Mackenzie Hawk

2-11-20
St. Joseph- Warren
Tuesdays 7a-1p

Physical and Gesta onal Age Assessment of the Newborn

Date and Time of Birth: 2-9-2020 at 14:54 Sex: Male

Infant’s age: 41 hours Gesta onal Age: 39 weeks AGA
APGAR scores: 9/9 Feeding: Breast
Maternal Blood Type: A posi ve Prenatal Care: 18 visits
Mother’s Age: 19 G: 3 T: 0 P: 0 A: 2 L: 0
Type of Delivery: vaginal- induced
Length of Labor: (1) 14.5 hrs (2) 24 min (3) 3 min
Augmenta on of Labor: ar cial ROM and IV Pitocin
Assis ve interven ons: midline episiotomy w/ repair and epidural for pain management
Maternal History
Maternal Use of Alcohol or Street Drugs: marijuana during pregnancy
Maternal Use of prescribed Meds: aspirin and penicillin V
Maternal Exposure to AIDS, Hepa s, Rubella, TORCH: rubella nonimmune, RPR nonreac ve,
HIV nega ve
Signi cant Medical History: history of chlamydia, PTSD, depression and anxiety, GBS posi ve
(and treated x5), hidradeni s suppura va
Familial history: thyroid issues, heart disease, asthma, hypertension, anemia, pancrea c cancer,
diabetes mellitus, brother is au s c
Addi onal Factors: teenage mother and father, mother fell down the stairs at 27 wks pregnant

Neonatal Assessment

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 Vital Signs: Temp- 97.9 F axillary Apical Heart Rate- 124

Respira ons- 50 Blood Pressure N/A
Measurements: Chest circumference- 32.5 cm
Head circumference- 35 cm
Weight- 7lb 5 oz
Length- 20 in
Skin: Color appropriate for ethnicity, generalized erythema, and good turgor noted. Small
amount of lanugo present on shoulders and back. Stork bite to le eye, milia present on nose.

Head: Adequate size, sutures appropriate with no overlapping. Fontanels so , open, and correct
shape. Hair lies at with silky texture.

Neck: Appropriate ROM, some head control with appropriate head lag. Can turn head from side
to side.

Face: Facial features symmetrical, ears well formed with fast recoil. Responds to surrounding
noises such as other baby cries. Breathes through patent nares w/ no discharge noted. Lips and
tongue pink and moist, hard palate intact. Roo ng, sucking, and swallow re exes intact.

Trunk and Chest: Torso normal shape and symmetrical. Breast buds present. Apical pulse
auscultated w/ no murmurs or extra sounds. Regular rate and rhythm. Breath sounds clear
through all elds. Clavicles straight and intact, without crepitus or apparent pain upon
palpa on.

Abdomen: So , rounded and symmetrical w/ movements upon respira ons. Bowel sounds
ac ve. Umbilicus clean and dry w/ no umbilical hernia present.

Extremi es: Fully formed, all digits present w/ formed nails. Maintains exion. All pulses
palpable. Hands and feet covered with creases.

Hips: Femoral pulses palpable. No disloca on noted. Abduc on of thighs >60 degrees.




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 Spine: Straight, at, vertebrae intact. No horizontal shi of alignment.

Posture: Vertex posture with arms and legs in moderate exion.

Genitals: Both testes present, descending into scrotum. Scrotum covered with rugae and
symmetric. Circumcised on 2/11/20 at 0730. Voids: 2

Bu ocks/Anus: Anus patent and midline; present “wink” re ex. Stooling appropriately since
birth. Stools: 3

Neuromuscular: Strong, symmetric movement bilaterally. Moro, tonic neck, palmar and plantar
grasp, Babinski, blink, gag, cough, sneeze, roo ng, sucking, swallow re exes all well developed.

Sensory Abili es: Passed hearing test, gazes occasionally when awake, and soothed by touch
and cuddling.

Behavioral Pa erns: Pt is breas eeding well. Has wakeful periods every 3 to 4 hours. Cry is
strong and indicates hunger, pain/discomfort, or a en on seeking. Responds well with soothing
voice, cuddling, or food.

Laboratory Values:
Hgb: [15-20] Bilirubin: [about 6-12] 7.4 (41 hrs old)
RBC: [4.1-7.5] Blood glucose: [40-97] 54
Hct: [43-61] Urine: pale, acidic, low spec gravity
Ballard Score- Matura onal Assessment of Gesta onal Age
Neuromuscular Maturity
Posture: 3
Square Window: 3
Arm Recoil: 4
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 Popliteal Angle: 5
Scarf Sign: 3
Heel to Ear: 3
TOTAL: 21
Physical Maturity
Skin: 3
Lanugo: 2
Plantar Surface: 4
Breast: 3
Eye/Ear: 3
Genitals: 2
TOTAL: 17
Total Es mate of Gesta onal Age: 38 weeks Actual Gesta onal Age: 39

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