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 __37.4____ HR ___148___ Resp ___58___ Bld glucose ___n/a___
APGAR Score 1 min __7___ 5 min __9__ Resuscitation measures: 20 sec of PP
ventilation
____________________________________________________________________
Ilotycin 12:50 (time) Vit K 12:50 (time) Length ____20____ Wt. ___8lb 2oz_____
Nursed in L&D Yes
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)
Infant was crying occasionally, attempting to nurse from mothers breast, breath sounds
are clear, all motor functions appear to be intact at this time, movement of all extremities is
visible, no visible abnormalities present.

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 __36.6____ HR __140____ Resp __48____
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: Symmerty/shape _____+_____ Molding __________ Cephalhematoma _____
Caput succedaneum ______ ISE 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 -vertical
placement, well- formed and complete, upper ear meets head even with imaginary line
drawn from outer canthus of 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 -cylinder
Clavicles: Intact ___+__ Fracture ______________________________
Breasts: Palpable tissue ____+__ Engorgement ______
Heart sound: RRR ____+____ Other ________

Genitals: Voided: Date ____n/a____ Time ____n/a____ Color of urine
________________
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
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 Stool N Type ______
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 __+___ ___+___
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: RN placed finger
in corner of babies mouth
brushing cheek, baby turned
head
touch or stroke from side
of mouth toward cheek
infant turns head to side
touched
Sucking: RN placed pinky
in infants mouth causing a
suckling effect
place nipple or gloved
finger in mouth, rub against
palate
infant begins to suck
Moro: The baby was
allowed to drop back
slightly causing arms and
legs to wave wildly
let infants head drop back
approx. 30 degrees
sharp extension and
abduction of arms followed
by flexion and adduction to
embrace position
Stepping: baby was held up
causing legs to lift
alternately

hold infant so feet touch
solid surface
infant lifts alternate feet as
if walking
Grasp/hand: baby clenched
finger

press finger against base of
infants fingers
fingers curl tightly
Grasp/foot: toes closed over
finger

press finger against base of
infants toes
toes curl forward
What is your overall assessment and prognosis for this infant (do not say good):
Sutures palpable with small separation between each, anterior fontanel diamond-shaped,
posterior fontanel triangular, hair silky and soft, ears well-formed and complete, symmetric
appearance and movement of face, parts proportional and appropriately placed, chest
cylinder shaped, abdomen rounded and soft, bowel sounds present, labia majora dark,
covered labia minora, reflexes present and intact, vitals WNL, equal and bilateral
movement of extremities, correct number and formation of fingers and toes, legs equal in
length, abduct equally, normal position of feet, no openings observed or felt in vertebral
column, anus patent. Prognosis is a healthy baby girl with all neurological and physical
functions in tact 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
Necessary
Assessments/Interventions
Rationale
risk for infection
r/t open
umbilical stump




Observe and report signs of
infection such as redness,
warmth, discharge, and
increased body temperature.
instruct family members on
proper hand hygiene before
handling baby, sponge bathe
baby until cord falls off,
proper education on stump
cleansing
It is important to note that the exposed
necrotic tissue of the umbilical stump is
readily colonized and infected by
pathogenic bacteria. Ready access of
the bacteria into the systemic
circulation places neonates at high risk
for infection (McConnell, Lee,
Couilard, & Sherrill, 2004, p. 211).
Although cord infections are rare in the
United States, proper precautions are a
must still.
ineffective
thermoregulation
r/t immaturity of
neuroendocrine
system


Routinely measure
temperature of infant in the
axilla using electronic
thermometer, keep head
covered, use blankets to keep
infant warm, keep infant
covered during procedures,
transport and testing, keep
room warm.
Immediately after delivery if no action
is taken, the core and skin temperatures
of a term neonate can decrease at a rate
of approximately 0.1C and 0.3C per
minute respectively (Waldron &
MacKinnon, 2007, p. 101). This is
where skin to skin contact is important
immediately after birth to allow for
conduction of body heat from mother,
also drying of baby and placing in
warm dry blanket will assist with









maintaining of body heat. Another
factor is the body surface area of the
baby, the baby will lose heat due to
evaporation, convection, conduction
and radiation (Murray & McKinney,
2014, p. 372).
breastfeeding r/t
normal oral
structure and
gestational age
greater than 34
weeks




encourage and facilitate early
skin-to-skin contact, rooming-
in and breastfeeding on
demand, monitor breastfeeding
process and identify
opportunities to enhance
knowledge and experience
regarding breastfeeding, give
encouragement/positive
feedback related to
breastfeeding mother-infant
interactions, monitor for s/s of
nipple pain and/or trauma,
monitor infant responses to
breastfeeding
Benefits of breastfeeding include:
immunologic benefits, lower incidence
of diabetes, asthma, obesity, some
cancers, SIDS, properties of breast milk
change as babies needs change,
constipation less likely, less likely to
result in overfeeding (Murray &
McKinney, 2014, p.439).
Benefits to mother: oxytocin release
enhances uterine involution, reduction
in the incidence of some cancers,
mother more likely to rest while
feeding, convenience, economical,
infant less likely to be ill (Murray &
McKinney, 2014, p.439).
References
McConnell, T. P., Lee, C. W., Couilard, M., & Sherrill, W. W. (2004). Trends in umbilical cord
care: scientific evidence for practice. Newborn & Infant Nursing Reviews, 4(4), 211-222.
Retrieved from http://www.medscape.com/viewarticle/497030_3
Murray, S. S., & McKinney, E. S. (2014). Foundations of Maternal-Newborn and Womens
Health Nursing (6th ed.). St. Louis, MO: Elsevier Saunders.
Waldron, S., & MacKinnon, R. (2007). Neonatal thermoregulation. Infant, 3(3), 101-104.
Retrieved from http://www.infantgrapevine.co.uk/pdf/inf_015_nor.pdf