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Comp NEWBN Assessment

Comp NEWBN Assessment

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Published by: n2biology on Nov 15, 2012
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12/04/2012

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CYPRESS COLLEGEHEALTH SCIENCE DIVISIONDepartment of NursingCLINICAL COMPETENCIESNURSING 197 MATERNAL/NEWBORN NURSINGStudent Name: ____________________________________________________  TITLE:
PHYSICAL ASSESSMENT
:
NEWBORN
SUCOMMENTS1. INITIAL ASSESSMENTa. Places infant in radiant warmer and attaches probe (if applicable).b.Completes identification transfer with L&D nurse.c.Assess neonate for stability and obtains initial vital signs.d.Completes weight and measurements per agency procedure.e.Administers newborn medications safely per agency policy andprocedure.2.INTEGUMENTARYa.Maintains infant temperature throughout examination and bath.b.Examines skin surfaces for color, turgor, rashes, bruising,edema, birthmarks, and/or desquamation.c.Performs a gestational age assessment.3.CRANIOFACIAL - EENT - NECK a.Observes the head and face for symmetry, shape, and evidenceof birth trauma.b.Assesses the eyes for position, clarity, discharge, hemorrhage &reaction to light.c.Inspects the ears for position, shape, firmness, patency, &drainage.d.Assesses the nose for patency, & flaring.e.Inspects the mouth & oral cavity.f.Palpates the fontanels and sutures for size and fullness.g.Observes the neck for mobility, masses, position of trachea andcondition of clavicles.4.RESPIRATORYa.Observes rate and quality of respirations noting any tachypnea,retractions or grunting.
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 TITLE:
PHYSICAL ASSESSMENT
:
NEWBORN
SUCOMMENTSb.Inspects the chest for shape and symmetry.c.Auscultates the lungs and notes the presence of anyadventitious sounds.d.Examine breast tissue for size and stippling.5.CARDIOVASCULARa.Observes for evidence of insufficiency by evaluating color andcapillary refill time.b.Locates the PMI and palpates the major peripheral pulses.c.Auscultates the heart for rate, rhythm and murmurs.6.ABDOMINAL/GI/GUa.Observes the abdomen for shape & appearance; auscultates forbowel sounds.b.Inspects the umbilical cord for three vessels, color, size anddrainage.c.Assesses the genitalia for appearance, edema, position,patency or congenital anomalies and note presence of urine.d.Assesses anal patency and note the presence of stool.7.MUSCULOSKELETALa.Observes the resting posture of the neonate.b.Assesses for spontaneous movements and ROM.c.Assesses the back and spine for straightness, symmetry ogluteal folds & pilonidal dimpling.d.Palpates the hips for clicks or dislocation.8.NEUROLOGICALa.Observes and tests for the following reflexes:1.Sucking and rooting2.Palmar and plantar grasps3.Moro4.Babinski
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