Newborn Assessment

Antepartal risk factors (This will be obtained from the

mother's chart!):
Maternal Age: 20 years old
Gravida/Para(GTPAL): 1/0
Gestational Age: 39 weeks
Onset of Prenatal Care: 08/18/15
Maternal Blood type: A+
Planned/Unplanned pregnancy: Planned
Maternal Substance abuse: Marijuana Gestational Diabetes: No
Maternal Infections: No
Abnormal US findings: No
Additional information: Baby looked good on the ultrasound

Admission data (This will be obtained from the babys

chart!):
Temp: 36.8 degrees C
HR: 140
Respirations: 52
Blood glucose: N/A
APGAR Score: 1 min: 8
5 min:9
Resuscitation measures: N/A
Eye antibiotic: 10:30 am
Vitamin K 10:30 am
Length: 54 cm Wt.: 3.48Kg
Nursed in L&D: Yes

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: 36.8

Color: Pink: +
Acrocyanosis:

Pale:

HR: 120

Respirations: 34

Mottles: Plethoric: Jaundice: Stained:

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: N/A
Cry: Lusty: + Weak: Shrill:

Head: Symmetry/shape: symmetric

Molding: Cephalohematoma:
Caput succedaneum: FSE mark: Other: N/A
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: N/A
Describe normal position: observed in relation to eyes and nose, ears were
symmetrical and in line with both eyes
Skin tags:

Nose: Symmetry: symmetric

Flaring:

Patent: Left: + Right: +

Eyes:

both eyes were symmetrical and midline on the face and in line with
ears, both relative to nose position also.
Right
Left
Subconjunctival hemorrhage ____ ____
Nevi on lids
____ ____
Edema
____ ____
Red reflex
_N/A_ _N/A_
Other
____ ____

Mouth: Mucous membranes: Pink: +

Pale: Cyanotic:

Teeth: N/A Epsteins pearls: N/A

Hard palate: Intact: + Abnormal: N/A
Soft palate: Intact: + Abnormal: N/A
Lips: Cleft: Drooping: Symmetry: +

Anterior chest: Symmetrical: Shape: Rounded

Clavicles: Intact: + Fracture:
Breasts: Palpable tissue: Engorgement:
Heart sound: RRR: 12 Norm: +
Other: baby resting peacefully on mother

Genitals: Voided: Date: 4/3/16

Time: 16:38 Color of urine: yellow

Male:
Urethral orifice: Normal position: N/A Abnormal (describe): N/A
Testes (#/location): N/A Scrotum: N/A Pendulous: N/A Rugated: N/A
Other: N/A
Female:
Labia majora: Completely covers minora: + Partially covers minora:
Labia minora protruding: Vaginal discharge: Hymenal tag:
Both genders:
Anal patency: Yes
Stool: Yes
Type: Greenish/dark meconium

Spinal Column: Pilonidal dimple:

Tuft of hair: + Symmetry:+ Intact: +

Abdomen: Symmetry: + Other: N/A

Umbilical cord: # of vessels: 3

Protruding base:

Extremities:
Symmetry
Movement
Digits (number)
Flexion creases
Palmar creases
Sole creases

Right
_+__
_+__
_10 _
_+__
_+__
_+ __

Left
_+__
_+__
_10_ (Fingers/toes each side)
_+__
_+__
_+__

Hips:
Intact Dislocated subluxation
Right:
__+__
_____
Left
__+__
_____

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

Reflexes:
Reflex: Describe what you

Describe the procedure

observed

Rooting: Baby turned

towards the side of the
cheek that was touched
Sucking: baby sucked well
while feeding
Moro: (startle reflex)
Arms/Legs extended when
unswaddled and baby was
stimulated

touch the cheek and the baby should turn

Newborn will turn its head to anything that

towards the stimuli

strokes/cheek or stimulation.

Observed while feeding

Grasp/foot: (plantar reflex)

baby curled toes around
finger when there was
pressure on the foot

mouth is touched.

Baby extended arms/legs and fingers in response

the infant caused the reflex

to loud noise or other stimuli.

swaddled
N/A

Grasp/hand: (Palmar
grasp) Baby grasped my
fingers

Instinctively begins sucking when the roof of the

The stimuli of touching and unswaddling

Did not perform because baby was

Stepping: N/A

Describe normal responses

Lift baby, baby should put one foot in front of the

other when on a flat surface.

placed fingers against infant palm, baby

Object stroked palm and fingers will instinctively

grasped

close and grasp it

placed finger at the bottom of the foot

Plantar flexion of foot where toes move away

under the toes.

from shin and curl down.

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

The baby's outlook is healthy, her respirations and heart rate were
within normal limits. She does not appear to have any rashes or
birthmarks at this time. She is pink in color and her skin tone is
appropriate for her ethnicity. All of the observed reflexes were in
tact, she remained calm for a majority of the assessment however
cries when disturbed from time with mother. She is easily

consoled. She is cluster feeding at the moment and all bowel

sounds are active and loud. The infant is stooling dark greenish in
color and voiding normally. Mother and father are both present in
the room and are social with the infant.

Nursing
Diagnosis

Necessary
Rationale
assessments/Interventions

1. Risk of infection
related to immune
system immaturity

- Encourage frequent hand

washing and every time before
touching infant
- Observe and report signs of
infection

2. Ineffective breast
feeding related to
mother/infant
anatomy

3. Risk of
disturbance in
body temperature
related to
immaturity

the infant has an

immature immune
system, hand washin
significantly decrease
the transfer of bacteri
the infant. Parents sh
also be taught what s
look for such as fever
when to report those
symptoms.
Encourage frequent feedings
Observing the mothe
breast feeding allows
Lactation consult
education on if any
Observe mother breast feeding
techniques need to b
altered. Encouraging
frequent feedings ma
sure that the infant ha
access to food and al
lactation consult shou
be placed to help the
mother increase the
productiveness while
breast feeding.
Monitor infants temperature
Monitoring the infant
Assess environment for
temperature allows u
sources of heat loss
recognize when the b
Teach parents what to do when needs to be wrapped
temperature is below or above to preserve heat or
normal
unwrapped to release
heat. Teaching paren

about what to do for t

child if temperature is
abnormal once home
allows for a safe
environment for the in

References:
Dochterman, J. M., & Bulechek, G. M. (2004). Nursing interventions classification (NIC). St.
Louis, MO: Mosby.
Nanda Books. (n.d.). Retrieved April 12, 2016, from http://www.nandabooks.com/2012/10/ineffective-breastfeeding-nursing.html
Piotrowski, K. A., & Lowdermilk, D. L. (2016). Study guide: Maternity & women's health care
Deitra Leonard Lowdermilk, Shannon E. Perry, Kitty Cashion, Kathryn Rhodes Alden. St.
Louis, MO: Elsevier.