Newborn Assessment

Antepartal risk factors (This will be obtained from the mother's chart!):
Gestational Age _24__ Onset of Prenatal Care _pre-pregnancy___ Maternal Blood type _A+_
Planned/Unplanned pregnancy _planned__ Maternal Substance abuse _no_
Gestational Diabetes _no_ Maternal Infections___GBS+ (PCN given 4 hours prior to delivery)__
Abnormal US findings _none_ Additional information _none__

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

Temp _36.9_ HR __134__ Respirations _40__ Blood glucose _N/A__
APGAR Score: 1 min _3__ 5 min ___9__ Resuscitation measures: __intubated with 3 cm ET tube, suction, PPV 90
seconds, CPAP 4 minutes___________
Eye antibiotic __0527_ (time) Vitamin K __0527__ (time)

Length ___50.5 cm___ Wt. ___2.876 kg_____

Nursed in L&D: 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 _36.8__ HR __148___ Respirations __52__

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: Symmetry/shape ____+______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 _ aligned to outer canthus when
imaginary line is drawn __ 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 __ ____

Clavicles: Intact ____+____Fracture __ _____
Breasts: Palpable tissue __ +____ Engorgement ____ _________

Heart sound: RRR ___+_____Other ______ __________________________

Genitals: Voided: Date __4/10/15___ Time ___1500_____ Color of urine ____Clear___

Male: Urethral orifice: Normal position __ ______ Abnormal (describe) ___ _________
Testes (#/location) ___ ____________________________________________________
Scrotum ___ ___ Pendulous __ ____ Rugated ___ ___ Other _______ ____
Female: Labia majora: Completely covers minora __ ___ Partially covers minora __+___
Labia minora protruding ___ ___ Vaginal discharge __+____ Hymenal tag __+____
Both genders: Anal patency:

Spinal Column:

Stool:

Type ___meconium_______

Pilonidal dimple __ ____ Tuft of hair ___ ___

Symmetry ___+___ Intact ___+___

Abdomen: Symmetry ___+___ Other __ __________________

Umbilical 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 procedure

Rooting: rooting reflex is

present

Procedure involves touching

the cheek near the mouth.

The normal response is

turning the head toward the
stroked side.

Sucking: sucking reflex is

Procedure involves the mouth

or palate being touched.

The normal response is the

infant beginning to suck.

Moro: moro reflex is present.

Procedure involves the head

and trunk being dropped 30
degrees from a slightly raised
position.

The normal response is the

arms and legs extend and
abduct with fingers fanning
open and thumbs and
forefingers forming a C.
Arms then flex and embrace,
legs extend and flex.

Stepping: stepping reflex is

Procedure involves the infant

being held upright with feet
touching a solid surface.

The normal response is the

infant lifting one foot and then
another giving to appearance
of stepping.

Procedure involves palm

being touched near the base of
the fingers.

The normal response is the

infant grasping the finger.

Procedure involved foot

being touched near the toes.

The normal response is the

toes curling over the finger.

present.

present.

Grasp/hand: hand grasp is

present.

Grasp/foot: foot grasp is

present.

Describe normal
responses

What is your overall assessment and prognosis for this infant (do not say good):
My overall assessment and prognosis for this infant is great, if proper measures are taken.
For example, this baby has a great chance of developing normal hip flexion as long as the parents
properly apply the harness for the correct amount of time. If they do not follow the prescribed
way, the baby is at risk for having developmental problems with her hips. The child doesnt
appear to have any lasting effects from requiring resuscitation at birth. As long as the baby is
properly kept warm and harness applied, everything should progress beautifully. I feel very good

about the parents following through with the plan of care because they are very perceptive with
their learning concerning their first child.

On the basis of your assessment, list 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

Necessary
Assessments/Interventions
Apply harness properly, avoid
Activity
swaddling to allow movement,
intolerance r/t
avoid sling carriers, comfort
pavlik harness
baby by soothing or
pacifiers, never unfasten
straps, remove only as
directed, do not lie baby on
side, check hip ROM as
directed (nurse only)
Monitor temperature, explain
Risk for ineffective heat loss mechanisms to
thermoregulation
parents, radiant warmers, give
r/t transition
baby a hat, swaddle, skin to
skin contact, when washing
dry quickly (Cinar & Filiz,
2006).
Impaired gas
Assess for impaired gas
exchange r/t apnea exchange (tachycardia,
following Ccyanosis, pulse ox decrease),
section
perform resuscitation as
appropriate, skin to skin
contact

Rationale
Harness is restrictive to baby.
She has limited ROM with legs.
She screams any time the
harness is manipulated
(Schwend, Shaw, Segal, 2014).

All newborns are at risk, but

this baby is at more risk due to
the difficulty transitioning from
intrauterine to extrauterine life

Baby was born via C-section

and required emergency
resuscitation measures. APGAR
scores were 3 at 1 minute
requiring tubing, PPV, and
CPAP

Cinar, N. D., & Filiz, T. M. (2006, April). Neonatal Thermoregulation. Journal of Neonatal
Nursing, 12(2), 69-74. Retrieved from CINAHL (10.1016/j.jnn.2006.01.006).
Murray, S. S., & McKinney, E. S. (2014). Foundations of Maternal-Newborn and Women's
Health Nursing (6th ed., pp. 393-394). St. Louis, MO: Saunders.
Schwend, R. M., Shaw, B. A., & Segal, L. S. (2014, December). Evaluation and Treatment of
Developmental Hip Dysplasia in the Newborn and Infant. Pediatric Clinics of North
America, 61(6), 1095-1107. Retrieved from CINAHL (10.1016/j.pcl.2014.08.008).