Newborn Assessment

Antepartal risk factors (This will be obtained from the mother's chart!):
Maternal Age ___28___Gravida/Para(GTPAL) 1-1-0-0-1 Gestational Age___38 1/7____
Onset of Prenatal Care__6 weeks_______ Maternal Blood type __O+____
Planned/Unplanned pregnancy _planned_ Maternal Substance abuse___no__ Gestational
Diabetes___no_____ Maternal Infections___none___ Abnormal US findings ___none_______
Additional information _____________________________________________________

Admission data (This will be obtained from the babys chart!):

Temp __38____ HR ___140___ Respirations ___48___ Blood glucose _64_____
APGAR Score: 1 min ___8__ 5 min __9___ Resuscitation measures: ____none_
____________________________________________________________________
Eye antibiotic ___07:30_ (time) Vitamin K __0:735_ (time)

Length __21in.______ Wt.

__8lbs 10oz______
Nursed in L&D: Yes

No

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):
Please use the following code:
+ = Present/normal

= Not present

NA = Not applicable

Vital Signs: Temp ___38___ HR ___148___ Respirations ___40___

Color: Pink _+_____ Pale __ ____ Mottles ___ ___ Plethoric __ ____
Jaundice __ ____ Stained ___ ___ Acrocyanosis __+____

Skin: Clear ____+__ Pressure marks ___ ___ Abrasions __ ____ Dry __ ____
Ecchymosis ___ ___ Petechiae ___ ___ Nevi ____ __ Milia ____ __
Rash _ _____ Lanugo __ ____ Vernix __ ____ Mongolian spots ___+___

Respirations: Regular __+____ Grunting ___ ___ Abdominal ___ ___ Retracting __ ____
Shallow ___ ___ Nasal flaring _ _____ Sighing ___ ___ Other ______
Cry: Lusty ___+___ Weak ______ Shrill ______

Head: Symmetry/shape: Round, symmetric Molding ____ ______ Cephalohematoma ___

Caput succedaneum ____ __ FSE mark ___ ___ Other ___ ___
Anterior fontanel: Flat ___+___ Full ______ Depressed ______
Posterior fontanel: Flat ___+___ Full ______ Depressed ______
Sutures

Overriding

Separated

Approximated

Coronal

________

________

____+_______

Sagittal

________

________

_____+______

Lambdoidal

________

________

____+_______

Ears: (describe exact location & how you determined if it was normal)
Position: Normal ___+___ Abnormal ______ Describe normal position: In line with eyes
Skin tags _ _____

Nose: Symmetry ____+____ Flaring ____ __ Patent: Left ___+__ Right ____+_
Eyes: (describe what you found) Symmetric in size and shape
Right

Left

Subconjunctival hemorrhage

__ ___

__ ___

Nevi on lids

_ ____

__ ___

Edema

__ ___

___ __

Red reflex

__N/A___

__N/A ___

Other

___ __

__ ___

Mouth: Mucous membranes: Pink ___+___ Pale ___ ___ Cyanotic __ _____
Teeth ____ __ Epsteins pearls ___ ___
Hard palate: Intact ___+___ Abnormal _______________________________
Soft palate: Intact ___+___ Abnormal ________________________________

Lips: Cleft _____ _ Drooping ___ ___ Symmetry __+____

Anterior chest: Symmetrical __+____ Shape _Round__

Clavicles: Intact _____+____Fracture ______ __________________________
Breasts: Palpable tissue ___+___ Engorgement ___ __________
Heart sound: RRR ____+____ Other _________________________________

Genitals: Voided: Date ____9/19____ Time ___10:02AM_ Color of urine ____Clear

Male: Urethral orifice: Normal position ___+__ Abnormal (describe) ___ _________
Testes (#/location) _2, descended____________________________________________
Scrotum ___+___ Pendulous __ ____ Rugated ___+___ Other _____________________
Female: Labia majora: Completely covers minora __NA_ Partially covers minora __NA___
Labia minora protruding ___NA_ Vaginal discharge ___NA Hymenal tag ___NA_
Both genders: Anal patency:

Y N

Stool:

Y N Type ___Meconium____

Spinal Column: Pilonidal dimple ___ ___ Tuft of hair ___ ___
Symmetry __+____ Intact ___+___

Abdomen: Symmetry __+____ Other ____________________

Umbilical cord: # of vessels _3_____ Protruding base ______ ____________

Extremities:
Right

Left

Symmetry

___+___

____+__

Movement

__+____

___+___

Digits (number)

___10___

___10___

Flexion creases

___+___

___+___

Palmar creases

__+____

___+___

Sole creases

___+___

__+____

Intact

Dislocated/subluxation

___+___

___ ___

Hips:
Right

Left

___+___

___ ___

Neuro-muscular: Tone: Normal ___+_ Lethargic ___ _ Rigid ___ _ Tremors ___ _

Reflexes:
Reflex: Describe what
you observed

Describe the procedure

Rooting: Infant searched for

stimulus

-Touch infants lip, cheek,

or corner of mouth w/
nipple or finger
- Touch infants lip, cheek,
or corner of mouth w/
nipple or finger
-Hold infant at semi-sit, let
head and trunk fall back 30
degrees
-Hold infant vertically
allowing one foot to touch
table
-place finger in palm of
infants hand
-place finger at base of toes

Sucking: sucked on
examiners finger
Moro: Infant extended and
then brought in arms
Stepping: infant lifted feet
and legs off table
Grasp/hand: grasped fingers
Grasp/foot: toes curled
around finger

Describe normal
responses
-Infant turns head towards
stimulus and opens mouth
- Infant turns head towards
stimulus and opens mouth
- extension of arms, fingers
fan out
-Infant will simulate
walking, picking feet up off
table
-infants fingers curl round
examiners finger
-toes curl downward

What is your overall assessment and prognosis for this infant (do not say good):
This is a very healthy baby boy, who does not have any abnormalities that will prevent
him from adjusting to extrauterine life. The newborn had an Apgar score of 8 and 9, so this is a
good indicator the he will not have any complications in the near future. He did not show any
signs of respiratory distress or abnormal vital signs. The assessment was normal and he did not
have any abnormalities that would cause concern. Overall, he was very healthy and has a good
prognosis.

On the basis of your assessment, list 2-3 nursing diagnoses for this
baby and the teaching interventions you would use for each nursing
diagnosis. Please include the rationale for your actions. You must
have at least two references other than your textbooks for your
rationales. Be sure your assessment and interventions correspond to
your nursing diagnosis.

Nursing Diagnosis
Ineffective airway
clearance

Risk For Infection

Necessary
Assessments/Interventions
-Watch infants for signs of
respiratory distress
-auscultate lungs and monitor
respirations
-position on back when sleeping
-monitor vital signs and review
maternal record for any risk
factors

-maintain neutral thermal

environment, and monitor
Risk for imbalanced temperature
body temperature

Rationale

-To identify problems with a block

-to assist newborn with clearing ai
- positioning on back prevents asp
suffocation

-An elevated temperature, hypogly

abnormal vitals could be a sign of
-The baby could be at risk for infe
mother has predisposing infection

- To identify changes and prevent h

cold stress. It is also important to a
from evaporation or convection to
in temperature that could be dang
newborn

References:
Knobel, R. B., Guenther, B. D., & Rice, H. E. (2011). Thermoregulation and Thermography
in Neonatal Physiology and Disease. Biological Research for Nursing, 13(3), 274
282. http://doi.org/10.1177/1099800411403467
Lowdermilk, D. Perry, S. Cashion, K. Alden, K. (2012). Maternity & Womens Health Care.
11th Edition.
Visscher, M. Adam, R. Brink, S. Odio, M. (2014). Newborn infant: physiology, development,
and care. Clinics in Dermatology. Volume 33(3).