Madison Scrocco 1

Newborn Health Assessment

Date of Birth: 9/23/2019 Time of Birth: 0117 M/F: male Infants Age (hrs): 32 hrs old
Gestational Age: 39 weeks SGA/AGA/LGA: AGA APGAR: 7/9
Feeding: bottle fed- Similac advanceBlood Type: A+ Coombs Test: negative
Maternal Blood Type: A+ Prenatal Care Visits: 16 Mother’s Age: 32 yo
G: 5 T: 5 P: 0 A: 0 L: 5 Delivery: spontaneous vaginal
Augmentation of Labor: Pitocin administration (IV) Assistive Interventions: none
Length of Labor-- Stage 1: 10hr 35min Stage 2: 12min Stage 3: 10min
Maternal use of Substances: none
Maternal use of OTC Medications: prenatal vitamin-- Fe fumarate PO
ondansetron (Zofran)-- 4mg tablet Q8h PRN for nausea
glyburide (Glynase)-- 5mg QD PO
vitamin B-6 (Pyridoxine)-- 100mg QD PO
Maternal exposure to AIDS, Hepatitis, Rubella, TORCH: none
Significant medical/obstetric history: gestational diabetes, posterior shoulder dystocia
Familial history of congenital anomalies, metabolic health deviations: none
Additional factors affecting fetal growth and development: single mother with a good
support system in place

Physical Assessment
VITAL SIGNS
Temperature: 99.9 Pulse: 140 Respirations: 44 Blood Pressure: 78/41

MEASUREMENTS
Length: 49.5cm Weight: 9lbs 3oz Head Circumference: 37.5cm
Chest Circumference: 32cm

SKIN
Appropriate color for ethnicity; no rash/petechiae; slight discoloration of the face, bruise noted
on forehead; skin smooth, warm, dry; turgor elastic; scant lanugo covering shoulders and back;
vernix caseosa noted only in the creases of the skin.

HEAD
Sutures mobile; fontanels open and soft; minimal cephalohematoma noted to the right of the
suture line; hair silky and in single strands.

NECK
Creases apparent; neck supple; freely movable; symmetric.
FACE
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Symmetric in shape and movement; eyes symmetric, blue-grey color, sclera white, corneas clear
with no opacities, eyelids symmetric in size and movement, pupils equal and reactive bilaterally,
eyebrows distinct; ears well positioned and straight with outer canthus of eyes, soft and pliable,
pinna well formed, turns head towards sound; nose small, preferential nose breather, nares patent
bilaterally, no discharge; mouth lips pink and symmetric, tongue pink and moist, moves freely,
hard palate intact, oral mucosa pink and moist, gag, sucking, swallowing, and rooting reflexes
intact.

TRUNK AND CHEST

Nipples well formed and well spaced; cylindrical shaped chest; breath sounds clear to
auscultation; respirations unlabored; symmetric bilateral chest rise that moves synchronously
with abdomen; apical pulse/S1 and S2 audible at 4th intercostal space left of the midclavicular
line; heart rate and rhythm regular; clavicle straight and intact without crepitus; shoulders
symmetric.

ABDOMEN
Soft, rounded, non-tender to light palpation; abdominal respirations synchronized with chest
expansion; umbilical stump clean and dry.

EXTREMITIES
Fully formed, correctly placed, with full range of motion and freely movable; well perfused with
brisk capillary refill; arms and legs of equal length; brachial, femoral, and pedal pulses strong
and equal bilaterally; soles of feet covered with creases; all digits present and distinct; hips
freely movable, negative Ortolani’s maneuver, gluteal folds symmetric; spine midline and
straight, flat, freely movable, no tuft of hair or dimple on lower back, closed vertebral column
with intact vertebrae; posture vertex with extremities in moderate flexion, fists clenched.

BUTTOCK/ANUS
Gluteal folds symmetric; anus patent with rectal temperature; wink reflex intact; meconium
passed within 24hrs.

GENITALS
Symmetric scrotum covered with rugae; both testicles descended; scant hydrocele noted;
correctly placed urinary meatus.

ELIMINATION
Urination infant is having 3 wet diapers/day; stools meconium passed 9/23/2019 at 1530, infant
has since had two stools/day.
NEUROMUSCULAR
Easily aroused; motor with generalized flexion, full range of motion, strong and symmetric tone
and strength, head lag present; reflexes well developed, well coordinated, intact, moro, tonic
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neck, palmar and plantar grips, babinski, blink, gag, cough, sneeze, rooting, suck and swallow all
present.

SENSORY ABILITIES
Hearing infant can move eyes in response to sound; vision infant can gaze gently, limited
accommodation; touch infant is soothed by warmth, cuddling, and swaddling.

BEHAVIORAL PATTERNS
Feeding: variations in interest and hunger; bottle feeds well
Sleep-wake cycles: wakeful periods every 3hrs
Social: cry is strong and medium pitched; cry indicates hunger, pain, or attention seeking;
increased alertness to soft, high pitched voices

Laboratory Values

Test Normal Value Results Reason

Hemoglobin 15-20g/dL

Hematocrit 43-61%

RBC 4.1-7.5ml/dL

Bilirubin 4-6mg/dL 11.5 Immature liver

Blood Glucose 40-97mg/dL 58

Urine Pale, acidic, low SpG

Gestational Age Assessment

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The newborn I assessed was 32 hours of age when I completed the Ballard Score. He
was a caucasian male weighing 9lbs 3oz at birth with a length of 49.5cm and a head
circumference of 37.5cm. At 1 and 5 minutes, his APGAR’s were 7 and 9 indicating an easy
transition into extrauterine life.
In terms of neuromuscular maturity, this newborn was resting in general flexion. The
square window of his wrist was 30 degrees, and his arm recoil was a full 90 degrees. His
popliteal angle was 90 degrees, his scarf sign showed his elbow at a 90 degree angle with his
forearm across his stomach, and his heel to ear brought his knees to his chest with his knee
flexed at less than a 90 degree angle. Overall, the neuromuscular maturity score for this newborn
was a 23/25.
In terms of physical maturity, his skin was the consistency of parchment paper with deep
cracking but no visible vessels, and he was mostly bald regarding his lanugo. Plantar creases
covered the soles of his feet entirely, and his areolas were symmetric bilaterally measuring at
5mm. This newborn opened his eyes to stimuli, and his ears were formed and firm with instant
recoil. Lastly, his scrotum has visible rugae and descended testicles. Overall, the physical
maturity score for this newborn was a 22/25.
When adding the neuromuscular and physical maturity scores together, this newborn
scored a total of 45/50 points on the gestational age assessment. A score of 45 correlates with a
baby born at 42 weeks gestation; however, based on our mothers’ last menstrual period and
ultrasounds, this newborn was 39 weeks gestation at birth.

Student Self-Growth
In preparation for this assessment, I had to review my instructor how to complete the
Ballard Gestational Age Assessment correctly. It was not difficult to complete the full
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assessment on this particular newborn because he was in a quiet and alert state. The entire
assessment did not take nearly as long as figuring out how to correctly document all of my
findings and put it into words. I feel that my performance was satisfactory what with my limited
skill set and basic knowledge of Obstetrics and newborn health. Although our assessment skills
play a vital role in our profession, this assignment taught me that documentation may be even
more important than that. While it is true that documentation is a time consuming part of our
job, it is also our main form of communication between other health care professionals and
health care providers. As the youngest in my family, I have not been around newborns or infants
very much in my life. Coming into this clinical I was very nervous to interact with such small,
fragile patients. So in terms of personal growth, this assignment helped me to become much
more comfortable with assessing newborns. As for professional growth, I feel that my
documentation skills and communication with colleagues has improved greatly.