Newborn Assessment

Antepartal risk factors (This will be obtained from the mother's chart!):
Maternal Age __26____Gravida/Para(GTPAL) ___G1P0___Gestational Age__39-4_____
Onset of Prenatal Care__4/20/15_______ Maternal Blood type __O+____
Planned/Unplanned pregnancy __Planned______Maternal Substance abuse__None_______
Gestational Diabetes__None______ Maternal Infections__GBS+________ Abnormal US
findings ___None___________
Additional information ____GHTN_________________________________________________

Admission data (This will be obtained from the babys chart!):

Temp __36.7____ HR __154____ Respirations __60____ Blood glucose __NA____
APGAR Score: 1 min ___8__ 5 min ___9__ Resuscitation measures: _____________
____________________________________________________________________
Eye antibiotic __1550____ (time) Vitamin K _1545_____ (time)

Length __54cm______

Wt. ____3.940____
Nursed in L&D: Yes

No

NOW YOU ARE READY TO DO A PHYSICAL ASSESSMENT ON THIS

BABY (to be completed by you the day you are caring for the baby):
Please use the following code:
+ = Present/normal

= Not present

NA = Not applicable

Vital Signs: Temp _36.8_____ HR __144____ Respirations __48____

Color: Pink ___+___ Pale ___ ___ Mottles _+_____ Plethoric __ ____
Jaundice __ ____ Stained __ ____ Acrocyanosis ___+___

Skin: Clear _+_____ Pressure marks ___+___ Abrasions _+_____ Dry ___ ___
Ecchymosis __ ____ Petechiae ___ ___ Nevi ___ ___ Milia __ ____
Rash ______ Lanugo ___ ___ Vernix __ ____ Mongolian spots __ ____

Respirations: Regular __+____ Grunting __+____ Abdominal ____+__ Retracting ___ ___
Shallow __ ____ Nasal flaring ___ ___ Sighing ___ ___ Other ______
Cry: Lusty __+____ Weak __ ____ Shrill _ _____

Head: Symmetry/shape _____+_____ Molding ____+______ Cephalohematoma __ ___

Caput succedaneum ___+___ FSE mark __ ____ Other ______
Anterior fontanel: Flat __+____ Full ___ ___ Depressed _ _____
Posterior fontanel: Flat ____+__ Full __ ____ Depressed _ _____
Sutures

Overriding

Separated

Approximated

Coronal

____ ____

____ ____

______+_____

Sagittal

____ ____

____ ____

______+_____

Lambdoidal

_____ ___

_____ ___

______+_____

Ears: (describe exact location & how you determined if it was normal)
Position: Normal __+____ Abnormal __ ____ Describe normal position __Inline with
canthus__________
Skin tags __ ____

Nose: Symmetry ____+____ Flaring __ ____ Patent: Left __+___ Right _+____
Eyes: (describe what you found)
Right

Left

Subconjunctival hemorrhage

__ ___

__ ___

Nevi on lids

___ __

__ ___

Edema

___ __

__ ___

Red reflex

___NA__

__NA___

Other

___NA__

__NA___

Mouth: Mucous membranes: Pink __+____ Pale ___ ___ Cyanotic ___ ____
Teeth __ ____ Epsteins pearls _ _____

Hard palate: Intact __+____ Abnormal ____ ___________________________

Soft palate: Intact ___+___ Abnormal ___ _____________________________
Lips: Cleft __ ____ Drooping __ ____ Symmetry ___+___

Anterior chest: Symmetrical __+____ Shape __Barrel____

Clavicles: Intact ___+______Fracture ___ _____________________________
Breasts: Palpable tissue ___+___ Engorgement ___ __________
Heart sound: RRR ____+____ Other ___ ______________________________

Genitals: Voided: Date __10/31/15_ Time ___1800 Color of urine_ Clear Yellow__
Male: Urethral orifice: Normal position ____+____ Abnormal (describe) ___ _________
Testes (#/location) ___2 Descended
_________________________________________________
Scrotum __+____ Pendulous __+____ Rugated __ ____ Other _____________________
Female: Labia majora: Completely covers minora _NA____ Partially covers minora __NA___
Labia minora protruding __NA____ Vaginal discharge __NA____ Hymenal tag __NA____
Both genders: Anal patency:

Y N

Stool:

Y N Type ___Meconium____________

Spinal Column: Pilonidal dimple ___+___ Tuft of hair _ _____

Symmetry _+_____ Intact __+____

Abdomen: Symmetry ___+___ Other ____________________

Umbilical cord: # of vessels __3____ Protruding base ____+______________

Extremities:
Right

Left

Symmetry

__+____

__+____

Movement

___+___

__+____

Digits (number)

___10___

___10___

Flexion creases

___+___

__+____

Palmar creases

___+___

__+____

Sole creases

____+__

__+____

Hips:
Intact

Dislocated/subluxation

Right

__+____

__ ____

Left

__+____

__ ____

Neuro-muscular: Tone: Normal ____+__ Lethargic __ ____ Rigid ___ ___ Tremors
______

Reflexes:
Reflex: Describe what
you observed

Describe the procedure

Describe normal
responses

Rooting: Infants head

Touch finger to infants lip,

Infant turns head toward

turned toward stimulus

cheek, corners of mouth

finger and opens mouth

Sucking: Infant sucked well

Put infant to mothers breast

Infant head turn to nipple,

on finger and nipple when

to initiate sucking

open mouth and begin to

breast fed

suck

Moro: Touch infant with

Infant startled when held

Symmetric abduction of

cold stethoscope, startled

and dropped

extremities.

Stepping: Hold infant up,

Hold infant vertical, feet

Stimulated walking or

puts feet down and pushes

touch table or surface

alternating flex/extension of

upward from counter

Grasp/hand: Infant grasps

feet
Place finger in infants palm

finger in hand

Fingers of infant wrap

around finger

Grasp/foot: Infant grasps

Place finder at base of

Toes of infant wrap around

finger with toes

infants toes

finger

What is your overall assessment and prognosis for this infant (do not say good):
Baby boy was born cesarean section, with no complications during procedure. Immediate
skin to skin contact for one hour after birth. Attempted breast feeding. APGAR scores were 8 and
9, good prognosis of baby. Baby boy was born within normal percentiles of height and weight
with adequate cry and vital signs after delivery.

On the basis of your assessment, list 2-3 nursing diagnoses for this baby and the teaching
interventions you would use for each nursing diagnosis. Please include the rationale for your
actions. You must have at least two references other than your textbooks for your rationales.
Be sure your assessment and interventions correspond to your nursing diagnosis.

Nursing Diagnosis
Risk of infection r/t
babys unhealed
umbilical cord

Necessary
Assessments/Interventions
Keep cord stump clean and dry.
Let scab dry and fall off on its
own.
Know s/s of infection: redness,
swelling, pus, fever.

Rationale
Umbilical site is a relevant site for bacterial
colonization and source for infection.
Correct hygiene cleansing, and drying substantially
reduces the risk of infection

Deficient knowledge
r/t safety in post
partum period

Learning readiness of parents.

Teaching by example then having
parents demonstrate skills.
Anticipatory guidance.

Adults choose what they want to learn and participate

in learning.
Shows nurse and parent that they are ready and able to
perform tasks for infant care and allows opportunity to
ask questions.

Risk for aspiration r/t

poor gag reflex

Burping, do not lay baby flat

immediately after feedings.
Succtioning mouth and nose

Aspiration causes changes in oxygenation in blood

levels and bodys pH. Increases in carbon dioxide and
cyanosis. Laying child flat increases risk of aspiration

flares if necessary.

into bronchioles

References
Berti E, Bertini G. Management of the umbilical cord stump: a review. Children's Nurses: Italian Journal Of Pediatric
Nursing Science / Infermieri Dei Bambini: Giornale Italiano Di Scienze Infermieristiche Pediatriche [serial online].
March 2011;3(1):7-9 3p. Available from: CINAHL, Ipswich, MA. Accessed November 13, 2015.
Frello A, Carraro T. Nursing and the relationship with the mothers of newborns in the neonatal intensive care unit. Revista
Brasileira De Enfermagem [serial online]. May 2012;65(3):514-521 8p. Available from: CINAHL, Ipswich, MA.
Accessed November 13, 2015
El-Radhi, A. S. (2015). Management of common neonatal problems. British Journal Of Nursing, 24(5), 258-265 8p.
doi:10.12968/bjon.2015.24.5.258

References:
GRADING RUBRIC FOR NEWBORN ASSESSMENT
Below Expectations

Needs Improvement

Meets Expectations

Exc

(15 points)
Assessment has > 8 blanks
spaces, has poor analysis
(0 points)
Does not complete the care plan

(20 points)
Assessment has 9-12 blank spaces

(30 p
Asse
and e
(15 p
Choo
diagn

C. Interventions

(0 points)
Does not have any interventions

(10 points)
Has chosen inappropriate nursing
interventions

D. Rationale for
interventions

(0 points)
Does not have any rationales for
interventions

(10 points)
Stated inappropriate rationales for
nursing interventions

(25 points)
Assessment has 1-5 blanks
spaces, analysis lacks depth
(10 points)
Chooses 2 appropriate nursing
diagnosis based on the
assessment
(15 points)
Has chosen 2-3 appropriate
nursing interventions for each
diagnosis
(15 points)
Stated appropriate rationales for
nursing interventions for each
diagnosis

E. APA format, grammar,

spelling, & clarity of ideas

(0 points)
>10 errors in grammar or
spelling; Ideas are not presented
clearly.

(1 points)
5-10 errors in grammar or
spelling; Ideas are almost always
presented clearly

(3 points)
<5 errors in grammar or spelling;
Ideas are presented clearly

F. References

(0 points)
Has no citations and references

(2 points)
Has citations and references from
current textbooks.

(4 points)
Has citations and references from
other nursing textbooks,
Spectrums care plans or medical
websites.

A. Assessment
B. Nursing diagnosis

(5 points)
Chooses inappropriate nursing
diagnoses based on the assessment

(20 p
Has c
nursi
nursi
(20 p
In-de
interv
with
supp
(5 po
APA
in gra
prese

(10 p
Has c
journ