You are on page 1of 11

Jamie

Wertz
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 36.8oC (axillary) HR 127 bpm Resp 54
APGAR Score: 1 min: 8 & 5 min: 9

Bld glucose NA

Resuscitation measures: Tactile Stimulus

____________________________________________________________________
Ilotycin: 2302 (time) Vit K: 2302 (time) Length: 49.5 cm Wt.: 6 lbs., 8.5 oz.
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)

NIPS Score is 0; Mom was holding baby; Strong cry; Easily consoled; HR RRR; No respiratory distress noted; Capillary refill < 3;
Skin is pink and warm; Lung sounds clear bilaterally; Abdominal is soft, round and non-distended; Bowel sounds active; Moves all
extremeties equally bilaterally; Nursed in L&D.

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):
Temp: 36.9oC (axillary)
Color: Pink

Jaundice
Skin: Clear

Pale

Stained

Resp: 42

Plethoric

Acrocyanosis

Mottles

Petechiae

Lanugo

Dry

Milia

Abrasions

Pressure marks

Ecchymosis
Rash

HR: 142

Vernix

Nevi

Respirations: Regular

Grunting

Shallow

Nasal flaring

Cry: Lusty

Weak

Head: Symmerty/shape

Molding

Mongolian spots

Abdominal

Sighing

Retracting

Other NA

Shrill

Caput succedaneum ISE mark

Cephalhematoma

Other NA

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
Skin tags

Abnormal

Flaring

Describe normal position: Symmetrical; in line with outer canthi of eye bilaterally

Nose: Symmetry

Patent: Left

Right

Eyes: (describe what you found)


Right

Left

Subconjunctival hemorrhage

Nevi on lids

Edema

Red reflex

Other

NA

NA

Mouth: Mucous membranes: Pink

Pale

Cyanotic

Teeth

Epsteins pearls

Hard palate: Intact

Soft palate: Intact

Abnormal NA
Abnormal NA

Symmetry +

Lips: Cleft Drooping

Anterior chest: Symmetrical + Shape Circular


Clavicles: Intact

Fracture NA

Breasts: Palpable tissue


Heart sound: RRR

Engorgement

Other NA

Genitals: Voided: Date 11/21/14

Time 2200 - 2300 Color of urine NA

Male: Urethral orifice: Normal position NA Abnormal (describe) NA


Testes (#/location) NA
Scrotum NA Pendulous NA Rugated NA Other NA
Female: Labia majora: Completely covers minora Partially covers minora
Labia minora protruding

Vaginal discharge + Hymenal tag

Posterior: Pilonidal dimple

Tuft of hair

Spinal column: Symmetry


Anal patency: Yes

Anterior Abd: Symmetry

Intact

Stool: Yes

Type: Meconium

Other NA

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: The newborns cheek was


touched and the newborn turned toward
the side that was stroked and began
sucking

When stroking the newborns cheek, the


newborn should turn toward the side that
was stroked and should begin to make a
sucking movement.

The newborn turns head toward the side that


was stroked and begins a sucking movement.

Sucking: The infants lips were touched


and the newborn opened her mouth and
began sucking

Either place a gloved finger in the


newborns mouth or touch their lips and
the newborn will open their mouth and
elicit a sucking motion.
Place the newborn on their back, support
the upper body weight of the supine
newborn by the arms using a lifting
motion without lifting the infant off the
surface and then release the infant; the
infant will startle and hands will curl to
form a c shape.
Hold the infant upright and forward with
the soles of his or her feet touching a flat
surface.

The infant elicits a sucking response on a


gloved finger or when lips are touched.

Grasp/hand: The infant grasped both of


my pointer fingers when placed in her
hands bilaterally

Placing a finger on the newborns open


palm. Attempting to remove finger will
elicit a stronger grasp.

The newborn should grasp the finger placed in


palm bilaterally.

Grasp/foot: The infants toes curled


around both my pointer fingers bilaterally

Placing a finger on the newborns sole by The newborn should grasp the finger placed in
the toes, the newborn should grasp the
sole of foot bilaterally.
finger with their soles bilaterally.

Moro: The infant was startled on her own


and made c-shape hands bilaterally

Stepping: The infant, while being held


with both feet on the padding in the infant
cart, brought both of her feet up and down
in a stepping/marching motion

(Ricci, 2009, 564-566)

The newborn will startle; its arms and legs will


spontaneously move and hands will make a c
shape bilaterally.

The infant should make a stepping or


marching/walking motion, alternating flexion
and extension with the soles of the feet.

What is your overall assessment and prognosis for this infant (do not say good):
Baby Girl Xs physical assessment noted the anterior and posterior fontanels were soft and flat; the sutures were approximated.
The infant was alert, calm and cooperative after being breastfed, arousing to sound and tactile. The infants eyes and ears are
symmetrical bilaterally, and the nose and mouth are symmetrical also. The infants heart rate and respiratory rate is within normal
limits for a newborn. The infant displayed positive reflex and neuromuscular tone is normal. Bowel sounds are active in all four
quadrants bilaterally; patient passed her first meconium stool and I changed her diaper. The infant voided earlier in the morning. Two
birthmarks noted above eye lids bilaterally. Skin is pink and dry. No lesions or rashes noted.

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
1. Effective breastfeeding
related to basic
breastfeeding knowledge

Necessary
Assessments/Interventions
1. Provide infant contact with mother
skin-to-skin and have infant nurse
within first hour of birth
2. Instruct proper positioning
3. Nurse 8-10 times in 24-hour period
4. Monitor stools and voids

2. Disturbed sleeping
pattern related to new
environment

1. Identify factors that may facilitate or


interfere with normal patterns.
2.

Rationale
Having the infant within the first hour of birth promotes
bonding and encourages milk production
Proper positioning is important for the infant to be able to
latch onto the breast and help to prevent nipple soreness
Nursing the infant 8-10 times in a 24-hour period
encourages milk production and provides adequate
nutrition for infant growth
Monitoring stools and voids allows parents and
physicians to ensure infant is getting enough nutrition
and fluids
Practice rooming-in by allowing mother and infant to
remain together for 24 hours a day (Shealy et. Al, 2005)
Follow a consistent bedtime routine
Bathe the baby at night
Read a book or sing lullabies
Keep a low-stimulation environment
Recognize signs the infant is tired such as rubbing eyes,
flicking the ears, or yawning and stretching often
(Davis, Parker & Montgomery, 2004)

3. Ineffective
thermoregulation related
to transition

1. Monitor skin color and temperature


2. Monitor for and report signs and
symptoms of hypothermia and
hyperthermia

3. Immediately after delivery, dry baby


and maintain warm body temperature
by skin-to-skin contact with mother

Place baby in gradient warmer


Move baby away from drafts and cold surfaces
Ensure babys head is covered with a hat and baby is
swaddled in blanket when away from warmer
Ensure skin-to-skin, also called Kangaroo Care, at least
one hour after birth of infant because benefits include
warmth, stability of heart beat and breathing, decreased
crying, increased weight gain, increased breastfeeding
and increased time spent in the deep sleep and quiet alert
states (American Academy of Pediatrics, 2014)
Maintain environmental temperature between 89.6 and
92.3OF in newborns room

References
About Skin-to-Skin Care (2014, August 20). In American Academy of Pediatrics. Retrieved November 27, 2014, from
http://www.healthychildren.org/English/ages-stages/baby/preemie/Pages/About-Skin-to-Skin-Care.aspx
Davis KF, Parker KP, Montgomery GL. 2004. Sleep in Infants and Young Children: Part One: Normal Sleep. Journal of Pediatric
Health Care. 18: 130-7. Retrieved from http://www.babycenter.in/a7654/establishing-good-sleep-habits-newborn-to-threemonths#ixzz3KKTi9QmI.
Ricci, S.S. (2009). Essentials of maternity, newborn, and women's health nursing. (3rd ed.). Philadelphia, PA: Lippincott, Williams and
Wilkins.
Shealy, K., Li, R., Benton-Davis, S., & Grummer-Strawn, L. (2005). The CDC Guide to Breastfeeding Interventions. In Centers for
Disease Control and Prevention. Retrieved November 27, 2014, from
http://www.cdc.gov/breastfeeding/pdf/breastfeeding_interventions.pdf