Lindsay Johnson

Newborn Assessment
Antepartal risk factors (This will be obtained from the mother's chart!):
Maternal Age __24__Gravida/Para(GTPAL) __21001_Gestational Age_39(6)_
Onset of Prenatal Care__4/9/15__ Maternal Blood type _B pos___
Planned/Unplanned pregnancy __planned__Maternal Substance abuse__none__ Gestational
Diabetes__N/A__ Maternal Infections__N/A__ Abnormal US findings _small fundal height___
Additional information __history of crohns disease________

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

Temp __37.1C__ HR _140_ Respirations _60_ Blood glucose _N/A (only required if baby over
2724g__
APGAR score: 1 min __9_ 5 min __9_ Resuscitation measures: _none needed____
____________________________________________________________________
Eye antibiotic __0850___ (time) Vitamin K __0850____ (time) Length _21 inches__ Weight __7
lb. 11 oz.______
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 _37.1C +__ HR _140 +__ Respirations _60 +___
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 _aligned with eyes__
Skin tags __ ____

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

Left

Subconjunctival hemorrhage

__ ___

__ ___

Nevi on lids

___ __

__ ___

Edema

__ ___

___ __

Red reflex

__ N/A_

__ N/A_

Other

__ ___

__ ___

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 ____N/A____ Time ____N/A____ Color of urine __N/A___

Male: Urethral orifice: Normal position ___N/A____ Abnormal (describe) ___N/A___
Testes (#/location) __N/A__________________________________________________
Scrotum __N/A__ Pendulous __N/A__ Rugated __N/A____ Other _N/A_____________
Female: Labia majora: Completely covers minora ___+__ Partially covers minora __ ___
Labia minora protruding __ ____ Vaginal discharge ___ ___ Hymenal tag __ ____
Both genders: Anal patency:

Y N

Stool: Y N Type __N/A___________

Spinal Column: Pilonidal dimple ___ __ Tuft of hair ___ ___

Symmetry __+____ Intact __+____

Abdomen: Symmetry __+___ Other _N/A___________________

Umbilical cord: # of vessels __3____ Protruding base __ ________________

Extremities:
Right

Left

Symmetry

__+___

__+___

Movement

__+___

__+___

Digits (number)

__5___

__5___

Flexion creases

__+___

__+___

Palmar creases

__+___

__+___

Sole creases

__+___

__+___

Intact

Dislocated/subluxation

Right

___+___

___ ___

Left

___+___

___ ___

Hips:

Neuro-muscular: Tone: Normal _+_ Lethargic _ ___ Rigid_ ___ Tremors __ ____

Reflexes:
Reflex: Describe what
you observed

Describe the procedure

Describe normal
responses

Rooting: baby looking for

Put baby on mothers chest.

Baby will move around

breast.
Sucking: baby sucks on

Put finger in babys mouth.

looking for nipple.

Baby would close mouth

finger.
Moro: baby moved arms

Initiated by picking baby

around finger and suck.

Baby will appear startled

and legs out like startled.

up from isolet and putting

throwing hands in air.

Stepping: baby moved feet

down.
Touch babys feet to flat

Baby moves feet in walking

in walking motion.
Grasp/hand: baby wrapped

surface.
Put my finger in babys

motion on counter.
Baby will wrap fingers

fingers around my finger.

Grasp/foot: baby wrapped

palm.
Put my finger on sole of

around nurses finger.

Baby will wrap toes around

toes around finger.

babys foot.

nurses finger.

What is your overall assessment and prognosis for this infant (do not say good):
This baby had stable vital signs (37.1C, 140, 60). Skin was dry, pink, with cap refill <3 seconds.
Baby had acrocyanosis which was of no concern. Mongolian spots were noted in the center of
the lower back. Palate was intact, with pink, moist mucosa. Apical heart rate was regular and
easily audible. Respirations were equal and unlabored. Chest rise and fall was symmetric with no
retractions. Lusty cry was present. Genitals were normal. The outlook for this infant is promising
as there were no abnormal findings present that indicated signs of downs syndrome or other
diseases.

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

Necessary
Assessments/Interventions

Rationale

Ineffective
thermoregulation related to
newborn transition to
extrauterine life.

Assessment: Ineffective thermoregulation

was assessed because the infant
temperature is at a higher rate when in
utero. Upon delivery the baby had a
temperature of 37.1C, however, during our
second baby assessment the baby
temperature had dropped to 36.9C. This
finding was not dramatically concerning as
it is related to birth of the infant.
Interventions: Keep the head of the infant
covered with a proper fitting hat, swaddle
the infant with a receiving blanket, keep
the room temperature at a warmer
temperature, and use heated isolet for
assessments when infant must be exposed.
Assessment: The stump of the umbilical
cord is exposed to outer environment with
little protection from bacteria entering.
Interventions: Educate parents about hand
hygiene when caring for umbilical stamp,
educate parents about signs of infected
umbilical stump, maintain protocol for
prevention of umbilical stump infection,
and review standards of infection
surveillance.
Assessment: After birth, during skin to
skin, the infant was having difficulty
latching on both breasts. This led to stress
on the newborn and resulted in crying as

Thermoregulation is an expected issue among infants as the

temperature in utero is elevated to that of the extrauterine temperature
(Petty, 2010). In utero, the placenta maintains a heat exchange and
keeps the fetus at a temperature from 37.6 37.8C (Petty, 2010). Since
the extrauterine temperature is lower, this places the infant at risk for
hypothermia. Newborns also have a surface area that is three times
greater than adults, making it significantly harder to regulate their
temperature (Petty, 2010). Since infants have no ability to shiver to
warm themselves up, they pull from their brown fat reserves to
produce heat energy (Petty, 2010).

Risk for infection related to

exposure of umbilical cord
stump.

Ineffective breastfeeding
related to inability to latch
on to nipple correctly.

There are actually thousands of deaths each year that occur directly
related to infection related to bacteria entering the body via the
umbilical cord (Vural & Kisa, 2006). Umbilical cord infection,
otherwise known as omphalitis, is one of the main causes of increasing
rates of neonatal morbidity and mortality (Vural & Kisa, 2006). Vural
and Kisa (2006) did a study reporting the most proper way to clean the
umbilical cord and prevent infection turning into sepsis in neonates.

According to Rossman and Ayoola (2012), exclusive breastfeeding

during the first year of life has been associated with decreased infant
mortality, better future physiological, mental, and social development,
as well as decreased risk for obesity. It is important to educate mothers

well as stress on the mother.

Interventions: Assess mothers history
with breastfeeding, discuss and
demonstrate different positions and tools
to use while breast feeding, educate about
newborns actions that mean the want for
breast milk (like rooting), and keep the
infant with mother skin to skin as long as
possible.

the importance of breast feeding in all situations, especially when the

infant is having trouble latching. The mother may become discouraged
and want to give up, however, they may just need additional teaching
to make it work.

References
Petty, J. (2010). Fact sheet: Normal post natal adaptation to extrauterine life. Thermoregulation and glucose hemostasis. Journal of Neonatal
Nursing, (16)5, 198-199. Doi: 10.1016/j.jnn.2010.07.006
Rossman, C. & Ayoola, A. (2012). Promoting individualized breastfeeding experiences. The American Journal of Maternal Child Nursing, (37)3,
193-199. Doi: 10.1097/NMC.0b013e318247db71
Vural, G. & Kisa, S. (2006). Umbilical cord care: A pilot study comparing topical human milk, povidone-iodine, and dry care. Journal of Obstetric,
Gynecologic & Neonatal Nursing, (35), 123-128. Doi: 10.1111/j.1552-6909.2006.00012.x

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