Newborn Assessment

Antepartal risk factors (This will be obtained from the

mother's chart!):
Maternal Age 29____Gravida/Para(GTPAL) _31011 Gestational Age_39/2______
Onset of Prenatal Care_March 2015____ Maternal Blood type __O+____
Planned/Unplanned pregnancy ___planned___Maternal Substance abuse__N/A_______
Gestational Diabetes___No_____ Maternal Infections___No_______ Abnormal US
findings __No____________
Additional information _____________________________________________________

Admission data (This will be obtained from the babys

chart!):
Temp _36.6___ HR _132_ Respirations _42___ Blood glucose _N/A_____
APGAR Score: 1 min __8___ 5 min __9___ Resuscitation measures: _suction bulb,
skin to skin, touching of newborn.
Eye antibiotic __2:51 pm_ (time) Vitamin K 2:53 pm_ (time)

Length __21 inches__

Wt. _8.5 lbs____

Nursed in L&D: Yes

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

Vital Signs:

= Not present

NA = Not applicable

Temp 36.6_ HR _132_____ Respirations __42____

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: in line with
eyes
Skin tags ___ ___

Nose: Symmetry ____+____ Flaring __ ____ Patent: Left _+____ Right __+___
Eyes: (describe what you found)
Right

Left

Subconjunctival hemorrhage

Nevi on lids

Edema

Red reflex
Other

N/A

N/A

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 ___+_____ Other _____ ____________________________

Genitals: Voided: Date __N/A___ Time _N/A__ Color of urine

_N/A_____________
Male: Urethral orifice: Normal position __+______ Abnormal (describe)
___________
Testes (#/location) 2, descended
Scrotum __+____ Pendulous _ ____ Rugated _+_____ Other ___
Female: Labia majora: Completely covers minora _N/A Partially covers minora _N/A_
Labia minora protruding _N/A Vaginal discharge _N/A_____ Hymenal tag _N/A_____
Both genders: Anal patency:

Stool:

Y N Type ___meconium___

Spinal Column: 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

__+____

__+____

Intact

Dislocated/subluxation

Right

__+____

__ ____

Left

__+____

__ ____

Hips:

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

Tremors ______

Reflexes:
Reflex: Describe what
you observed

Describe the procedure

Describe normal
responses

Rooting: Infant turns head

Touch finger to infants lip, Infant turns head toward

toward stimulus.

cheek, corner of the mouth. finger and opens mouth.

Sucking:Infant sucked well

Put infant to mothers breast Infant turns head to nipple,

on finger and mothers nipple.to initiate sucking.

grasps, and sucks.

Moro: Touch infant w/ a cold Infant startles when held and Infant should have symmetric
stethescope, infant startles.

then dropped 3 degrees.

Stepping: Hold infant up,

arms.
Hold infant up vertically, let Infant stimulated to walk,

stimulates walking.

feet touch the table surface. alternates flexion and

Grasp/hand: Infant grasps

extension of feet.
Place finger in infants palm. Infants fingers should curl

finger in palm.

abduction and extension of

around finger.

Grasp/foot: Infant grasps

Place finger at base of

Infants toes should curl

finger with toes.

infants toes.

downward.

What is your overall assessment and prognosis for this infant (do not say good):
Healthy male baby delivered vaginally. Limited complications during birth, immediate
skin to skin contact and breastfeeding. High APGAR score after birth represents good
prognosis of overall health. Baby was born at adequate length and weight for gestational
age and with adequate cry and vital signs.

On the basis of your assessment, list 2-3 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

Rationale

RF aspiration R/T -Neonatal

-Neo team present to
meconium
team present immediately assess infants
passage in
at birth,
respiratory status and
utero.
ready to
intervene if needed.
provide
-Meconium aspiration can
necessary cause serious infections in a
interventions.
newborn.
-Parents
-If baby cries right away-good
prepared for
sign, no further measures
possible
taken b/c resp. status
complications
considered okay.
.
RF ineffective
-Immediate
-Cold stress needs to be
thermoregulatio skin to skin
avoided by maintaining
n R/T newborn
contact.
neutral thermal environment.
transition to
-Head
-Hyper/hypothermia can lead
extrauterine life. provided by
to brain damage if
swaddling,
unresolved.
radiant heat -Baby accustomed to very
warmer.
warm environment in utero,
-Avoid cool
so struggles to regulate its
air, windows. own temperature outside of
-Moniter
the womb.
axillary temp.
RF infection R/T -Observe for -Temperature increase is main
immature
signs of
sign of infection so should be
immune system. infection and
closely monitered.
report
-When infection occurs,
immediately. immune system is activated
-Assess
and signs of infection occur.
axillary temp.
-Keeping baby in neutral
-Assess skin
thermal environment
frequently.
decreases risk for infection.
-Maintain
warm
environment.

REFERENCES

Beligere, N., & Rao, R. (2008). Neurodevelopmental outcome of

infants
with meconium aspiration syndrome: report of a study
and literature review. J Perinatol, 28, S93-S101.
Knobel, R., & Holditch-Davis, D. (2010). Thermoregulation and
Heat Loss Prevention After Birth and During Neonatal IntensiveCare Unit Stabilization of Extremely Low-Birthweight
Infants. Advances In Care, 10, S7-S14.
http://dx.doi.org/10.1097/anc.0b013e3181ef7de2
Luriechildrens.org,. (2015). Preventing Infections in Newborns |
Lurie
Children's, Hospital in Chicago. Retrieved 16
November 2015, from
https://www.luriechildrens.org/enus/care-services/
specialtiesservices/infectiousdisease/treatmentsPages/infections-newborns.aspx
Nandanursingdiagnosislist.org,. (2015). Newborn Nursing
Diagnosis |
Nanda Nursing Diagnosis List. Retrieved 16
November 2015, from
http://www.nandanursingdiagnosislist.org/newborn-nursingdiagnosis/

References:
GRADING RUBRIC FOR NEWBORN ASSESSMENT
Below
Expectations

Needs
Improvement

A. Assessment (15 points)

(20 points)
Assessment has > Assessment has 98 blanks spaces,
12 blank spaces
has poor analysis
B. Nursing
diagnosis

C.
Interventions

(0 points)
(5 points)
Does not complete Chooses
the care plan
inappropriate
nursing diagnoses
based on the
assessment
(0 points)
(10 points)
Does not have any Has chosen
interventions
inappropriate
nursing
interventions

Meets
Expectations

Exceptional

(25 points)
(30 points)
Assessment has 1-5 Assessment has no
blanks spaces,
blank spaces and
analysis lacks
exceptional analysis
depth
(10 points)
(15 points)
Chooses 2
Chooses 3
appropriate nursing appropriate nursing
diagnosis based on diagnosis based on
the assessment
the assessment

(15 points)
(20 points)
Has chosen 2-3
Has chosen 4 or
appropriate nursing more appropriate
interventions for
nursing
each diagnosis
interventions for
each nursing
diagnosis
D. Rationale for (0 points)
(10 points)
(15 points)
(20 points)
interventions Does not have any Stated inappropriate Stated appropriate In-depth discussion
rationales for
rationales for
rationales for
of the nursing
interventions
nursing
nursing
interventions for
interventions
interventions for
each diagnosis with
each diagnosis
citations/evidencebased support
outside of textbooks
E. APA format, (0 points)
(1 points)
(3 points)
(5 points)
grammar,
>10 errors in
5-10 errors in
<5 errors in
APA format is
spelling, &
grammar or
grammar or
grammar or
excellent; no errors
clarity of ideas spelling; Ideas are spelling; Ideas are spelling; Ideas are in grammar or
not presented
almost always
presented clearly spelling, ideas are
clearly.
presented clearly
presented clearly
F. References

(0 points)
Has no citations
and references

(2 points)
Has citations and
references from
current textbooks.

(4 points)
Has citations and
references from
other nursing
textbooks,
Spectrums care
plans or medical
websites.

(10 points)
Has citations from
nursing journals < 5
years old.