Newborn Assessment • Conjunctivitis or discharges___________
Physical Assessment Findings • Jaundice__________
And Physiologic Functioning
Student Nurse: _____________________________
Patient’s Name:___________________ Age:______
Date Assessed:_____________________________
Vital signs:
Temperature:___________ Pulse rate:___________
Respiratory rate:___________ Blood pressure______
Posture:
• Symmetric posture_____________.
Face turned to side ____; flexed extremities____
Hands tightly fisted with hands covered by
fingers______.
• Asymmetric posture ___________.
• Knees and legs straightened_____ or in frog position.
Length
• Infants length ____ cm or _____ inches
Weight
• Infants height _____cm or _____ inches
Skin:
• Hair distribution lanugo over back ______; Lnugo
disappeared on extremities and other areas of the
body_____.
• Good skin turgor______.
• Color
Cyanosis and over the body_____.
Acrocyanosis_______; pallor
Pletnor reddish (ruddy) coloration_____.
Jaundice_______.
• Meconium staining of skin______; fingernails_____
and umbilical cord______.
• Dryness or peeling________
• Vernix_______
• Nails reach end of fingertips_______.
• Edema occur over buttocks____; back____; and
occiput_____:pitting edema
• Ecchymosis _________ Location________
• Petichae_______ Location_________
• Erythema toxicum (newborn rash)
______location_______________
• Hemangiomas vascular lesions present at birth; some
may fade, but others may be permanent.
o Strawberry bright red, raised,
lobulated_____ location__________
• Telangiectatic nevi (stork bites) flat red or purple
lesions ________.
• Milia enlarged sebaceous________. Mongolian spots
blue-green or gray pigmentation________.
• Abrasions or lacerations _________. Location
________.
• Port wine nevus ( nevus flammeus) flat pink reddish
purple lesion________.
Head:
(examine head and face for symmetry, paralysis, shape,
swelling, movement)
• Capput succedaneum___________.
• Cephalohematoma or subperiosteal
hemorrhage__________________.
• Molding________________
• Forceps Marks or U-shaped bruising________.
• Head Circumference ______ cm or _____inches
• Fontanelles
o Enlarrged or bulging_________
o Sunken__________
o Size- posterior may be obliterated because
of molding______; generally closes 2-3
months. Anterior is palpable generally
closes in 12-18 months.
• Sutures junctions of adjoining skull bones.
o Overriding
o Extensive separation
Face
• Symmetry of facial movements _______
Eyes
• Color- sclera white ____; blue sclera_____
Eye color usually slate-gray _____; brown____; or
dark blue______
• Hemorrhagic area______ edema of the eyelids
________.
• Pupils equal in size___ and constrict equally to bright
light_____
• Brushfield’s spots or white or yellow pinpoint areas on
iris_____
• Abnormal placement of eyes or small eye
opening_____
• Strabismus or crossed-eyed appearance_______
Nystagmusp
Nose:
• Patency __________
• Nasal flaring______ appropriate shape of nose_____
• Discharges or stuffiness is _______. septum should be
midline_______
Ears:
• Formation large flabby ears that slant forward
_________.
• Position in relation to the eye or helix (top of ear) on
the same plane as the eye _______; low set ears____
• Skin tags_____
Mouth:
• Size-small mouth______ (fist mouth)_____ Mocuos is
membranous; pink in color_____
• Hard and soft palate closed__________
• Size of tongue- does not end much pastline of the
gums______. Excessively large tongue_______
• Teeth- predeciduoud teeth_______
• Epstein’s pears or small white nodules found on sides
or hard palate______
• Frenulum lengua or thin ridge of tissue running from
basal tongue along undersurface to topof
tongue_____
• Sucking blisters labial taberales or thicker midlines of
upper lip that may be filled with blood_____
Neck:
Examine the following:
• Mobility-infant can move the head from side to side
_____; lymph nodes____ clavicular fractures_____
• Torticolis appears as spasnoche____ one sides
contraction of neck muscles______
• Stiffness and hyperextension____________
• Clavicle are intact________
• Mass- cystic hygroma or soft usually seen laterally;
over the neck clavicle_____
Chest:
• Circumference _________ and
symmetry___________
Breast:
• Engorgement noted ___________________________
• Nipples and areola are less formed and
profound___________
Respiratory System
• Rate:
• Rhythm of respirations may be shallow with irregular
rhythm
o Respiratory movement are symmetrical
_______ and mainly diaphragmatic_______
o Periodic breathing resumption or respiration
after 5-15 seconds________
o Observe abnormal respiratory signs_______
• Breath sounds determined by auscultation
Cardiovascular System
• Rate__________
• Heart sounds- second sound higher than fist third and
sharper______________ than first/third and heard
rarely________ ; murmurs___________
• Pulses equally and strength of brachial __________;
radial ________; pedal _____________ and femoral
pulses _________; lack of femoral pulses ________
• Acrocyanosis of distal extremities_________; location
of any cyanosis_________; color changes with
time_______ and when crying__________
• Blood pressure_____________
Abdomen
• Shape- cylindrical_________; protrudes
slightly_____moves synchronously with chest during
respiration_______
• Distension________________________
• Palpate abdomen for masses; gap between rectus
muscles is common, palpate liver and spleen.
• Auscultate abdomen in all four quadarnts________
• Umbilical cord:
 o Normally contains two arteries and one
vein_____
o Signs of infection around______
o Meconium staining_____
o umbilical hernia_______

Genitalia

Male Chest and breasts

• testes in scrotal sac____ ; scrotal sac appears

markedly wrinkled due to rugae_____
• Edema present on scrotal sac___________
Hydrocele_______
• Glans penis- urethral opening is normally central Head and neck
________ opening dorsal (hypospadias)________
opening dorsally (epispadias) _________ abnormally
adherent foreskin (phimosis)
Back

• Spinal column to normal curvature ___________, Nervous system

closure ____, pilonidal dimple of sinus _______ also
for tufls of hair or skin disruptions_________________
• Examine anal for anal opening______________,
response of anal sphincter____________,
fissures___________. Face

Musculoskeletal system
• Examine extremities for fractures_______,
paralysis_________, range of motion_____________,
irregular position_________ Musculoskeletal system
• Examine fingers and toes for number and separation:
extra digits, polydactyly________; fused digits,
syndactyly___________
• Examine hips for dislocation- with the infant in supine
position, flex knees and abduct hips to side and down
to table surface_________; clicking sound indicates Eyes
dislocation ( ortolan’s sign)___________
• Assymetrical gluteal folds___________
• Examine feet for structural and positional deformities-
club foot_____ or metatarsus adductus (inward turning
of foot)__________________.
Genitalia
Neurologic system
• neurologic mechanisms are immature automatically
and physiologically; as a result; uncoordinated
movements, labile; temperature regulation and lack of
control over musculature and characteristic of infant
• Examine muscle tone, head control and reflexes
Ears
Interpretation of the data:

Posture:

Mouth

Cardiovascular system

Nose

Length and weight

Abdomen

Respiratory system

Skin
 Saint Paul University Dumaguete
College of Nursing

In Partial Fulfillment of the Requirements in NCM 104

NEWBORN ASSESSEMENT

Submitted by:

Peñalber, Valerie Y.

BSN III-C

Submitted to:

Mrs. Heide H. Sibonga, RN