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Neonatal Assessment Guide

Neonatal Assessment Guide

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Published by: run.rebel.run on Dec 19, 2008
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07/16/2015

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Felician College Department of Nursing and Health Management Nursing 370
Neonatal Assessment Guide / Independent Study
 Nursing students will perform the following newborn assessment with the clinicalinstructor’s assistance during the clinical nursing experience. The purpose of thisassessment is to increase the student’s knowledge about newborn physical assessmentand to increase the student’s observational skills.
The clinical instructor will assign students the week before this assignment is due.
Students are required to complete the column entitled
“Norms & PossibleAlterations”
 prior to meeting with the clinical instructor for the hands-on clinicalnewborn assessment.
Students will describe fully what they see, hear, and feel during the clinicalnewborn assessment in the column entitled
“Description of Findings”
(this will be handed in the week following the experience to the clinical instructor).
References other than course textbooks must be listed.
Grading will be
O
=outstanding,
S
= satisfactory, or 
U
= unsatisfactory Neonates InitialsStudent NameGrade
Assessment AreasNorms/Possible AlterationsDescription oFindingsGeneral Appearance
Briefly describe(ex, dark hair, pink, flexed)
Weight & Measurement
1.Weight – include range& average2.Height – include range& average3.TemperatureAxillary-Rectal (optional)4.Head CircumferanceHead disproportionately largefor the body, neck looks short,chin rests on chest, prominentabdomen, sloping shoulders,narrow hips, rounded chest2500-4000 g (5lb, 8oz., -8lbs.13 oz.)48 – 52 cm (18 -22 in.)36.4 – 37.2C (97.5 – 99F)36.6-37.2C (97.8-99F) 36.8 C(98.8F) desired32-37cm (12.5-14.5 in.) 2cmGreater than chestcircumference1
 
5.Chest Circumference
Posture:
 briefly describe
Skin
1.Colo2.Texture3.Turgo4.Pigmentation5.Jaundice6.Normal VariationsEx. Rashes, ET rash,Mongolian spots, birthmarks, bruises, petechiae.
Head Assessment
1.General appearance2.Size (related to body)3.Common VariationsDefine and explain thedifferences betweenCaput Succedaneum &Cephalhematoma.32.5 cm, 1-2 cm less than headWider than it is longBody usually flexed, handsmay be tightly clenched, andneck appears short becausechin rests on chest.Consistent with race.European- pink-tinged, Africanor Native American pale pink with yellow tinge, Asian –pink to rosy red, yellow tinge.Smooth, soft, flexible, mayhave dray, peeling hands andfeet.Elastic, returns to normalshape after pinchingClear, milia across bridge of nose, forehead, or chin willdisappear within a few weeksCafé-au-lait spots (one or two)Mongolian blue spots commonover dorsal area and buttocksin dark-skinned infantsErythema toxicumTelangiectatic nevi, rashesPetechiae of head or neck Round, symmetric, and moveseasily from left to right and upand down, soft and pliableGreater than chestcircumference, head one fourthof body sizeMoldingCaput succedaneum (longlabor and birth disappears in 1week, cephalhematoma(traumaduring birth, may persist up to3 months)2
 
4.FontanelsA.AnterioFontanelB.Posterior FontanelC.Pulsation?D.BulgingE.Sunken
Hair
1.Texture2.Distribution
Face
1.Symmetry2.Spacing of features3.Movement
Eyes
1.General placement andappearance2.Colo3.Any tears?4.Pupils react to light?Palpation of juncture of cranial bones3-4cm long by 2-3 cm widediamond shaped1-2 cm at birth, triangle shapedSlight pulsationModerate bulging noted withcrying, stooling; pulsationswith heartbeat-Smooth with fine texturevariations, depends on ethnic backgroundScalp hair high over eyebrows(Spanish-Mexican hairline begins midforehead to neck)Symmetric movement of allfacial features, normal hairline,eyebrows & eyelashes presentEyes-ears at same level,nostrils equal size, cheeks full,and sucking pads presentMakes facial grimacesSymmetric when resting andcryingBright and clear; even placement, slight nystagmus(involuntary cyclic eyemovement)Blue-gray or slate-blue-grayBrown color at birth in dark-skinned infants-React to light byaccommodation, light reflexdemonstrated at birth or by 3weeks of age3

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