Leigh Anne Koonmen

Newborn Assessment
Newborn Physical Assessment Please use the following code:

+ = Present/normal

= Not present

NA = Not applicable

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

Temp ___36.3___ HR ___120___ Resp ___44___ Bld glucose __NA____
APGAR Score 1 min __9___ 5 min __9___ Resuscitation measures: Tactile stimulation__
__placed on pre-warmed table under radiant warmer__________________________________
Ilotycin _0838_ (time) Vit K _0838__ (time)

Length __19 in__ Wt. _3285 g__

Nursed in L&D YN
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)
The newborn is well nourished, well-developed, and healthy. Skin is pink without jaundice. Breath and
lung sounds are clear. Regular heart rhythm, no murmurs. Abdomen soft, not distended, active bowel
sounds. Umbilicus is well attached. Testes descended bilaterally. Vigorous cry, easily consoled. Good
muscle tone and moves extremities equally. Capillary refill is <2seconds. Anterior and posterior fontanels
are flat and soft.

NOW YOU ARE READY TO DO A PHYSICAL ASSESSMEDNT ON THIS BABY (to be completed
by you the day you are caring for the baby):
Temp _36.3__ HR _116_ Resp _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 ___NA___

Cry: Lusty __+____ Weak ______ Shrill ______

Head:Symmerty/shape __+/rounded__ Molding __________ Cephalhematoma _____
Caput succedaneum ______ ISE mark ______ Other ___NA___
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 outer canthi of the eye
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 _barrel-shaped
Clavicles: Intact ___+___ Fracture ______________________________
Breasts: Palpable tissue ___+___ Engorgement ______

Heart sound: RRR ___+_____ Other ___NA_____

Genitals: Voided: Date ________ Time ___NA_____ Color of urine ______NA__________

Male: Urethral orifice: Normal position ___+_____ Abnormal (describe) ____________
Testes (#/location) _________two testes, 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____
Posterior: Pilonidal dimple ______ Truft of hair ______
Spinal column: Symmetry ___+___ Intact __+____
Anal patency: Y N

Stool YN Type _meconium_____

Anterior Abd: Symmetry ___+___ Other ____________________

Cord: # of vessels ___3___ Protruding base ______
Extremities:
Right

Left

Symmetry

__+____

__+ ___

Movement

__+____

__+____

Digits (number)

__10____

__10____

Flexion creases

__+____

__+____

Palmar creases

__+____

__+____

Sole creases

__+____

__+____

Intact

Dislocated/subluxation

Right

___+___

______

Left

___+___

______

Hips:

Neuro-muscular: Tone: Normal __+____ Lethargic ______

Rigid ______ Tremors ______

Reflexes:
Reflex: Describe what you

Describe the procedures

Describe normal responses

observed
Rooting:
Positive, normal response
Sucking:
Positive, normal response
Moro:
Positive, normal response

Stepping:
Positive, normal response
Grasp/hand:
Positive, normal response
Grasp/foot:
Positive, normal response

Placed gloved finger in

newborns mouth

Newborn sucks on gloved

finger

Touch newborns lip, cheek,

or corner of the mouth with
fingertip
Hold newborn in a semisitting position and allow
the head and trunk to fall
back to a 30 degree angle

Newborn turns head toward

the stimulus, opens mouth,
and sucks
Newborn assums sharp
extension and abduction of
the arms with the thumbs
and forefingers in a Cshape, followed by flexion
and adduction into an
embrace position
Newborn simulates
walking, alternately flexing
and extending the legs
Newborn grasps finger

Hold newborn verticle,

allow one foot to touch a
surface
Put finger in palm of
newborns hands
Put finger under newborns
toes

Newborn wraps toes around

finger

What is your overall assessment and prognosis for this infant (do not say good):

Infant appears healthy, well-nourished, and well-developed. Positive maternal-infant bonding.

Due to low temperatures, care plan created for hypothermia. No other concerns at this time.

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
Effective Breastfeeding
r/t Basic Breastfeeding
Knowledge

Necessary
Assessments/Interventions
1. Provide early mother/infant contact
opportunity to breastfeed within one
hour of birth
2. Evaluate suck reflex
3. Position newborn on back or side
after feeding
4. Reinforce or provide information
about breastfeeding

Ineffective
Thermoregulation r/t
Transition

1. Immediately after delivery, dry baby

and maintain skin to skin contact with
mother
2. Apply cap to prevent heat loss

Rationale
1. Babies who do not have skin to skin contact at birth are at a
greater risk of not being breastfed.
2. This will indicate how much milk the infant is receiving; the
amount of milk flow influences the strength of sucking and the
number of pauses during breastfeeding (Pollock, 2013).
3. A left lateral position during feeding and post-feeding helps
reduce GERD (Hammell, 2009).
4. Providing thorough teaching will reduce complications after
discharge (Murray & McKinney, 2014).
1. Infants placed skin-to-skin with the mother immediately after
birth are more likely to have stable temperatures (Murray &
McKinney, 2014, p. 418).
2. Prevents heat loss through the head and helps maintain
thermoregulation (Brookside Associates, 2007).

3. Monitor newborns temperature

3. Monitoring temperature will indicate effectiveness of
4. Place newborn under radiant warmer interventions to maintain temperature (Ward & Hinsley, 2009).

as needed

Risk for Infection r/t

Ineffective Umbilical
Cord Care

1. Teach parents cord care prior to

discharge and stress importance of
keeping the cord clean and dry
2.Monitor for signs of infection, such
as a red and moist cord, foul smells, or
purulent drainage coming from the
cord
3. Fold diapers of newborns down
below umbilical cord

4. This will ensure the newborn is not using excess oxygen and
glucose to maintain body temperature (Murray & McKinney,
2014).
1. Evidence-based practice guidelines show that cleaning the
cord with water when necessary and keeping it clean and dry is
the best method of cord care (Murray & McKinney, 2014, p.
422).
2. Umbilical vessels are still patent a few days following birth,
which allows pathogens access to the bloodstream. Umbilical
cords are colonized by bacteria from environmental sources.
(Whitmore, 2010).
3. Folding diapers below the umbilical cord and keeping it
uncovered facilitates the cord drying (Whitmore, 2010).

4. Teach parents signs of infection

4. Instruct parents to call physician if signs of infection at the
umbilical cord are present (Cincinnati Childrens Hospital, 2013).

References:
Brookside Associates Medical Education Division (2007). Lesson 8: Care of the normal
newborn infant. Retrieved from
http://www.brooksidepress.org/Products/Obstetric_and_Newborn_Care_II/lesson_8_Sect
ion_1.htm
Cincinnati Childrens Hospital Medical Center (2013). Your babys umbilical cord. Retrieved
from
http://www.cincinnatichildrens.org/health/u/cord-care/
Hammell, G.L. (2009). Critical review: The effects of left lateral body positioning on GERD,
during feeding and post-feeding of the preterm infant [Masters thesis]. Retrieved from
http://www.uwo.ca/fhs/csd/ebp/reviews/2008-09/Hammell.pdf
Murray, S.S., & McKinney, E.S. (2014). Foundations of maternal-newborn and womens health
nursing. (6th ed.). St. Louis, MO: Elsevier Saunders.
Pollock, J. (2013). Oral motor skills in breastfeeding infants [PowerPoint slides]. Retrieved from
http://www.springfieldul.org/Custom/Library/1/documents/2013-0205/OralMotorSkillsinBreastfeedingInfants.pdf
Ward, S.L., & Hinsley, S.M. (2009). Maternal-child nursing care: Optimizing outcomes for
mothers, children, & families. (1st ed.). Philadelphia, PA: F.A. Davis Company.
Whitmore, J.M. (2010). Newborn umbilical cord care: An evidence based quality improvement
project [Doctoral dissertation]. Retrieved from
http://repository.usfca.edu/cgi/viewcontent.cgi?article=1006&context=dnp