Briana Lytle

Newborn Assessment

5 December 2021
 Baby boy H was born on October 13th, 2021, at 7:28 AM at a gestational age of 39 weeks.

On the day of care, he was 48 hours old. He was small for gestational age weighing 5 pounds 8

ounces and 19 inches long. His APGAR scores were 9 and 9. The mother was planning on bottle

feeding and was pumping every few hours. They did not type and screen the baby because the

mother was A+. The mother was rubella non-immune, Hepatitis negative and the GBS was

unknown. The coombs test was negative, and the bilirubin level was 7.1. The mother said she

had only 8 prenatal visits. She said she didn’t start until after the first trimester and was between

doctors while moving to Ohio. The mother was 24 years old and was a G3T1P1A2L1. Baby boy

H was delivered via cesarean section due to placenta previa. There was no augmentation of labor

or assistive interventions of labor. The mother’s drug screen came back positive for marijuana

and opiates, but she denies the use of opiates. the mother denied use of over-the-counter

medications and there was no known exposure to TORCH, rubella, AIDS or hepatitis. The only

significant medical history related to labor is the development of placenta previa resulting in

cesarean section at 39 weeks. The mother denies any significant family medical history of

congenital abnormalities.

Baby Boy H upon assessment had a heart rate of 136, respirations were 44, and a

temperature of 97.7 degrees Fahrenheit. The baby’s head circumference was 31 cm, and the

chest circumference was 32 cm. the babies skin color is consistent with genetic background, and

slightly pink tinged. The skin is smooth and soft with good elasticity and milia present on the

face. The head had no molding due to it being a cesarean. The fontanels were open, flat, and soft.
The baby has very little hair, but it is silky. The neck appears short and freely movable. The face

is symmetrical with blue eyes and slightly edematous eyelids. Ears are symmetrical with pinna in

a straight line with the inner and outer canthus of the eye. The baby responds to sound with the

startle reflex. The nose is small flattened and narrow with symmetrical nares both appearing to

be patent. Lips are pink, symmetrical, and midline. The tongue is pink, moist and moves freely.

Hard palate is intact. The babies gag, sucking, swallow, rooting reflexes are all present.

Cylindrical chest, both sides of the chest move symmetrically & synchronously with abdomen

during respiration. There is protrusion of the xyphoid cartilage. The apical pulse is audible and

located lateral to mid-clavicular line at the 3rd intercostal space. The clavicle is straight and

intact without crepitus and the shoulders are symmetrical. The abdomen is soft and round and

seen moving on respirations with active bowel sounds. No discharge noted around umbilical

cord. Extremities are fully formed with full range of motion. They rest in a flexed position. Arms

are equal length and legs are equal length. No digits are missing, and all pulses are palpable. The

spine is flat and straight, and he buttocks is symmetrical. The baby has had 2 stools since birth.

The baby’s testes are symmetrical, and the family decided against circumcision. The baby voided

3 times while I was at clinical.

Before assessing the newborn, I reviewed the different systems and normal ranges for

each. It was difficult because this was my first newborn assessment on my own and I had very

little experience with babies. I think I did a decent job for it being my first time I just was a little

slow on my assessment time. I learned that it can be difficult to assess the baby’s breath sounds

because I kept hearing the heartbeat and it threw me off. I am now more confident in my

newborn assessment skills and with be more smooth and quick next time.

Nursing Diagnoses:
Risk for impaired fetal gas exchange

Risk for aspiration r/t cesarean section