NEWBORN ASSESSMENT AND DOCUMENTATION

VS 8A 3P Birth Wt: Last Wt: LABS: Blood type Bilirubin PKU BEHAVIOR STATE: quiet, alert active, alert HEAD: molding fontanelles soft, flat edema describe EYES: discharge symmetric pupils reactive to light EARS: passed hearing test level with outer canthus of eye NARES: MOUTH: lip/palate intact Epsteins pearls CLAVICLES: HEART: rate brachial pulses femoral pulses LUNGS/CHEST: clear symmetrical expansion grunting other equal bilaterally retractions chest circumference FEMALE labia majora cover minora ABDOMEN: soft, nondistended tight, distended BOWEL SOUNDS: UMBILICAL CORD: Abd circumference hernia FEEDINGS: present moist clamp on absent drying 3 vessels VOIDS: Time Color Amount Time Type Amt/Length INTAKE/OUTPUT vaginal discharge describe site murmur GENITALIA: MALE testes descended x2 circumcised urethral meatus tip of penis describe site rhythm: regular irregular intact crepitus REFLEXES: moro palmar grasp plantar rooting Babinski sucking stepping natal teeth patent flaring skin tags SKIN: rash mongolian spots COLOR: pink circumoral cyanosis other acrocyanosis jaundice facial trunk cyanosis milia abrasions hemangioma other: red reflex O.U. pupils equal other MUSCLE TONE BACK: flexed spine straight flaccid sacral dimple irritable sleeping STOOL: SUTURES: approximated overriding widened head circumference EXTREMITIES: moves all equally syndactyly polydactyly creases symmetrical hip click BLADDER: voided since delivery nondistended meconium brown other yellow, seedy transitional crying ANUS: patent BM since delivery Coombs Hgb/Hct MEDS RECEIVED: Vit K EES Hep B HBIG

STOOLS:

Time

Color

Amount

Jan-09

NU4104.docx