NEWBORN NURSERY OBSERVATION SHEET

Describe
Birth Date: Skin Sex:

Textbook Information:
Complete PRIOR to clinical

Infant Observations:
Completed in nursery day of clinical

Birth Weight:

Color: inspect and palpate: inspect seminaked newborn in well-lit, warm area without drafts; natural daylight best (when quiet and alert)

Evidence of jaundice Texture: inspect and
palpate for intactness, smoothness, texture, edema, pressure points

Posture & Body Movement

Observe for birthmarks or bruises: Inspect and palpate for location, size, distribution, characteristics, color, if obstructing airway or oral cavity Normal Variations: Mongolian spot (bruising on back at buttocks) in AA, Asian, and NA. Variations/Possible Problems: Capillary hemangiomas; Nevus flammeus: portwine stain; Nevus vasculosus: strawberry hemangioma; Cavernous hemangioma AVG Findings: Generally pink varying with ethnic origin; Acrocyanosis (blue extermities) Normal Variations: Mottling (blotches), Harlequin sign, Plethora, Telangiectases, Erythema toxicum neonatorum, Milia, Petechiae, Ecchymoses, Birthmark Variations/Possible Problems: Dark red (preterm, polycythemia), Gray (hypotension, poor perfusion), Pallor (CV problem, CNS damage, blood dyscrasia, blood loss, twin-to-twin transfusion, infection), Cyanosis (hypothermia, infection, hypoglycemia, cardiopulmonary diseases, neurologic, or respiratory malformations), Gen. Petechiae (clotting factor deficiency, infections), Gen. Ecchymoses (hemorrhagic disease) AVG Findings: None at birth Normal Variations: Present in up to 60% of term infants in 1st week of life Variations/Possible Problems: Present within 1st 24hrs (increased hemolysis, Rh isoimmunization, ABO incompatibility) AVG Findings: Eyelid edema, Opacity Normal Variations: Slightly thick, superficial cracking, peeling of hands or feet, Some fingernail scratches Variations/Possible Problems: Edema on hands/feet, Pitting over tibia, periorbital (overhydration, hydrops), Texture thin, smooth, or of medium thickness; rash or superficial peeling visible (preterm, posterm), Texture thick (posterm), Skin tags, webbing, Papules, pustules, vesicles, ulcers, maceration (impetigo, candidiasis, herpes, diaper rash) AVG Findings: Vertex: arms, legs in moderate flexion; fists clenched; Resistance to having extremities extended for examination or measurement, crying possible when attempted; Cessation of crying when allowed to resume curled-up fetal position (lateral); Normal spontaneous movement bilaterally asynchronous (legs flex and extend in alternating fashion) but equal extension in all extremities Normal Variations: Frank Breech: legs straighter and stiff, newborn assuming intrauterine position in repose for a few days; Prenatal pressure on limb or shoulder possibly causing temporary facial asymmetry or resistance to extension of extremities Variations/Possible Problems: Hypotonia, relaxed posture while awake (preterm or hypoxia in utero, maternal medications, neuromuscular atrophy); Hypertonia (CNS disorder, chemical dependent); Limitation of motion in any of extremities

constricted.almost brown underneath. tumor) Term Newborns: 2. jerky. blink: AVG Finding – blink reflex Normal Variations – edema if eye prophylaxis instilled Assess for discharge: AVG Finding . Sunset (increased intracranial pressure) AVG Findings: Blink Reflex. and brown are usually VERY dark grey.if they are going to stay blue.Quiet alert . thrombus.Describe .. watch their parents’ faces.Asleep . dilated. and respond to people talking to them Signal hunger. movement. No tears Normal Variations – Some discharge or tears Variations/Possible Problems – purulent discharge (infection). retinoblastoma [cat’s eye reflex]).. following to midline Normal Variations: Transient strabismus or nystagmus until 3-4 months Variations/Possible Problems: Persistent strabismus.Color . discomfort. Most caucasions are born with blue. Possible problems: lens opacity or absence of red reflex (congenital cataracts. or fussiness.. Bounding Infant Observations: Completed in nursery day of clinical Eyes . Doll’s eyes (increased intracranial pressure).Crying Textbook Information: Complete PRIOR to clinical Newborns readily assumes in utero position – refer to maternal chart for fetal presentation Smile.None. desire for attention. chemical conjunctivitis from eye med is common... This only an average. fixed (intracranial pressure. Lesions: coloboma.to go to just brown!!! (but again. open eyes wide in dark. absence of part of iris (congenital). move in synchrony with speech. Duration is highly variable.. PERRLA Variations/Possible Problems: Edema if eye prophylaxis drops or ointment instilled. posterior tibial AVG Finding: equal and strong Variations/Possible Problems: Weak or absent (decreased CO. jaundiced sclera (hyperbilirubinemia) AVG Findings: Random.. brachial.Epicanthal folds when present with other signs (Downs. Pupils unequal. vocalize. sensitive to light. cri-du-chat) Check for symmetry in size/shape Check eyelids for size. possible coarctation of aorta if weak on left and strong on right).Ability to see Vital Signs . requires no tx Normal Variations: subconjunctival hemorrhage. possibly from rubella.Coordination . eyes will follow light…5 Days: black/white patterns…2 Months: Color Peripheral Pulses: femoral. it depends on ethnic background) By 6-12 months eyes will take their pigment on. 5min-2hrs Check for placement on face: AVG Finding – eyes and space between eyes each 1/3 the distance from outerto-outer canthus Normal Variations . popliteal. pink color of iris (albinism).5ft. uneven focus possible briefly.darker blues usually go to hazel or green.Epicanthal folds in some ethnicities Variations/Possible Problems . they will be lighter blue at birth. pain.. medications. to blue brown color.

inadequate clothing. grunting. retractions. maternal analgesics possibly reducing thermal stability in newborn) AVG Findings: Visible pulsations in left midclavicular line. Apical pulse in 4th intercostal space 120-140 bts/min.Respirations . No adventitious sounds audible on insp/exp. Stabilization (1-2 days): 30-40 breaths/min. proximity to heating unit or in direct sunlight. radiation Variations/Possible Problems: Subnormal (preterm birth.Heart Rate . S4. Heat loss from evaporation. Murmur. low environmental temp. Bradycardia: persistent <80 bts/min (congenital heart block.2C. Quality – S1 and S2 sharp and clear Normal Variations: 80-100 bts/min (sleeping) to 180 bts/min (crying). Murmur. Crackles (fine) Variations/Possible Problems: Apneic episodes: >20 sec (preterm infant: rapid warming or cooling of infant. conduction.Regularity Best observed by: Observing at rest . dehydration). CNS or blood glucose instability). Breath sounds: Crackles (course). chemical dependence. Temp not stabilized by 6-8hr after birth (if mother received mag sulfate.Rate . 5th intercostal space. stabilized by 8-10hr of age Normal Variations: 36. S3. Bradypnea: <25 breaths/min (maternal narcosis from analgesics or anesthetics. Tachypnea: >60 breaths/min (RDS. labored breathing. rhythm. wheezing. excessive clothing. Expiratory grunt (narrowing of bronchi). possibly irregular for brief periods. Crackles may be heard after birth. Tachypnea: >60 breaths/min (RDS. First Period: 50-60 breaths/min. bronchial: loud. Bradypnea: <25 breaths/min (maternal narcosis from analgesics. infection.Describe Textbook Information: Complete PRIOR to clinical AVG Findings: Axillary: 37C. Increased (infection. newborn less able to conserve heat by vasoconstriction. periodic breathing. and depth when infant is awake. Stridor (upper airway occlusion) AVG: 40 breaths/min Normal Variations: 30-60 breaths/min Variations/Possible Problems: Apneic: >20 sec (preterm. Sounds: distant. transient tachypnea of the newborn. poor quality. distress or apnea (>20sec). Second Period: 50-70 breaths/min. especially after crying. CNS or blood glucose instability. pneumonia). Breath sounds. rhonchi. birth trauma). rhythm. Short periodic breathing episodes and no evidence of resp.5-37.Temperature . diarrhea and dehydration). maternal lupus). clear Normal Variations: 30-60 breaths/min. and depth when infant is awake Infant Observations: Completed in nursery day of clinical . especially over base or at left sternal border in interspace 3-4 Variations/Possible Problems: Tachycardia: persistent >180 bts/min (RDS. high environmental temp. Arrhythmias: irregular rate. Heart on right side of chest (dextrocardia). birth trauma). congenital diaphragmatic hernia). Distress evidenced by nasal flaring. cong diaphragmatic hernia AVG Finding: Tendency to be shallow and irregular in rate. tendency to be shallow and irregular in rate. often accompanied by reversal of intestines AVG Findings: 40 breaths/min. convection.

persistent response is sign of an abnormality Umbilical cord Circumcision Stools Moro reflex (startle): with infant on flat surface. abrupt noise Tonic neck reflex: with infant in supine neutral position. (turn head to right and extremities assume opposite position. phototherapy) Characteristic Response: Symmetric abduction and extension of arms. Redness/drainage (infection). flat. hydrocephaly. Bleeding/oozing (hemorrhagic disease). Within 24 hrs becomes covered with yellow exudate. if so apply pressure. breech presentation. Frequent/watery (infection. 1 vein. Hernia: herniation of abd contents through cord opening. cesarean birth) Variations/Possible Problems: Severe molding (birth trauma). turn head to one side . Large. Molding Normal Variations: Slight asymmetry from intrauterine position. whitish gray. smaller than anterior Normal Variations: Same as Anterior Variations/Possible Problems: Same as Anterior Infant Observations: Completed in nursery day of clinical Yes AVG Findings: ¼ of Body of Length. hemorrhage. Legs may follow similar pattern. Response is present at birth-8wks. Depressed (dehydration) AVG Findings: Triangle. clavicle. or humerus.8cm Variations/Possible Problems: circumference less than or equal to 4cm less than head = infection AVG Findings: 2 arteries. bulging (tumor. Lack of molding (preterm. Normal/not infection! Use only water to clean. possibly extensive Check for bleeding. AVG Findings: meconium followed by transitional and soft yellow stool Variations/Possible Problems: No stool (obstruction). cord clamp in place for 24hr Normal Variations: Reducible umbilical hernia Variations/Possible Problems: 1 artery (renal anomaly). opposite arm and leg flex. Response disappears by 3-4mo After 6wk. arms are adducted in embracing motion and return to relaxed flexion and movement. Difficulty in feeling fontanels possible because of molding Variations/Possible Problems: Full. Asymmetric response may connote injury to brachial plexus. followed by cry. defect covered with thin. Responses in leg are more consistent. drying.Describe Anterior fontanel Posterior fontanel Are they open? Head circumference Chest circumference Textbook Information: Complete PRIOR to clinical AVG Findings: 5cm diamond increasing as molding resolves Normal Variations: Variation in fontanel size with degree of molding. arm and leg on that side extend. Persistent response after 6mo indicates possible neurologic abnormality such as CP. hypothyroidism). infection). make a loud. no intestinal structures within cord. delayed bone age. soft (malnutrition. Indentation (fracture from trauma) Head and Chest are the same for first 1-2 days after birth AVG Finding: 33-35cm Normal Variations: 32-36. friable membrane. Characteristic Response: With infant facing left side. demarcation between cord and skin. odorless. fingers fan out and form a C with thumb and forefinger. dry around base. Meconium stained (intrauterine distress).

Frequently noted in ethnic origins. Malpositioned or widely spaced Term: Pinnia is firm. Preterm-walk on toes Response is normally present for 3-4wk. Normal Variations: No molding (preterm. Soft and flat. 3-10mm. symmetrically placed. Nipples: supernumerary along nipple line. AVG finding. breech) Variations/Possible Problems: Severe molding (birth trauma). Collection of blood between a skull bone and its periosteum that does not cross a cranial suture line (from forceps) Infant Observations: Completed in nursery day of clinical Grasp reflex Molding of the head Caput succedaneum Milia Mongolian spots Erythema toxicum Acrocyanosis Cephalhematoma Subconjunctival hemorrhage Breast tissue Ear cartilage resilience Sole creases Nails Red blotch on sclera Term: Nodule approx 6mm. Well lined (wrinkled). allowing one foot to touch table surface Textbook Information: Complete PRIOR to clinical Characteristic Response: Infant will simulate walking. The skull appears large and heavy. stands away from head and springs back quickly. Palmar: place finger in palm in hand Characteristic Response: fingers curl around examiner’s fingers Plantar: place finger at base of toes Characteristic Response: toes curl downward Face appears small in relation to the skull. Neonates-no nails. Indentation (fracture from trauma) Edematous area of scalp (from vacuum extraction) Milk bumps Bluish black areas of pigmentation commonly found on back or buttocks.Describe Stepping reflex: hold infant vertically under arms or on trunk. well formed. cesarean. Transient rash last approx. Term-walk on soles. Requires no tx Bluish color in extremities (arms. Post-term-past fingertip . 3wks. Over 2/3 of foot in term infants. Normal and appears intermittently over the first 7-10 days. Nipples prominent. especially with exposure. slightly curved with slow recoil. alternating flexion and extension of feet. Normal Variations: Nodule approx. secretion of witch’s milk Variations/Possible Problems: Lack of breast tissue. legs). Curves over time and become thick cartilage.

Hypertonia (chemical dependence. maternal medications. Refer to maternal chart for fetal presentation. fused labia Labia majora: edematous. crying possible when attempted. relaxed posture while awake (preterm or hypoxia in utero. covered with rugae. Resistance to having extremities extended for examination or measurement. central nervous system [CNS] disorder). Cessation of crying when allowed to resume curled-up fetal position (lateral). edematous. Normal spontaneous movement bilaterally asynchronous (legs flex and extend in alternating fashion) but equal extension in all extremities. Some vernix caseosa between labia possible Labia. noncommunicating Variations/Possible Problems: Scrotum smooth and testes undescended (preterm. scrotum Rugae (wrinkles):large. legs in moderate flexion. Prenatal pressure on limb or shoulder possibly causing temporary facial asymmetry or resistance to extension of extremities. Full range of motion. symmetric contour Normal variations: feet appearing to turn in but can be easily rotated externally. Limitation of motion in any of extremities. positional defects tending to correct while infant is crying Possible Problems: increased tonicity. absence of vaginal orifice Labia minora: protrusion over labia majora Normal Variations: Blood-tinged discharged. Hydrocele. surgical). Elbow crosses the chest to the opposite shoublder midline without any resistance. clonus. absent scrotum. clitoris Head lag Total head lag normal in newborn. position. Enlarged clitoris with urinary meatus on tip. covering labia minora Normal Variations: Edema and ecchymosis after breech birth Variations/Possible Problems: Widely separate and labia minora prominent (preterm). and type of birth (vaginal. Virilized female-extremely enlarged clitoris. Normal Variations: Increased pigmentation by pregnancy hormones Variations/Possible Problems: Ambiguous genitalia (not well distinguished from enlarged clitoris). pendulous in term. micropenis. newborn assuming intrauterine position in repose for a few days. Bifid scrotum. Textbook Information: Complete PRIOR to clinical AVG Findings: Vertex: arms. Normal Variations: Frank breech: legs straighter and stiff. fists clenched. Hydrocele.Describe Posture: inspect newborn before disturbing for assessment. Normal Variation: Scrotal edema and ecchymosis if breech birth. Testes: palpable on each side Normal Variation: Bulge palpable on inguinal canal Variations/Possible Problems: Undescended (preterm) Infant Observations: Completed in nursery day of clinical Scarf sign Testes. cryptorchidism). Possible Problems: Hypotonia. Inguinal hernia Clitoris: edematous. prolonged tremors (CNS disorder) Ankle & wrist . small. since newborn readily assumes in utero position. neuromuscular disorder such as spinal muscular atrophy).

Abundent (preterm) Infant Observations: Completed in nursery day of clinical Weeks: Circle which one you think fits 90%+ 10-90% -10% LGA AGA SGA Labs: Hgb. Blood Glucose Serum Bilirubin Blood Type/RH 14-24 g/dl 44-64% Term Newborn: 50-60 mg/dl 3 Days: 60-70 mg/dl 5 mg/dl = jaundice (jaundice beyond 7-10days requires further investigation) .Describe Lanugo Estimate gestational age Describe any abnormalities observed in newborn nursery Textbook Information: Complete PRIOR to clinical AVG Finding: Over shoulders. pinnae of ears. Hct. forehead Normal Variations: Variation in amount Variations/Possible Problems: Absent (postterm).

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