Ferris State University

NURS 342
Summer 2010
Newborn Assessment
Newborn Physical Assessment Please use the ollowin! co"e#
+ = Present/normal = Not present NA = Not applicable
A"mission "ata $ This will be obtained from the babys chart!):
Temp HR: 36.8 Resp: 148 bpm Bld glucose: not present
APGAR Score 1 min: 8 min: 9 Resuscitation measures: Delayed cord clamping to pre
warm infant, tactile stimulation
!lot"cin 13:2 #time$ %it & 13:2 #time$ 'engt( !4.6 cm )t* 386! grams
Nursed in '+, " N
A-ter "ou (a.e read t(e in-ant/s c(art and gat(ered t(e in-ormation0 gi.e "our assessment
o- t(is in-ant/s status 1(en it 1as 1 (our a-ter birt( #gi.e details0 not 2good3$
!n-ant 1as under radiant 1armer* !n-ant/s color is consistent 1it( race* Respirator"
assessment -ound t(at lungs 1ere clear bilaterall"* Respirator" rate 1as 1it(in t(e normal
limits o- 45675 bpm* Heart beat 1as normal 1it(in t(e normal limits o- 1556175 bpm
and rate 1as stead" and regular* Anterior -ontanels 1ere so-t and -lat* !n-ant/s s8in 1as
so-t0 dr" and intact* T(ere 1as no e"e drainage* !n-ant 1as easil" aroused and
demonstrated a lust" cr"* !n-ant (ad -ull range o- motion o- all limbs*
N%& '%U AR( R(A)' *% )% A P+'S,-A. ASS(SS/()N* %N *+,S 0A0'
$to be com1lete" by you the "ay you are carin! or the baby2#
Temp 36.! HR 146 bpm Resp 4! bpm
-olor# Pin8 # Pale 9 : 9999 ;ottles 9 : 99999 Plet(oric 9 : 99999
<aundice 99 : 9999 Stained 9 : 99999 Acroc"anosis 9 : 99999
S3in# =lear # Pressure mar8s 9 : 99999 Abrasions 99 : 9999 ,r" #
>cc("mosis 99 : 9999 Petec(iae 99 : 9999 Ne.i 9 : 99999 ;ilia 9 : 99999
Ras( 99 : 9999 'anugo 99 : 9999 %erni? 99 : 9999 ;ongolian spots 9 : 99999
Res1irations# Regular # Grunting 99 : 999 Abdominal 99 : 99 Retracting 9 : 99
1
S(allo1 : 99999 Nasal -laring 9 : 99999 Sig(ing 99 : 999 @t(er 9NA9999
=r": 'ust" $ )ea8 9 : 99999 S(rill 99 : 9999
+ea"# S"mmert"/s(ape %ound ;olding 99 : 99999999 =ep(al(ematoma 99 : 999
=aput succedaneum 9 : 99999 !S> mar8 9 : 99999 @t(er 999NA999
Anterior -ontanel: Alat $ Aull 9 : 99999 ,epressed 9 : 99999
Posterior -ontanel: Alat $ Aull 99 : 9999 ,epressed 99 : 9999
Sutures @.erriding Separated Appro?imated
=oronal 999 : 999 99 : 999 99 : 999999
Sagittal 99 : 999 99 : 999 999 : 99999
'ambdoidal 9 : 99999 999 : 99 9999 : 9999
(ars# #describe e?act location + (o1 "ou determined i- it 1as normal$
Position: Normal #Abnormal 99 : 9999 ,escribe normal position e&en wit' bot' eyes
S8in tags 9 : 99999
Nose# S"mmetr" # Alaring 9 : 99999 Patent: 'e-t yes Rig(t yes
(yes# $describe 1(at "ou -ound$
Rig(t 'e-t
SubconBuncti.e (emorr(age 9 : 9 9 : 99
Ne.i on lids 9 : 99 99 : 9
>dema 9 : 99 99 : 9
Red re-le? 9 : 99 9 : 99
@t(er 9NA99 99NA9
/outh# ;ucous membranes: Pin8 # Pale 9 : 999 ="anotic 9 : 999
Teet( 9 : 999 >pstein/s pearls 99 : 9999
Hard palate: !ntact # Abnormal 99 : 999999999999999999999999
So-t palate: !ntact # Abnormal 999 : 99999999999999999999999
'ips: =le-t 9 : 99999 ,rooping 9 : 99999 S"mmetr" 9#99999
Anterior chest# S"mmetrical 9#99999 S(ape 9#99999
=la.icles: !ntact # Aracture 9 : 999999999999999999999999
Breasts: Palpable tissue 9 # 999 >ngorgement 9 : 99999
Heart sound: RRR 99steady, regular, strong99 @t(er 9NA99999
C
4enitals# %oided: ,ate ()13)213 Time 8:4! =olor o- urine unable to tell
;ale: Dret(ral ori-ice: Normal position *+ Abnormal #describe$ *+
Testes #E/location$ *+99999999999999999999999999999999999999999999999999
Scrotum *+ Pendulous *+ Rugated *+ @t(er *+
Aemale: 'abia maBora: =ompletel" co.ers minora # Partiall" co.ers minora 9 : 9999
'abia minora protruding 999 : 999 %aginal disc(arge # ,mucous- H"menal tag 9 : 99
Posterior# Pilonidal dimple # Tru-t o- (air 9 : 99999
Spinal column: S"mmetr" # !ntact 99#9999
Anal patenc": " N Stool " N T"pe .econium
Anterior Ab"# S"mmetr" # @t(er 99999999999999
=ord: E o- .essels 3 Protruding base *o %//D+
(5tremities#
Rig(t 'e-t
S"mmetr" 00#000 00#0000
;o.ement 00#000 99#9999
,igits #number$ 999!99 9 !99
Ale?ion creases 99+999 9#0999
Palmar creases 99#999 99#9999
Sole creases 99+999 99#0999
+i1s#
!ntact ,islocated/sublu?ation
Rig(t 9#9999 99 : 0999
'e-t 9#9999 99 : 0999
Neuro6muscular# Tone: Normal 9#9999 'et(argic 9 : 9999
Rigid 99 : 9999 Tremors 99 : 9999
4
Re-le?es:
Re-le?: ,escribe 1(at "ou
obser.ed
,escribe t(e procedures ,escribe normal responses
Rooting :Bab" turned (ead
to1ards m" -inger 1(en !
rubbed on (er c(ee8*
Rub inde? -inger b" bab"/s
mout(
Normal -or a ne1born is -or
t(e bab" to turn -ace
to1ards t(e rubbing on t(e
-ace
Suc8ing: Bab" suc8 on
-inger 1(en place in (er
mout(*
)it( a glo.es -inger place
in in-ants mout(*
Normal response -or a
ne1born is -or t(e in-ant to
suc8 on -inger*
;oro: Bab"/s arms and leg
e?tended*
Hold bab" under t(e nec8
and arms and gentle drop
bab"0 as i- to ma8e t(e bab"
-eel li8e t(e" are -alling*
Normal response -or a
ne1born is t(at t(eir arms
and legs 1ould -ull" e?tend
out as i- reac(ing -or
somet(ing*
Stepping: Bab" li-ts legs
and -eet as i- s(e 1as
1al8ing*
Hold bab" under arm pits
1(ile supporting t(e bab"/s
(ead* Gentl" touc( t(e
bab"/s -eet to t(e bassinet*
Normal response is -or t(e
bab" to li-t legs as i- t(e"
1ere 1al8ing*
Grasp/(and: Bab" 1raps (er
-ingers around m" -inger*
Gentl" place -inger across
in-ant/s palm*
Normal response i- -or
ne1born to 1rap t(eir
-ingers around "our -inger*
Grasp/-oot: Bab"/s toes curl
around -inger*
Gentl" place -inger across
t(e bab"/s -oot at t(e base
o- toes*
Normal response -or a
ne1born is -or bab"/s toe to
curl around -inger*
)(at is "our o.erall assessment an" prognosis -or t(is in-ant #do not sa" 2good3$:
A-ter re.ie1ing t(e in-ant/s APGAR score and a (ead to toe assessment it appears t(e
in-ant s(ould de.elop at a normal rate* S(e (asn/t (ad an" di--iculties 1it( temperature
regulation or 1it( breast -eeding* S(e appears to be 1it(in all t(e normal limits -or an
in-ant o- (er gestational age*
F
On the basis of your assessment, list at least TWO nursing diagnosis for this baby and all the teaching
interventions you would use for each nursing diagnosis. Please include the rationale for your actions.
You must have at least two references besides your textbooks for your rationales. Be sure your
assessment and interventions correspond to your Nursing iagnosis.
Nursin! )ia!nosis Necessary
Assessments7,nterventions
Rationale
1* >--ecti.e
breast-eeding
related to basic
breast-eeding
8no1ledge
C* At ris8 -or
ine--ecti.e
temperature
regulation related
to immaturit"
1* Pro.ide in-ant contact 1it(
mot(er s8in to s8in and (a.e
in-ant nurse 1it(in -irst (our o-
birt(
C* !nstruct proper positioning
4* Nurse G615 times in CF (our
period
F* ;onitor stools and .oids
1* Dse t(e same met(od to record
temperature #i*e* au?iliar"$
C* &eep (ead co.ered
4* &eep in-ant co.eredH blan8et
F* S8in to s8in #8angaroo care$
Ha.ing t(e in-ant nurse 1it(in t(e -irst (our o- birt(
promotes bonding0 and encourages mil8 production*
Proper positioning is important -or t(e in-ant to be able to
latc( onto t(e breast and (elp to pre.ent nipple soreness*
Nursing t(e in-ant G615 times in a CF (our period (as
encourages mil8 production and pro.ides adeIuate
nutrition -or in-ant gro1t(*
B" monitoring stools and .oids allo1s parents and
p("sicians to ensure in-ant is getting enoug( nutrition and
-luids*
B" using t(e same met(od -or ta8ing t(e in-ants
temperature allo1s -or consistent and accurate
temperature measurement*
&eeping t(e in-ant co.ered in clot(ing0 blan8et and a (at
(elps t(e in-ant conser.e (eat and t(ere-ore (elps to
regulate in-ants temperature
S8in to s8in care (elps to 8eep in-ants temperature
regulated b" t(e mom trans-er (er (eat to t(e in-ant*

4* At ris8 -or
in-ection related
to brea8 in s8in at
umbilical cord
site
1* &eep umbilical stump dr"
C* &eep umbilical stump clean
4* Pro.ide in-ant a sponge bat( till
umbilical stump -alls o--s
F* 'et umbilical stump -all o-- on
its o1n
&eeping t(e umbilical cord dr" (elps t(e cord -all o--
-aster and pre.ent in-ection* )et0 moist0 dar8 areas are
breeding grounds -or bacteria* T(at/s is 1(" it is
recommended to 8eep t(e cord dr"0 clean0 and to in-ant
sponge bats tills t(e umbilical cord -alls o--*
'etting t(e umbilical cord -all o-- on its o1n means t(at
nature (as done its Bob* Ta8ing t(e umbilical cord o--
prematurel" could cause in-ection*
7
Re-erences
Bo"d0 A* >*0 + SpatJ0 ,* '* #C514$* Breast-eeding + (uman lactation: education and circular issue -or pediatric nurse practitioners*
1ournal of 2ediatric 3ealt' 4are, 2(#C$0 G46K5* /Retrie.ed -rom: (ttp://56
d?*doi*org*libcat*-erris*edu/15*1517/B*ped(c*C511*54*55
!mdad0 A*0 Bautista0 R*0 Senen0 &*0 D"0 ;*0 ;antaring0 !*0 + B(utta0 L* #C514$* Dmbilical cord antiseptics -or pre.enting sepsis and
deat( among ne1borns* 4oc'rane Database of 5ystematic %e&iews0 #$
'unJe0 &* #C51C$* T(ermal protection o- t(e ne1born in resource6limited en.ironments* 1ournal of 2erinatology0 320 41M64CF*
Retrie.ed -rom Retrie.ed -rom: (ttp://56go*galegroup*com*libcat*-erris*edu
;ulder0 P*0 <o(nson0 T*0 + Ba8er0 '* #C515$* >?cessi.e 1eig(t loss in breast-ed in-ants during t(e postpartum (ospitaliJation*
167**: 1ournal 6f 6bstetric, 7ynecologic 8 *eonatal *ursing0 39#1$0 16C7* doi:15*1111/B*1C67K5K*C55K*515G*?
P(illips0 R* #C514$* T(e sacred (our: uninterrupted s8in6to6s8in contact immediatel" a-ter birt(* *ewborn and 9nfant *ursing %e&iew0
13#C$0 7M6MC* (ttp://d?*doi*org/Retrie.ed -rom: (ttp://o6d?*doi*org*libcat*-erris*edu/15*154/B*nanir*C514*5F*551
M