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Antepartal risk factors (This will be obtained from the mother's chart!):
Maternal Age ___28___Gravida/Para(GTPAL) 1-1-0-0-1 Gestational Age___38 1/7____
Onset of Prenatal Care__6 weeks_______ Maternal Blood type __O+____
Planned/Unplanned pregnancy _planned_ Maternal Substance abuse___no__ Gestational
Diabetes___no_____ Maternal Infections___none___ Abnormal US findings ___none_______
Additional information _____________________________________________________
__8lbs 10oz______
Nursed in L&D: Yes
No
= Not present
NA = Not applicable
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 ______
Overriding
Separated
Approximated
Coronal
________
________
____+_______
Sagittal
________
________
_____+______
Lambdoidal
________
________
____+_______
Ears: (describe exact location & how you determined if it was normal)
Position: Normal ___+___ Abnormal ______ Describe normal position: In line with eyes
Skin tags _ _____
Nose: Symmetry ____+____ Flaring ____ __ Patent: Left ___+__ Right ____+_
Eyes: (describe what you found) Symmetric in size and shape
Right
Left
Subconjunctival hemorrhage
__ ___
__ ___
Nevi on lids
_ ____
__ ___
Edema
__ ___
___ __
Red reflex
__N/A___
__N/A ___
Other
___ __
__ ___
Mouth: Mucous membranes: Pink ___+___ Pale ___ ___ Cyanotic __ _____
Teeth ____ __ Epsteins pearls ___ ___
Hard palate: Intact ___+___ Abnormal _______________________________
Soft palate: Intact ___+___ Abnormal ________________________________
Y N
Stool:
Y N Type ___Meconium____
Spinal Column: Pilonidal dimple ___ ___ Tuft of hair ___ ___
Symmetry __+____ Intact ___+___
Extremities:
Right
Left
Symmetry
___+___
____+__
Movement
__+____
___+___
Digits (number)
___10___
___10___
Flexion creases
___+___
___+___
Palmar creases
__+____
___+___
Sole creases
___+___
__+____
Intact
Dislocated/subluxation
___+___
___ ___
Hips:
Right
Left
___+___
___ ___
Neuro-muscular: Tone: Normal ___+_ Lethargic ___ _ Rigid ___ _ Tremors ___ _
Reflexes:
Reflex: Describe what
you observed
Sucking: sucked on
examiners finger
Moro: Infant extended and
then brought in arms
Stepping: infant lifted feet
and legs off table
Grasp/hand: grasped fingers
Grasp/foot: toes curled
around finger
Describe normal
responses
-Infant turns head towards
stimulus and opens mouth
- Infant turns head towards
stimulus and opens mouth
- extension of arms, fingers
fan out
-Infant will simulate
walking, picking feet up off
table
-infants fingers curl round
examiners finger
-toes curl downward
What is your overall assessment and prognosis for this infant (do not say good):
This is a very healthy baby boy, who does not have any abnormalities that will prevent
him from adjusting to extrauterine life. The newborn had an Apgar score of 8 and 9, so this is a
good indicator the he will not have any complications in the near future. He did not show any
signs of respiratory distress or abnormal vital signs. The assessment was normal and he did not
have any abnormalities that would cause concern. Overall, he was very healthy and has a good
prognosis.
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
Ineffective airway
clearance
Necessary
Assessments/Interventions
-Watch infants for signs of
respiratory distress
-auscultate lungs and monitor
respirations
-position on back when sleeping
-monitor vital signs and review
maternal record for any risk
factors
Rationale
References:
Knobel, R. B., Guenther, B. D., & Rice, H. E. (2011). Thermoregulation and Thermography
in Neonatal Physiology and Disease. Biological Research for Nursing, 13(3), 274
282. http://doi.org/10.1177/1099800411403467
Lowdermilk, D. Perry, S. Cashion, K. Alden, K. (2012). Maternity & Womens Health Care.
11th Edition.
Visscher, M. Adam, R. Brink, S. Odio, M. (2014). Newborn infant: physiology, development,
and care. Clinics in Dermatology. Volume 33(3).