NUR 111 FA19

12/9/19

Newborn Assessment tool.

Learning outcome:
1. Document characteristics of the newborn prior to performing an assessment on a neonate in the clinical setting.
2. Perform and document assessment findings on a neonate in the clinical setting.

Instructions:
1. During lab begin documenting on the newborn characteristics side of the tool. Cite references using APA format.
2. Take the document to clinical and document an assessment of a neonate .

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 Vance-Granville Community College
ADN Program
Newborn Assessment

Student Name _________________________________ Date ______________________

Newborn Gender _________ DOB ___________ Time of Birth __________ Birth Weight ________ Gestational Age ______

APGAR 1 minute _____ APGAR 5 minutes _____ Suctioning (Bulb syringe, catheter, endotracheal) ____________________

Physical Assessment Category Newborn Characteristics Assessment Findings of Neonate

General Observations: The baby as a whole
A. Initial State
1. Posture

2. Movement

B. Body Proportions – Normal Ranges

1. Head circumference

2. Chest circumference

3. Length

4. Weight (Pounds and Grams)

C. Cry

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D. Temperature and route of temperature

Physical Assessment Category Newborn Characteristics Assessment Findings of Neonate

A. Skin
1. Color

2. Texture

3. Birthmarks

4. Lanugo

5. Vernix caseosa

6. Desquamation

7. Milia

8. Stork bites

9. Erythema toxicum

10. Mongolian spots

B. Head
1. Shape
a. Overriding

b. Molding

c. Caput succedaneum

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d. Cephalhematoma

Physical Assessment Category Newborn Characteristics Assessment Findings of Neonate

2. Head control

3. Abraisons

4. Circumference

* 5. *Compare head and chest

circumference*

6. Fontanels (anterior & posterior)

a. Flat or bulging

b. Soft or firm

c. Size

d. Shape

7. Hair
a. Pattern and Distribution

8. Eyes
a. Symmetry

b. Color

c. Movement

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 d. Tearing

e. Focusing

Physical Assessment Category Newborn Characteristics Assessment Findings of Neonate

f. Reaction to light

g. Pseudostrabismus

9. Nares patency

10. Mouth
a. Sucking pads/calluses

b. Ability to suck

c. Evidence of cleft lip/palate

d. Evidence of facial nerve

paralysis

e. Epstein pearls

f. Neonatal teeth

f. Presence of thrush

11. Ears
a. Location

b. Hearing

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 Physical Assessment Category Newborn Characteristics Assessment Findings of Neonate
C. Chest
1. Respiratory rate, pattern, effort

2. Breast
a. Bilateral

b. Witches milk

3. Cardiac
a. Rate

b. Heart sounds

c. Femoral pulses

d. Blood pressure

D. Abdomen
1. Intact

2. Bowel sounds

5. Umbilical cord (number and types

of vessels)
E. Genitals

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 1. Voiding; character, frequency

2. Stooling; character, frequency

3. Pseudomenstration

Physical Assessment Category Newborn Characteristics Assessment Findings of Neonate

4. Hypospadias/Epispadius

5. Imperfarated anus
F. Extremities
1. Upper extremities
a. Evidence of fractures

b. Evidence of Erb’s palsy

c. Acrocyanosis

d. Simian’s lines

e. Syndactyly

f. Polydactyly

2. Lower extremities
a. Evidence of factures

b. Evidence of dislocated hip

c. Acrocyanosis

d. Evidence of clubbed feet

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e. Syndactyly

f. Polydactyly

Physical Assessment Category Newborn Characteristics Assessment Findings of Neonate

G. Back
1. General appearance

2. Spine

3. Dimple (sinus tract)

H. Reflexes (describe & state when they

disappear)
1. Moro

2. Sucking

3. Rooting

4. Swallowing

5. Tonic neck

6. Grasp (bilateral palmar, plantar)

7. Babinski

8. Stepping/Dance

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 9. Crawling Reflex

10. Sneeze

11. Blink

Type of Medication/Immunization Medications/Immunizations Comments

J. Medications
1. Vitamin K
a. Purpose

b. Date, Amount, Route and Site

2. Eye Prophylaxis
a. Purpose

b. Name of ointment

c. Date, Site, Amount

K. Immunizations
1. Type

2. Date, Time, Route and Site

a. Lot number

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 b. Expiration Date

c. Manufacture

L. Additional findings or comments, Infant

reaction to exam

Pain Assessment Tools

Neonatal/Infant Pain Scale (NIPS)
(Recommended for children less than 1 year old) – A score greater than 3 indicates pain.

Pain Assessment Score

Facial Expression
0 – Relaxed muscles Restful face, neutral expression
1 – Grimace Tight facial muscles; furrowed brow, chin, jaw, (negative facial expressions – nose, mouth and brow)
Cry
0 – No Cry Quiet, not crying
1 – Whimper Mild moaning, intermittent
2 – Vigorous Cry Loud scream; rising, shrill, continuous (Note: Silent cry may be scored if baby is intubated as evidenced by
obvious mouth and facial movement.
Breathing Patterns
0 – Relaxed Usual pattern for this infant
1 – Change in Breathing Indrawing, irregular, faster than usual; gagging; breathing holding
Arms
0 – Relaxed/Restrained No muscular rigidity; occasional random movements of arms
1 – Flexed/Extended Tense, straight legs; rigid and/or rapid extension, flexion
Legs
0 – Relaxed/Restrained No muscular rigidity; occasional random leg movement
1 – Flexed/Extended Tense, straight legs; rigid and/or rapid extension, flexion
State of Arousal
0 – Sleeping/Awake Quiet, peaceful sleeping or alert random leg movement
1 – Fussy Alert, restless, and thrashing

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Cultural Considerations of the Mother/Family as it relates to the newborn:

Spiritual Consideration of the Mother/Family as it relates to the newborn:

Reference List: (Each line item (entry) must have a reference documented)

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