Newborn Assessment

Antepartal risk factors (This will be obtained from the mother's chart!):
Gestational Age_37 6/7 Onset of Prenatal Care_within 1st trimester Maternal Blood type _B+_
Planned/Unplanned pregnancy _planned_Maternal Substance abuse_no___ Gestational
Diabetes__no____ Maternal Infections__no______ Abnormal US findings __no__________
Additional information _none__________________________________________________

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

Temp _36.9_ HR _120__ Respirations _28___ Blood glucose _NA___
APGAR Score: 1 min _8___ 5 min _9___ Resuscitation measures: _none________
____________________________________________________________________
Eye antibiotic _00:25__ (time) Vitamin K _00:25_ (time)
Nursed in L&D: Yes

Length _47cm___ Wt. _2.685K_

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 __36.6_ 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 __symmetric_ 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 _top of ears level with
outer canthus of eye___________
Skin tags ______

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

Left

Subconjunctival hemorrhage

____

____

Nevi on lids

____

____

Edema

____

____

Red reflex

__NA_

_NA__

Other

_NA__

_NA__

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 _cylinder shape, nipples present and located
properly, normal variation_____
Clavicles: Intact ___+_____Fracture _______________________________
Breasts: Palpable tissue __+___ Engorgement _____________
Heart sound: RRR __148bpm_ Other ________________________________

Genitals: Voided: Date __4/11__ Time __01:00__ Color of urine _clear, yellow______
Male: Urethral orifice: Normal position ___+____ Abnormal (describe) ___________
Testes (#/location) __descended_____________________________________________
Scrotum ___+__ Pendulous _____ Rugated _+____ Other ____________________
Female: Labia majora: Completely covers minora _NA__ Partially covers minora _NA__
Labia minora protruding _NA___ Vaginal discharge _NA___ Hymenal tag _NA___
Both genders: Anal patency: Y N

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)

_5____

___5__

Flexion creases

__+___

___+__

Palmar creases

__+___

__+___

Sole creases

__+___

_+____

Intact

Dislocated/subluxation

Hips:

Right

___+__

_NA___

Left

__+___

_NA___

Neuro-muscular: Tone: Normal __+___ Lethargic _____ Rigid _____ Tremors _

Reflexes:
Reflex: Describe what
you observed

Describe the procedure

Describe normal
responses

Rooting: infant turned head

Touch or stroke form side

Infant turns head to side

To side when touched

of mouth toward cheek

touched

Sucking: infant began

Place nipple or gloved

Infant begins to suck

sucking

finger in mouth, rub against

Moro: infant extended arms

palate
Let infants head drop back

Sharp extension and

out when head was dropped

approximately 30 degrees

abduction of arms followed

back

by flexion and abduction to

Stepping: infant placed one

Hold infant so feet touch

embrace
Infant lifts alternate feet as

foot down and picked the

solid surface

if walking

Grasp/hand: fingers curled

Press finger against base of

Fingers curl tightly

around my finger

infants fingers

Grasp/foot: toes curled

Press finger against base of

around my finger

infants toes

other foot up

Toes curl forward

What is your overall assessment and prognosis for this infant (do not say good):
Overall assessment vital signs such as temperature, pulses, and respirations are within normal
limits. Weight measurement is within normal limits. Length is slightly below normal limits.
Posture is considered normal in movements and flexion of extremities. Cry is lusty and strong.

Skin is pink with normal variations such as Mongolian spots. Head has normal findings with
sutures palpable, fontanel soft and flat, and hair. Ears have normal findings with alignment, wellformed and complete. Face has normal findings with symmetric appearance and movement. Eyes
have normal findings being symmetric, eyes clear, pupils equal and react to light. Nose has
normal finding with both nostrils open to air flow. Mouth has normal findings with gums and
tongue pink, normal size and movement, lips and palate intact. Feeding has normal findings with
good suck and swallow coordination and retains feedings. Neck and clavicles have normal
findings with short neck, turns head easily side to side, infant raises head when prone, and
clavicles intact. Chest has normal findings with cylinder shape, symmetric, nipples present and
located properly. Abdomen has normal findings being rounded, soft, bowel sounds present, skin
intact, three vessels in cord, clamp tight and cord drying, meconium passed within 12-24 hrs.
Male genitals have normal findings with testes within scrotal sac, rugae on scrotum, prepuce
nonretractable, meatus at tip of penis. Upper and lower extremities have normal findings with
equal and bilateral movement, correct number and ratio of fingers and toes, nails to ends of digits
or slightly beyond, and flexion and good muscle tone. Back has normal findings with no
openings observed or felt in vertebral column, anus patent, and sphincter tightly closed. Reflexes
within normal findings. Mom and baby are doing well. Mom and baby are bonding well. I expect
mom and baby will continue to thrive and be discharged within normal hours.

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

Ineffective thermoregulation
related to immature
temperature control and
decreased subcutaneous body
fat

to monitor newborn closely to maintain

temperature and prevent hyperthermia and
cold stress
Monitor axillary temperature at least
every 8 hours; more frequently for infants at
high risk Provide heat/warm the newborn
using incubators radiant warmer, swaddling,
and skin-to-skin contact. Maintain thermal
neutral environment and avoid situations that
might predispose the infant to heat loss such
as cool air, drafts, bathing, and cold bedding.
Provide antipyretics if temperature is too high.

Marinating temperature will help to prevent hyperthermia which

can cause respiratory issues as well as neurological issues in
neonates. Prolonged, unrecognized cold stress may divert
calories to produce heat, impairing growth. Neonates have a
metabolic response to cooling that involves chemical
(nonshivering) thermogenesis by sympathetic nerve discharge of
norepinephrine in the brown fat. This specialized tissue of the
neonate, located in the nape of the neck, between the scapulae,
and around the kidneys and adrenals, responds by lipolysis
followed by oxidation or re-esterification of the fatty acids that
are released. These reactions produce heat locally, and a rich
blood supply to the brown fat helps transfer this heat to the rest
of the neonates body. This reaction increases the metabolic rate
and O 2 consumption 2- to 3-fold. Thus, in neonates with
respiratory insufficiency (eg, the preterm infant with respiratory
distress syndrome), cold stress may also result in tissue hypoxia
and neurologic damage. Activation of glycogen stores can cause
transient hyperglycemia. Persistent hypothermia can result in
hypoglycemia and metabolic acidosis and increases the risk of
late-onset sepsis and mortality.(Hypothermia in Neonates)

Risk for infection related

to maturational factors
and immature immune
system

Risk for aspiration

related to immature gag
reflux

Monitor vital signs every

4hoursInstitute aseptic precautions,
especially handwashing, around infant.
Teach MOC to wash hands often,
especially before handling infant
or after changing her diaper
Teach mom to not allow sick friends or
family to interact with infant

Because the newborn has a limited ability to combat infection,

prevention is of utmost importance. (Murray, 2014, pp. 418-425)
If newborn comes into contact with an illness they may not be
able to fight it off and it could result in sepsis, or have other
complications that could affect brain development and mental
status for the infant.

Teach mom about proper feeding

positions. Teach mom to burp infant
while feeding. Teach mom about
nipple sizes and flows. Assess to see if
infant has a good latch.

Teaching mom about proper feeding positions such as elevating

babies head while being fed, will help to decrease gag reflux and
aspiration of food. If baby is laying down too far it could cause
their gag reflux to be triggered. Teach mom to burp infant during
feedings, because a burp that is caught may cause baby to
aspirate the food. Teach mom about nipple sizes and flows
because the bigger nipples might be too big for baby causing the
nipple to go too far back in the mouth triggering gag reflux. Also
if the flow is too fast for the infant it can also stimulate the gag
reflux causing aspiration. You also want to check for a good
latch, because it could effect the babies ability to swallow food
and trigger gag reflux. You want to be sure to avoid aspiration,
because the contents, when aspirated could travel to newborns
lungs causing an infection.

References
Hypothermia in Neonates. (20155, January 1). Retrieved April 18, 2015, from
http://www.merckmanuals.com/professional/pediatrics/perinatal-problems/hypothermia-in-neonates
Murray, S., & McKinney, E. (2014). Foundations of maternal-newborn and women's health
nursing (6th ed., pp. 418-425). Saunders.