Newborn Assessment

Antepartal risk factors (This will be obtained from the mother's chart!):
Maternal Age 31 Gravida/Para(GTPAL) 4-3-0-1-3 Gestational Age 40 4/7
Onset of Prenatal Care10 weeks Maternal Blood type A negative
Planned/Unplanned pregnancy Planned Maternal Substance abuse N/A Gestational Diabetes N/A
Maternal Infections N/A Abnormal US findings N/A
Additional information _N/A____________________________________________________

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

Temp 36.5 HR 146 Respirations 60 Blood glucose N/A
APGAR Score: 1 min 8 5 min 9 Resuscitation measuresRubbing babys back to initiate
breathing outside of the womb
Eye antibiotic 0900 (time) Vitamin K 0900 (time)
Nursed in L&D: Yes

Length 21 in 53.5cm Wt. 3805 g/8 lb 6oz

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 36.4 HR 140 Respirations 44

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 Coarse crackles
Cry: Lusty ___+___ Weak ______ Shrill ______

Head: Symmetry/shape Round 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 Symmetric, centered
Skin tags ______

Nose: Symmetry ___+_____ Flaring ______ Patent: Left __+___ Right __+___
Eyes: (describe what you found)
Right

Left

Subconjunctival hemorrhage

_____

_____

Nevi on lids

_____

_____

Edema

__+___

__+___

Red reflex

__+___

___+__

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 10/1/15 Time 0800 Color of urine ________________

Male: Urethral orifice: Normal position ________ Abnormal (describe) Clear yellow
Testes (#/location) 2, descended
Scrotum ___+___ Pendulous ___+___ Rugated ___+___ Other _____________________
Female: Labia majora: Completely covers minora _N/A____ Partially covers minora _N/A____
Labia minora protruding __N/A____ Vaginal discharge __N/A____ Hymenal tag __N/A____
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)

___5___

___5___

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

Describe normal
responses

Rooting: Baby turned head

Brush babys cheek, his head

Baby should turn towards the

toward hand
Sucking: Baby sucked hand

will turn to find nipple

Babys hand brushes face, he

sensation
Baby should suck what

Moro: Babys arms and legs

will suck his hand

Lifted babys head and

touches his face

Baby should stretch out as he

stretched out

released it quickly, supported

is startled

Stepping: Baby lifted legs as if

again before hit padding

Hold baby upright with feet

Baby should move with

he were walking
Grasp/hand: Baby gripped

touching the flat surface

Put finger in babys hand, and

walking motions
Baby should grip fingers

finger
Grasp/foot: Baby curled toes

allow baby to grip

Place finger on babys foot,

Babys toes should curl

downward

and his toes curl down

downward

What is your overall assessment and prognosis for this infant (do not say good):
This infant has acclimated well to life on his own outside of the womb. His body is making the
proper adjustments for life, and he is progressing as he should be at this stage. This is a healthy
infant, with a stable prognosis if he continues to progress this way. There are no signs of any
ailments in this baby at this time.

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
Risk for altered nutrition r/t
insufficient breastfeeding

Ineffective thermoregulation
r/t transition to extrauterine
environment

Necessary
Assessments/Interventions

Assess mothers current knowledge level

with dietary needs for breastfeeding
Teach client that she will need an
additional 500 calories each day for
breastfeeding
Teach mother proper positioning and
technique for adequate breastfeeding
Refer client to a lactation consultant
Teach mother the importance of bringing
baby to all appointments

Promptly initiate skin to skin with parent

Keep infant away from direct exposure to
air currents
Limit water evaporation from skin during
bath time
Warm materials before contact with infant

Rationale

Baseline to ensure what the client already knows to begin the education
plan
The increased calories ensures that the mother will produce enough milk
to satisfy her infant
The chance of having a successful breastfeeding session is increased if
the baby is in the proper position to feed, and the mother and baby are
comfortable
A lactation consultant can ensure that the mother is aware of all of the
requirements with breastfeeding, and she can address any concerns that
she has with the process with her
Appointments will help the team to ensure proper infant growth and
nutrition status (Leifer, 2012)
Infants have a decreased ability to regulate temperature, and are more
susceptible to heat loss via evaporation, conduction, convection and
radiation than adults (Knobel, 2014)
Skin-to-skin is as effective as an incubator for rewarming the infant, and
for preventing hypothermia (Smith, 2014).
Infants that take immersion baths have a delayed incidence of
hypothermia compared to those with sponge baths because of the
decreased time of exposed wet skin to the air (Loring, et al. 2010)

References:
Knobel, R. (2014). Fetal and neonatal thermal physiology. Newborn and Infant Nursing Reviews,
14 (2), p. 45-49. doi: 10.1053/j.nainr.2014.03.003
Smith, J. (2014). Thermoregulation and temperature taking in the developing world: A brief
encounter. Journal of Neonatal Nursing, 20 (5), p. 218-229.
doi:10.1016/j.jnn.2014.03.002
Leifer, G. (2012). Maternity Nursing (11th ed.). St. Louis, MO: Elsevier
Loring, C. F., Reilly, J. E., Gregory, K., Gargan, B., LeBlanc, V., Lundgren, D., Walker, K., &
Zaya, C. (2010). Temperature control in the late preterm infant: A comparison of
thermoregulation following two bathing techniques. Journal of Obstetric, Gynecologic,
& Neonatal Nursing, 39 (s1), p. S92. doi: 10.1111/j.1552-6909.2010.01124.x

GRADING RUBRIC FOR NEWBORN ASSESSMENT

Below Expectations

Needs Improvement

Meets Expectations

Exc

(15 points)
Assessment has > 8 blanks
spaces, has poor analysis
(0 points)
Does not complete the care plan

(20 points)
Assessment has 9-12 blank spaces

(30 p
Asse
and e
(15 p
Choo
diagn

C. Interventions

(0 points)
Does not have any interventions

(10 points)
Has chosen inappropriate nursing
interventions

D. Rationale for
interventions

(0 points)
Does not have any rationales for
interventions

(10 points)
Stated inappropriate rationales for
nursing interventions

(25 points)
Assessment has 1-5 blanks
spaces, analysis lacks depth
(10 points)
Chooses 2 appropriate nursing
diagnosis based on the
assessment
(15 points)
Has chosen 2-3 appropriate
nursing interventions for each
diagnosis
(15 points)
Stated appropriate rationales for
nursing interventions for each
diagnosis

E. APA format, grammar,

spelling, & clarity of ideas

(0 points)
>10 errors in grammar or
spelling; Ideas are not presented
clearly.

(1 points)
5-10 errors in grammar or
spelling; Ideas are almost always
presented clearly

(3 points)
<5 errors in grammar or spelling;
Ideas are presented clearly

F. References

(0 points)
Has no citations and references

(2 points)
Has citations and references from
current textbooks.

(4 points)
Has citations and references from
other nursing textbooks,
Spectrums care plans or medical
websites.

A. Assessment
B. Nursing diagnosis

(5 points)
Chooses inappropriate nursing
diagnoses based on the assessment

(20 p
Has c
nursi
nursi
(20 p
In-de
interv
with
supp
(5 po
APA
in gr
prese

(10 p
Has c
journ