Health Care. 18: 130-7. Retrieved from http://www.babycenter.in/a7654/establishing-good-sleep-habits-newborn-to-threemonths#ixzz3KKTi9QmI.
Ricci, S.S. (2009). Essentials of maternity, newborn, and women's health nursing. (3rd ed.). Philadelphia, PA: Lippincott, Williams and
Wilkins.
Shealy, K., Li, R., Benton-Davis, S., & Grummer-Strawn, L. (2005). The CDC Guide to Breastfeeding Interventions. In Centers for
Disease Control and Prevention. Retrieved November 27, 2014, from
http://www.cdc.gov/breastfeeding/pdf/breastfeeding_interventions.pdf