COLEGIO SAN AGUSTN-BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

NURSING PROGRAM

OBSERVATIONAL CASE STUDY FOR THE NEWBORN

I. DATA OF THE NEWBORN

Name : Type of Delivery: Obstetrician:
Date of Birth: Type of Feeding:
Sex : Length of Pregnancy:
Time of delivery: Mother’s Name:
Apgar score : Pediatrician:

II. POINTS TO BE NOTED: (provide description of observation/findings)

A. Posture/Body Alignment and Symmetry
1. Sleeping
2. Crying
B. Eyes of the Newborn
1. First open
2. Color
3. Eye movements
4. Tears first shed
C. Behavior characterizing crying
D. Skin/Birth Marks
1. Mongolian spot
2. Mole
3. Strawberry marks
4. Lanugo
5. Physiologic Jaundice
E. Head
1. Size in relation to the rest of the body
2. Size compared to that of adult
3. Shape compared to that of adult
4. Size and shape of: a. Anterior fontanels b. Posterior fontanels
F. Extremities
1. Arms 3. Legs
2. Hand 4. Feet
G. Trunk
1. Neck 3. Abdomen
2. Chest 4. Back
H. Respiration
I. Pulse rate
J. Temperature
K. Evidence that the newborn can or can’t
1. See (vision)
2. Hear (hearing)
3. Feel (touch)
4. Taste
5. Smell
L. Umbilical Cord
M. Measurement of: a. Length b. Weight c. Head circumference
 N. Reflexes that are present at birth
1. Rooting reflex
2. Sucking reflex
3. Swallowing reflex
4. Extrusion reflex
O. Protective reflex
1. Blinking reflex
2. Coughing reflex
3. Sneeze
4. Yawn reflex
P. Reflexes which test spinal cord integrity
1. Magnet reflex
2. Cross extension reflex
3. Trunk-Incurvation reflex
Q. Other reflexes
1. Palmar grasp reflex 4. Tonic neck reflex or Fencing reflex
2. Plantar grasp reflex 5. Moro or Startle reflex 7. Landau reflex
3. Darwinian reflex 6. Babinski reflex
III. REFERENCES