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Ferris State University

NURS 342
Summer 2010
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 _36.7F_____ HR __156____ Resp ___46___ Bld glucose __58____
APGAR Score 1 min ___8__ 5 min __9___ Resuscitation measures: _skin to skin
contact with mom 1 minute after birth, newborn was wiped off well, and a hat was
provided and on newborns head. Suctioning using the bulb syringe was needed because
of excess secretions.
____________________________________________________________________
Ilotycin __1915____ (time) Vit K __1915____ (time) Length __19.5 in. Wt. 6lbs
8oz_
Nursed in L&D Y N
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)

One hour after birth infant was stable and skin to skin was provided considering
newborns low temperature. Chart indicated mom was having some trouble with
breastfeeding. The APGAR of 9 indicates an acceptable heart rate, respiratory effort,
muscle tone, response to irritation stimulus and color. When looking at the assessment
data it shows that these five characteristics that determine the APGAR score were
consistent and the baby is doing well.





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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 __36.8____ HR __148____ Resp __36____
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 : symmetric/round_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 Ears were aligned
with outer canthi of eyes. I knew that this was normal from reading my text book and the
appearance of the baby
Skin tags ______
Nose: Symmetry ___+_____ Flaring ______ Patent: Left ___+__ Right __+___
Eyes: (describe what you found)
Right Left
Subconjunctive hemorrhage _____ _____
Nevi on lids _____ _____
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Edema _____ _____
Red reflex _+____ ___+__
Other ___NA__ __NA___

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 _Regular RRR_______ Other __NA______

Genitals: Voided: Date __7/13/13______ Time ___2003_____ Color of urine
____yellow____________
Male: Urethral orifice: Normal position __NA______ Abnormal (describe)
__NA__________
Testes (#/location) NA
Scrotum _NA_____ Pendulous __NA____ Rugated _NA_____ Other _NA
Female: Labia majora: Completely covers minora _+____ Partially covers minora ____
Labia minora protruding ______ Vaginal discharge ______ Hymenal tag ______
Posterior: Pilonidal dimple ______ Truft of hair ______
Spinal column: Symmetry __+____ Intact __+____
Anal patency: Y N Stool Y N Type __muconium____
Anterior Abd: Symmetry __+____ Other __NA__________________
Cord: # of vessels __3____ Protruding base __1____
Extremities:
Right Left
Symmetry _+_____ __+____
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Movement __+____ ___+___
Digits (number) __5____ ___5___
Flexion creases __+____ ___+___
Palmar creases _+_____ __+____
Sole creases ___+___ __+____
Hips:
Intact Dislocated/subluxation
Right __+____ ______
Left __+____ ______

Neuro-muscular: Tone: Normal _+_____ Lethargic ______
Rigid ______ Tremors ______





Reflexes:
Reflex: Describe what you
observed
Describe the procedures Describe normal responses
Rooting: Newborn turned
towards the side that was
stroked and make sucking
movements

Performed by stroking the
newborns cheek
Newborns should turn
towards side that was
stroked and make sucking
movements
Sucking: When touching the
newborns lips she opened
her mouth and began a
sucking motion

Touching the newborns lip
or putting your finger in
their mouth
Newborns should elicit a
sucking motion and/or open
their mouth
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Moro: The newborn threw
her arms outwards and
flexed her knees; the arms
then returned to the chest.
The fingers also spread to
form a C. The newborn
initially appeared startled
then relaxed to normal
resting position

When placing the newborn
on their back, support the
upper body weight of the
supine newborn by their
arms, using a lifting
motion, without lifting the
newborn off the surface.
Release the arms suddenly
The newborn will throw
their arms outwards and
flex their knees; the arms
then return to the chest. The
fingers also spread to form
a C. The newborn initially
appears startled then relaxes
to normal resting position.
Stepping: The newborn
made a stepping motion

Assess the stepping reflex
by holding the newborn
upright and inclined
forward with the soles of
their feet touching the flat
surface.
The baby should make a
stepping motion or walking,
alternating flexion and
extension with the soles of
their feet.
Grasp/hand: Newborns hand
closed around finger

Placing finger on newborns
open palm
Newborns hand will close
around finger
Grasp/foot: Newborns toes
curled over finger

Place your finger just
below the newborns toes
Toes typically curl over
finger









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What is your overall assessment and prognosis for this infant (do not say good):
My overall assessment and prognosis of the infant was that she is stable. Her heart rate,
temperature, and respiration rates were regular and within normal limits. Her lungs were
clear, and abdomen was soft, non tender, and active in all four quadrants. Baby is
sleeping on and off which is normal. She is peeing and stooling which means she is
receiving enough breast milk. Mom and baby had some trouble breastfeeding but with
help it is getting better. I did not find any abnormalities for this newborn. If everything
goes well within the next 24-36 hours mom and baby will be discharged and able to go
home.









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On the basis of your assessment, list at least TWO nursing diagnosis 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 Necessary
Assessments/Interventions
Rationale
Ineffective thermoregulation
r/t immature compensation for
changes in environmental
temperature




Imbalanced nutrition: less
than body requirements r/t
poor feeding behaviors




Risk for infection related to
immature immunologic
response and extra-uterine
exposure.




1. Encourage skin to skin contact with the mother
2. Keep the newborn swaddled in a blanket and provide a
hat for the infants head to reduce heat loss through
conduction
3. Take the newborns temperature every 1-4 hours
depending on results
4. Wash the newborn in a warmed infant transporter to
avoid cold stress


1. Keep the newborn with the mother throughout the
hospital stay
2. Provide the mother with a breast feeding tracking sheet.
Watch for indicators of sufficient intake from infant: 6 to
10 wet diapers daily and feeding every 2 to 3 hours
3. Provide a lactation consultant to observe how the mother
is feeding the baby
4. Provide unrestricted periods of breastfeeding


1. Teach parents and visitors to wash hands before and after
providing care to newborn
2. Monitor the umbilical cord stump for signs of infection
3. Provide eye prophylaxis by instilling prescribed
medication soon after birth
4. Educate parents about appropriate home measures that
will prevent infections, such as practicing good hand
washing before and after diaper changes, keeping the
newborn well hydrated, avoid brining the infant into
crowds, observing for early signs of infection (fever,
vomiting, loss of appetite, lethargy, green watery stools,
drainage from umbilical cord site or eyes)
According to Caruana (2008), a study was conducted using newborns that had skin to skin contact
for 90 minutes compared to newborns that were placed in a crib. The study found that the average
temperature for a newborn that was placed in the crib was 36.7 degrees Celsius compared to 37.1
degrees Celsius for newborns who were skin to skin. This study proves that for effective
thermoregulation it is best to provide skin to skin contact for the newborn.



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According to Bystrova (2007), Studies suggest that mothers who room-in with their babies make
more milk, make more milk sooner, breastfeed longer, and are more likely to breastfeed
exclusively compared with mothers who have limited contact with their babies or whose babies
are in the nursery at night.





According to Rhee (2008), a study performed by the Achieves of Pediatric and Adolescent
Medicine found a 44 percent reduction in risk of death if mothers washed their hands prior to
handling their newborn infant. This study proves how important it is to educate family and
visitors on the importance of hand washing to reduce infection of newborns.

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References

Bystrova, K., Matthiesen, A., Widstrom, A., Ransjoarvidson, A., Wellesnystrom, B., Vorontsov, I., et al. (2007). The Effect Of
Russian Maternity Home Routines On Breastfeeding And Neonatal Weight Loss With Special Reference To Swaddling. Early
Human Development, 83(1), 29-39.
Caruana, E. (2008). Early Skin-to-skin Contact For Mothers And Their Healthy Newborn Infants.. Journal of Advanced Nursing,
62(4), 439-440.
Rhee, V., Mullany, L. C., Khatry, S. K., Katz, J., LeClerq, S. C., Darmstadt, G. L., et al. (2008). Maternal And Birth Attendant Hand
Washing And Neonatal Mortality In Southern Nepal. Archives of Pediatrics and Adolescent Medicine, 162(7), 603-608.