Newborn Assessment

NURS 341 Fall 2015

Daphne Fitzpatrick
NEWBORN ASSESSMENT
A form follows which should be used for completion of the Newborn Assessment. You should
take this form with you to your OB clinical experience and use it to guide your assessment of a
newborn. After you complete the assessment you are to complete the nursing diagnoses chart as
indicated by the rubric. You may use your textbook for much of your evidentiary support, but
should also use at least 1 peer reviewed journal article. This is due 1 week after your OB clinical
experience.

Newborn Assessment
Antepartal risk factors (This will be obtained from the mother's chart!):
Maternal Age _25_____Gravida/Para(GTPAL) __4/3____Gestational Age___41____
Onset of Prenatal Care____5wks_____ Maternal Blood type __O+____
Planned/Unplanned pregnancy __planned__Maternal Substance abuse__n/a____ Gestational
Diabetes____no__ Maternal Infections__no______ Abnormal US findings _____no_______
Additional information _____________________________________________________
Admission data (This will be obtained from the babys chart!):
Temp __37__ HR __132_ Respirations ___46_ Blood glucose ___-___
APGAR Score: 1 min __8__ 5 min _9___ Resuscitation measures: ____none_____
____________________________________________________________________
Eye antibiotic _0720_ (time) Vitamin K __ 720 (time)
Nursed in L&D: Yes

Length _51cm___ Wt. ___4.03 kg_

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):

+ = Present/normal
Vital Signs:

Please use the following code:

= Not present
NA = Not applicable

Temp ___36.8___ HR __140____ Respirations __48____

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 symmetrical placement
Skin tags ______
Nose: Symmetry __+______ Flaring ______ Patent: Left _+____ Right ___+__
Eyes: (describe what you found)
Right

Left

Subconjunctival hemorrhage

____

_____

Nevi on lids

____

_____

Edema

____

_____

Red reflex

____

_____

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 ___round___
Clavicles: Intact ____+______Fracture ________________________________

Breasts: Palpable tissue ______ Engorgement _____________

Heart sound: RRR ____+____ Other _________________________________
Genitals: Voided: Date _0930___ Time __1215__ Color of urine ___yellow_____________
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 _soft______________

Spinal Column: Pilonidal dimple ______ Tuft of hair ______

Symmetry ___+___ Intact ___+___
Abdomen: Symmetry ___+___ Other ____________________
Umbilical cord: # of vessels __3____ Protruding base __________________
Extremities:
Right

Left

Symmetry

__+____

__+____

Movement

__+____

__+____

Digits (number)

_+_____

__+____

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
Rooting:

Describe the procedure

Describe normal responses

Stimulus such as a stroke

near infants lips or cheek
applied.
Nipple or finger is put in
the infants mouth.

Infant will turn head

towards where touched.

Moro:

Startle the baby with a

noise, or falling movement.

Stepping:

Hold infant up and have the

feet touching a surface.

All legs and arms extend

out and forefinger forms a
C.
The infant makes walking
motions.

Grasp/hand:

Place finger on infants

palm.

Infants fingers curl around.

Grasp/foot:

Place fingers at the base of

toes.

Toes curl around in

response.

Sucking:

The infant responds by

sucking.

What is your overall assessment and prognosis for this infant (do not say good):
Newborn female infant born at term during a planned pregnancy with adequate prenatal
care. Mother is gravida/para 4/3 and is experienced with breastfeeding. Infant was born with a
different latch per mother and after physician and lactation consult a frenulectomy was
performed. Infants sucking became more productive soon after. Adequate vital signs, wet
diapers, and stool are present. Lung sounds clear and bowel sounds are present. A bilirubin level
of 8.1 was drawn when infant was a day old with a borderline result of 8.1 (<8.2 desired).
Mother agreed to stay one more day and consented to a redraw. Overall assessment and
prognosis of the infant is positive that infant will thrive if care progresses as is.

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
Risk for neonatal jaundice
as evidenced by bilirubin
level.

Ineffective infant feeding

pattern related to
ankyloglossia.

Ineffective
thermoregulation related to
immature compensation
for environmental
temperature.

Necessary Assessments/Interventions
Track lab orders and results of bilirubin.
Explain to parents why of test.
Watch infant for skin for signs with blanch test.
Encourage frequent breast feedings for
prevention.
Review infants latch.
Consult with mom on breast creases and
feeding soreness or pain.
Request lactation and physician consult if
evidence of ankloglossia appear to interfere
with feeding a cut of the frenulum by the
physician is performed.
Nurse monitors frenulum aftercare and healing.
Monitor feeding ability, urinary output.
Keep baby swaddled.
Check temperature as ordered.
Monitor for acrocyanosis or central cyanosis.
Encourage skin-to-skin
Encourage and monitor frequent feeding.

Rationale
Readmissions of infants with
hyperbilirubinemia is the main cause of infants
returning to the hospital and accounts for
around a quarter of admissions (Vanderwal &
Kyle, 2015, p.S25). The rate of these
admissions can be prevented with monitoring
of infant bilirubin levels, skin and feeding.
Effective feeding helps the baby thrive.
Ineffective feeding leads to pain for the
breastfeeding mother and insufficient food
supply for the infant. Monitoring feeding by
mother, nurse and physician are beneficial if
interventions are needed, (Bunik, Dunn,
Watkins & Talmi, 2014, p. 146). A
frenulectomy can increase ability to feed
effectively.
Newborns experiences change in environment,
have an immature ability to regulate, and have
a much larger body surface area. Many factors
such as different heat loss mechanisms, rooms
temp, clothing, metabolism and fat change the
ability to regulate temperature, so monitoring
and interventions are needed to reduce
environmental stress (Altimier, 2012, p. 51).

References
Altimier, L. (2012). Thermoregulation: What's new? what's not?. Newborn and Infant
Nursing Reviews, Vol.12(1), 51-63.
Bunik, M., Dunn, D., Watkins, L., & Talmi, A. (2014) Trifecta approach to
breastfeeding. Journal of Human Lactation, 30(2), 143-147.
Vanderwal, B., & Kyle, C. (2015). Decreasing newborn readmissions for
hyperbilirubinemia. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(S1),
S25.