ASSESSMENT AREA ASSESSMENT FINDINGS

I. General observation
A. Muscle tone Well-flexed; Active movements of arms and legs

B. Skin
1. Color Pink; no signs of central cyanosis, but with slight signs of peripheral
cyanosis

2. Texture Smooth and warm to touch

3. Turgor Fold of skin is elastic when grasped; fell back to form a smooth
surface after released
C. Cry Cried vigorously
II. Vital Statistics
A. Weight 3.3 kg
B. Length 51 cm
C. Head Circumference 33 cm
D. Chest Circumference 31 cm
E. Mid-arm Circumference 10 cm
F. Abdominal Girth 31 cm
III. Vital signs
A. Temperature 36.80C
B. Respiration 45 bpm

C. Heart Rate (Apical Pulse) 145 beats/min

ASSESSMENT AREA ASSESSMENT FINDINGS

IV. Head
A. Hair Brown and well-distributed
B. Scalp No lesions and bruising
C. Fontanelles
 Anterior 3x3 cm; Soft and not indented
Posterior 1 cm; small and palpable
D. Ears Normal alignment, patent canal
E. Eyes Red reflex present, no corneal cloudiness
F. Cheeks Milia present
G. Nose Midline septum, no drainage
H. Mouth No teeth, palate intact, midline uvula
V. Neck Lymph nodes non-palpable
VI. Clavicles Intact
VII. Chest
A. Breath sounds Rhonchi heard
B. Heart sounds No murmurs
C. Breasts Engorged breasts; witch’s milk present
VIII. Abdomen
A. Liver Palpable 1 cm, no masses
B. Spleen Palpable 1cm below left coastal margin
C. Kidneys Palpable and not enlarged
D. Femoral Pulses Strong and normal pulses
E. Umbilicus No signs of infection and separation

ASSESSMENT AREA ASSESSMENT FINDINGS

IX. Genitalia
A. Female
1. Labia little swollen and prominent labia major and clitoris
2. Vagina Thick, milky discharge present
3. Urethra Patent and no blockage
B. Male
1. Foreskin
2. Urethra
3. Scrotum
4. Testes
 X. Back
A. Spinal column Flat in the lumbar and sacral areas
B. Buttocks Mongolian spots present
C. Anus Patent and able to pass meconium
XI. Extremities
A. Upper
1. Arms Short and symmetrical
2. Palms Creases present
3. Fingers Complete, no extra fingers
B. Hips Abduct readily, both lie almost flat
C. Lower
1. Legs Bowed and short
2. Sole Flat; has many crisscross lines covering about 2/3 of foot
3. Toes Complete, no extra toes

ASSESSMENT AREA ASSESSMENT FINDINGS

XII. Reflexes
A. Blink Present and observable
B. Rooting Present and observable
C. Sucking Present and observable
D. Swallowing Present and observable
E. Extrusion Present and observable
F. Palmar Grasp Present and observable
G. Step (Walk)-in- Present and observable
Place
H. Placing Present and observable
I. Plantar Present and observable
J. Tonic Neck Present and observable
K. Moro Present and observable
L. Babinski Present and observable
M. Magnet Present and observable
N. Cross Present and observable
 Extension
J. Trunk Present and observable
Incurvation
K. Landau Not present
L. Deep Present and observable
Tendon

XIII. Behavioral States

XIV. Prioritized Nursing Diagnosis