Neonatal Assessment Guide

Room #/ NB initials: Room 222/ Baby girl V APGAR: (1) = 9, (5) = 9

Date of Birth: May 11, 2010 Vaccinations:
Age: 1 day old 5/11 Hep B 0.5ml IM right thigh
AOG: 40 2/7 weeks 5/11 Vit K 0.1ml IM left thigh
Dx: Term newborn, female delivered via NSD 5/11 Erythromycin ointment
@ 40 2/7 weeks AOG as 9,9, BS= 34wks, wt=3360kg
BL= 51.5cm, HC= 33cm AGA.

ASSESSMENT AREAS DESCRIPTION OF FINDINGS

General Appearance Head is proportioned with other parts of the
(black hair, pinkish and flexed) body.

Weight & Measurement

1. Weight 3360g (2500-4000g)
2. Height 51.5cm (48-52cm)
3. Temperature 36.6 C (36.5-37.5 C)
4. Head circumference 33cm (32-37cm)
5. Chest circumference 33cm

Posture

Skin
1. Color

2. Texture

3. Turgor

4. Pigmentation

5. Jaundice

6. Normal Variations
Ex. Rashes, ET rash, Mongolian spots,
Birthmarks, bruises, petechiae.
Head assessment

1. General appearance

2. Size (related to body)

3. Common variations define and explain

the differences between Caput
succedaneum & Cehalhematoma

4. Fontanels

A. Anterior fontanel

B. Posterior fontanel

C. Pulsation

D. Bulging

E. Sunken

Hair

1. Texture

2. Distribution

Face
1. Symmetry

2. Spacing and features

3. Movement
Eyes

1. General placement and appearance

2. Color

3. Any tears

4. Pupils react to light

5. Subconjunctival hemorrhage?

Nose

1. General appearance

2. Any sneezing

Mouth

1. Symmetry

2. Check for cleft palate

Ears

1. Position on head relative to the eyes

2. Symmetry

3. Cartilage (does the ear spring back

when folded)
Neck

1. Appearance

Clavicles

1. Appearance & size

2. Breast tissue (measure and describe)

3. Auscultate breath sounds

4. Describe general breathing

movements

5. Respiratory rate(one minute)

Heart

1. Auscultate heart sounds for one

minute and describe

2. What makes the HR vary?

Abdomen

1. Auscultate bowel sounds

2. Umbilicus

3. Palpate inguinal area

4. Describe voiding
Genitals Male

1. Penis

2. Placement of urinary meatus

3. Scrotum

4. Testes

Buttocks and anus

1. Symmetry

2. Pattern of stools

Extremities and trunk

1. General appearance

2. Symmetry

3. Complete a ROM & describe

4. Arms (equal)?

5. Spine

6. Hips

7. Legs

8. Feet
Reflexes

1. Moro

2. Rooting

3. Sucking

4. Palmar Grasp

5. Plantar Grasp

Activity

1. Neonate cries when?

2. Cry (pitch)
Sensory: What evidence is there that the baby
can or cannot:

1. Hear

2. Feel