POSTPARTUM ASSESSMENT TOOL

NEWBORN

Student’s Name: Year/Section/Group: BSN-2C GROUP 3

Name: Patient X Age: 16 days Sex: Female

Date and Time of Delivery: 10/25/22 @11:29 PM Method of Delivery: Cesarean Section

I. ANTHROPOMETRIC MEASUREMENTS

AT BIRTH ON THE DAY OF ASSESSMENT

Weight: 2.865 kgs Weight: 3.28 kgs

Length: 49 cm Length: 50 cm
Head Circumference: ___________ cm Head Circumference: 34 cm
Chest Circumference: ___________ cm Chest Circumference: 32 cm
Abdominal ___________ cm Abdominal 32 cm
Circumference: Circumference:

a) Weight
– Average Weight: 2.5 – 3.5 kgs.
– 4 – 7 kg. – suspect maternal illness such as DM.
– 5 – 10% loss of BW during first few days after birth because the newborn is no
longer under the influence of salt and fluid-retaining maternal hormones.
– additional weight loss during 2nd-3rd day of life as diuresis begins to remove a part
of their high fluid load.
– newborn voids and passes stool (approximately 75 – 90 % of the newborn’s
weight is fluid.
– regain BW within 10 days (breastfeeding) or within 7 days (milk formula).
– gains weight at about 2 lbs / month (6-8 oz / wk) for the first 6 months of life

b) Length
– 46-54 cms (rarely 57.5 cms)
– for mature female (53 cm / 20.9 in)
– for mature male (54 cm / 21.3 in)
 c) Head Circumference
– 33 – 35 cms (37 and above should be carefully investigated for neurologic
impairment)
– tape measure is drawn across the center of forehead and around the most
prominent portion of occiput
Note: BW, length, and HC should fall within the same percentile for the same child.
Weight and height are 50 % and head circumference is 90 % will have normal head
growth. Weight and head circumference is 50 % and height is 30 – 35 % will have
growth problem.
d) Chest Circumference
– should be 2 cms (0.75 to 1 inch) less than HC
– measured at nipple line – if edema is present: measurement will not be accurate
until the edema subsides.
II. APGAR SCORE

- A rating method used to assess a neonate’s well-being: 1 minute and 5 minutes after birth.

SIGN 0 1 2
Heart Rate Absence Slow (< 100) >100
Respiratory Effort Absence Slow, irregular Good strong cry
weak cry
Muscle Tone Flaccid Some flexion of Well flexed
extremities
Reflex Irritability
– Response to catheter in No response Grimace Cough or sneeze
nostril
No response Grimace Cry & withdrawal
– Slap to sole of foot of foot
Color Blue, pale Body normal Normal skin
pigment, coloring
extremities blue

Interpretation:

Score of 7 – 10 is considered good.

4 – 6 means the neonate’s condition is guarded and may need airway clearance
and supplemental oxygen.
under 4 means the neonate is in serious danger and needs resuscitation.

III. VITAL SIGNS

Body Temperature: 36.3 degrees celcius Blood Pressure: N/A

Cardiac Rate: 120 beats/minute Respiratory Rate: 36 beats/minute

IV. REFLEXES
 Feeding Neurologic Other Reflexes
Reflexes Reflexes
Sucking Moro Palmar Grasp
Rooting Landau Tonic neck
Extrusion Babinski Magnet
Swallowing Step-in-Place Blink
Gag

V. NUTRITIONAL STATUS
Breastmilk
Feeding

VI. PHYSICAL ASSESSMENT

General Appearance:

Flexed: Extended: Symmetric:

_____________________ ___________________ __________________

State of Arousal:

Deep Sleep: Drowsy: _____________________ Active Alert: _________________

Light Sleep: __________________ Quiet Alert: __________________ Crying:

Presence of Tremors: N/A

Others:
___________________________________________________________________________
_________

Skin

Color:

Pink: /Pale: ____________ Cyanotic: _____________ Jaundice:

_______________ Acrocyanotic: ______ Dusky: __________

Turgor: Good: / Poor: __________________________________

Tenting: Yes: / No: ___________________________________

Birthmarks: N/A

Hemangiomas: _______________ Mongolian Spots: _______________ Nevus

Flemmeus: ____________
Lanugo: None: Sparse: Abundant: ________________________

Presence of:

Petechiae
Pustule
Vesicle
Ecchymosis
Edema

Head

shape and size:

– normocephalic /
– microcephalic
– macrocephalic
sutures: N/A
– wide
– closed
fontanelles:

– soft/flat /
– depressed
– bulging

o caput succedaneum
o cephalhematoma
o molding
Hair

smooth /
wooly

Face

Eyes

color
 Black
discharges
sclera
conjunctiva
blink/startle reflex: yes or no

Ears

position pinnae:

o formed and firm /

o shapeless/floppy
others:

Nose

appearance
No swelling, bleeding, and lesions

Mouth

appearance

symmetry
buccal mucosa

o pink /
soft/hard palate

o intact /
secretions

o none /
o small
amount
o moderate
o copious
throat
No swelling, exudate, and lesions
ANOGENITAL AREA
– Female
o clitoris: prominent, not prominent o labia
EXTREMITIES

– Upper:
o symmetric o range of motion o muscle tone o palmar creases o others

– Lower:
o symmetric o range of motion o muscle tone o sole creases o others

– assess for: o size, symmetry and movement – arms & legs appear short, hands are
clenched into fists o unmoving suggests injury o muscle tone – ARM RECOIL - unflexing
the arms for 5 seconds then release the arm o the arm should return immediately to
flexed position
o SIMIAN LINE – DOWN SYNDROME - single palmar crease instead of 3 and
unusual curvature of
the little finger
o number and separation of fingers and toes
✓ POLYDACTYLY – extra digits (toes or fingers)
✓ SYNDACTYLY – webbing of fingers o plantar creases over anterior half of
sole of feet (may appear flat due to extra pad of fat in the longitudinal arch)
✓ If less than 2/3 or absent - prematurity o ORTOLANI MOVEMENT – to
assess stability of hip joints in NB and infants and presence of hip abnormalities

o ORTOLANI TEST:
1) Position baby on his back.
2) Hips and knees are flexed at right angles and abducted until the lateral
aspects of the knees are touching the table
3) A click or popping sensation may be felt if the joint is unstable (+
Ortolani’s sign) o TALIPES EQUINUS – associated with club foot (akuy);
characterized by tiptoe walking on 1 or both feet and foot is twisted and
relatively fixed in abnormal position

VII. LATEST LABORATORY RESULT

2
VIII. NURSING CARE PLAN

NCP FOR INFANT/MOTHER

ASSESS NURSING PLANNING INTERVENTI RATIONALE EVALUATI
MENT DIAGNOSIS ON ON

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: Vital verbalized the safety  ➢ Hold
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88 yo 
➢ RR: maam/sir” The
22 mother
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able to 
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doesn’t zed
know “ammok
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 properly n,
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ed kadagitay
insursuro
yo
maam/sir”

DOCUMENTATION