`SIR ARTHUR LEWIS COMMUNITY COLLEGE

DEPARTMENT OF HEALTH SCIENCES

NURSE-MIDWIFERY PROGRAMME

CUMULATIVE RECORD OF CLINICAL EXPERIENCES

NEONATOLOGY EXAMINATION LOG

SEM. 4 A/Y _2017__ STUDENT NAME: Nigella George

No. Date Client Age Initials Of

Term/ Intervention Instructor/
Int. Assessment Findings Preceptor
Preter
m

Infant was taken over attached to mothers breasts, good suckling reflex was
R.L Term
observed. Infant is active and alert, general posture of flexion. Physical

assessment was done.

Head circumference: 35; chest circumference 33cm, length 58 cm

P: 154 R: 46 T: 97.0F SPO2: 97% in room air. RBS: 50 mg/dl. Wt. 3.24 kg

Skin and mucus membrane pink and moist. Head round, nil swelling. Hair is

evenly distributed. Sutures fused, posterior and anterior fontanelles patent, no

bulging. Pupils reactive to light equally, no opacity noted sclera white. Pinna

intact and aligned with canthus of eyes. Nose patent. Mucous membrane pink
and moist, tongue freely movable, rooting and sucking reflex present. Uvula

central, no cleft lip or pallet. Neck short no webbing, Clavicle smooth and intact.

Respiration unlabored, chest rises and falls symmetrically. Lungs sound clear

bilaterally. Heart beat strong and regular sounds S1, S2 heard. Nipple prominent

and symmetrical.

Abdomen soft and not distended, bowel sounds heard x 4. Umbilical blood

vessels present, 2 arteries, one vein, femoral pulse equally bonding, Ortolani and

Barlow maneuver done, no hip dislocation noted. Urinary meatus at tip of penis.

Testes descended no lesions to groin, skin folds. Anus patent. Back appears

smooth lanugo observed. Spinal cord, well aligned, no dimpling to sacrum,

Mongolian spot seen to gluteus. All reflexes intact blink, suckling, rooting, moro,

palmer, plantar, gasp trunk incurvature and Babinski

DHS: 10/03
No. Date Client Age Initials Of
Term/ Intervention Instructor/
Int. Assessment Findings Preceptor
Preterm

21/7/2017 Term Infant was taken in the cot next to , Good cry and active and alert, general
I/O
K.A. posture of flexion. Physical assessment was done.

Head circumference: 33; chest circumference 30cm, length 57 cm

P: 148, R: 52T: 97.80F RBS: 84mg/dl. Wt. 3.31kg

Skin and mucus membrane pink and moist. Head round, nil swelling. Hair

is evenly distributed. Sutures fused, posterior and anterior fontanelles

patent, no bulging. Pupils reactive to light equally, no opacity noted sclera

white. Pinna intact and aligned with canthus of eyes. Nose patent. Mucous

membrane pink and moist, tongue freely movable, rooting and sucking

reflex present. Uvula central, no cleft lip or pallet. Neck short no webbing,

Clavicle smooth and intact. Respiration unlabored, chest rises and falls

symmetrically. Lungs sound clear bilaterally. Heart beat strong and regular

sounds S1, S2 heard. Nipple prominent and symmetrical.

Abdomen soft and not distended, bowel sounds heard x 4. Umbilical

blood vessels present, 2 arteries, one vein, femoral pulse equally bonding,

Ortolani and Barlow maneuver done, no hip dislocation noted. Urinary

meatus at tip of penis. Testes descended no lesions to groin, skin folds.

Anus patent. Back appears smooth lanugo observed. Spinal cord, well

aligned, no dimpling to sacrum, Mongolian spot seen to gluteus. All

reflexes intact blink, suckling, rooting, moro, palmer, plantar, gasp trunk

incurvature and Babinski

DHS: 10/03
No. Date Client Age Initials Of
Term/ Intervention Instructor/
Int. Assessment Findings Preceptor
Preterm

Infant was taken in a cot, nest to mother. Infant is active and alert,

general posture of flexion. Physical assessment was done.

Head circumference: 35; chest circumference 33cm, length 56 cm

P: 130, R: 48 T: 96.60F. Wt. 3.08kg

Skin and mucus membrane pink and moist. Head round, nil

swelling. Hair is evenly distributed. Sutures fused, posterior and

anterior fontanelles patent, no bulging. Pupils reactive to light

equally, no opacity noted sclera white. Pinna intact and aligned

with canthus of eyes. Nose patent. Mucous membrane pink and

moist, tongue freely movable, rooting and sucking reflex present.

Uvula central, no cleft lip or pallet. Neck short no webbing,

Clavicle smooth and intact. Respiration unlabored, chest rises and

falls symmetrically. Lungs sound clear bilaterally. Heart beat strong

and regular sounds S1, S2 heard. Nipple prominent and

symmetrical.

Abdomen soft and not distended, bowel sounds heard x 4.

Umbilical blood vessels present, 2 arteries, one vein, femoral pulse

equally bonding, Ortolani and Barlow maneuver done, no hip

dislocation noted. External genitalia appear normal, completely

covered clitoris Anus patent. Back appears smooth lanugo

observed. Spinal cord, well aligned, no dimpling to sacrum,

Mongolian spot seen to gluteus. All reflexes intact blink, suckling,

rooting, moro, palmer, plantar, gasp trunk incurvature and

Babinski
.
No. Date Client Age Initials Of
Term/ Intervention Instructor/
Int. Assessment Findings Preceptor
Preterm