Running Head: NEWBORN ASSESSMENT 1

Ferris State University

NURS 342
Summer 2010
Newborn Assessment
Newborn Physical Assessment Please use the ollowin! co"e#
+ = Present/normal = Not !resent NA = Not a!!li"a#le
$$% use" a &'& to in"icate not (resent) % coul" not in" the other symbol
on my com(uter*$$
A"mission "ata + This will be obtained from the babys chart!):
,em(# $%&' -R# 1() Res(# %) .l" !lucose# NA
AP/AR Score 1 min# % 0 min# * Resuscitation measures# +ela,ed "ord "lam!ing-
ta"tile stimulation- s.in to s.in /0en sta#le
%lotycin# NA 1time2 1it 2# )%)) 1time2 3en!th# '1&) in"0es 4t5# %&)1 l#s
Nurse" in 367# 3es
Ater you have rea" the inant8s chart an" !athere" the inormation) !ive your
assessment o this inant8s status when it was 1 hour ater birth +!ive "etails) not
9!oo":;
An 0our a4ter #irt0 t0e #a#, 0ad a regular 0eart r0,t0m- no murmur /as !resent& T0e
#a#ies res!irator, status /as t0at t0ere /as a regular rate and !attern- lungs /ere "lear to
aus"ultation& T0ere /as no grunting- nasal 4laring or retra"tions& T0e #a#, /as 5uiet and
alert and /0en t0e #a#, 4ell aslee!- t0e #a#, /as easil, aroused /it0 "are& T0e a#domen
/as so4t and nondistended- t0e #o/el sounds /ere a"ti6e& T0e #a#, is res!onding /ell
to #reast 4eeding a4ter t0e 4irst attem!t at #irt0& T0e s.in o4 t0e #a#, /as /arm and inta"t&
T0e #a#, 0ad ' 7+ #ands !la"ed #, t0e 0our mar.- a la# #and and a se"urit, tag& T0e
#a#, also seemed to #e a#le to 0ear sin"e t0e #a#, /ould turn to/ards t0e mom /0en
s0e8d tal. to t0e #a#,& Also- t0e #a#, a!!eared to #e loo.ing at 0er /0i"0 indi"ated s0e
"an see 0er mot0er&
N<4 =<U AR> R>A7= ,< 7< A P-=S%?A3 ASS>SS@>7N, <N ,-%S .A.=
+to be com(lete" by you the "ay you are carin! or the baby;#
NEWBORN ASSESSMENT '
,em(# $(&( -R# 11) Res(# $1
?olor# Pin.: #a#, is lig0t !in. Pale: /not !ale- #a#, is !in. @ottles#'A NA Plethoric#
NA
Baun"ice# /No 9aundi"e !resent Staine"# /does not a!!ear to #e stained
Acrocyanosis# /no #lue "olor !resent
SCin# :lear: no #um!s Pressure mar.s: A#rasions: +r,:
E""0,mosis: Pete"0iae: Ne6i: Milia:
Ras0: ;anugo: + <erni=: + Mongolian s!ots:
Res(irations# Regular: !resent/normal >runting: / No grunting A#dominal:
Retra"ting: /No retra"tions !resent
S0allo/: s0allo/ #reat0ing /0en slee!ing/resting Nasal 4laring: /no nasal 4laring
"urrentl, Sig0ing: /no sig0ing !resent Ot0er ??????
:r,: ;ust,: + "r, is lust, Wea.: /NA S0rill: /"r, is not s0rill
-ea"# S,mmetr,/s0a!e: 0ead is s,mmetri"- slig0tl, "one s0a!ed #e"ause o4 6aginal
deli6er, Molding: slig0tl, "one s0a!ed :e!0al0ematoma: /no 0ematoma !resent
:a!ut su""edaneum: /none noted 7SE mar. : Ot0er: NA
Anterior 4ontanel: @lat: + @ull: +e!ressed:
Posterior 4ontanel: @lat : + @ull: +e!ressed:
Sutures O6erriding Se!arated A!!ro=imated
:oronal +- little #it o6erriding- not totall, se!arated a#out an 0our a4ter #irt0
Sagittal +- little #it o6erriding- not totall, se!arated a#out an 0our a4ter #irt0
;am#doidal +- little #it o6erriding- not totall, se!arated a#out an 0our a4ter #irt0
>ars# 1des"ri#e e=a"t lo"ation A 0o/ ,ou determined i4 it /as normal2
Position: Normal: normal !osition A#normal: / NA +es"ri#e normal !osition: ears le6el
/it0 "orner o4 e,es
SCin ta!s# / none !resent
Nose# Symmetry# +/nose is s,mmetri" Flarin!# / no 4laring Patent# 3et# +/is !atent
Ri!ht# DAis !atent
>yes# +des"ri#e /0at ,ou 4ound2
Rig0t ;e4t
NEWBORN ASSESSMENT $
Su#"on9un"ti6e 0emorr0age
Ne6i on lids
Edema /NA /NA
Red re4le= N/A N/A
Ot0er N/A N/A
@outh# @ucous membranes# PinC# DAis !in. Pale# /NA ?yanotic# /NA- none noted
,eeth# /no teet0 >(stein8s (earls: not !resent
-ar" (alate# %ntact: +/ Hard- and inta"t- no 0oles Abnormal: /NA
Sot (alate# %ntact: +/inta"t- and no 0oles Abnormal# 'ANA
3i(s# ?let# /NA 7roo(in!: /NA Symmetry: +/li!s are s,mmetri"- !in.- smoot0
Anterior chest# Symmetrical# +/s,mmetri"al- Sha(e: #arrel s0a!ed
?lavicles# %ntact# +/inta"t- no #ro.en #ones Fracture# 'Ano 4ra"ture !resent
.reasts# Pal(able tissue: + - t0ere8s tissue t0ere >n!or!ement:
-eart soun"# RRR: +/regular- no murmur Ot0er: /NA
/enitals# 1oi"e"# DA3es- urinated and 0ad stool in dia!er 7ate: B'B1$ ,ime# 1'))
?olor o urine# !ale ,ello/
@ale# Urethral oriice# Normal (osition# NA Abnormal +"escribe; NA
,estes +EAlocation; NA
Scrotum# NA Pen"ulous# NA Ru!ate"# NA <ther# NA
Female# 3abia maFora# ?om(letely covers minora# :o6ers "om!letel, Partially
covers minora# NA- "o6ers entire area
3abia minora (rotru"in!: NA- "o6ered #, la#ia ma9ora 1a!inal "ischar!e# none
!resent -ymenal ta!# None !resent or noted
Posterior# Pilonidal dim!le: ,rut o hair: NA- no 0air !resent
S(inal column# Symmetry# D %ntact# D
Anal (atency: 3es Stool# 3es ,y(e: me"onium
Anterior Ab"# S,mmetr,: + Ot0er: N/A
?or"# E o vessels# $- ' arter,- 1 6ein Protruding #ase:
>Gtremities#
NEWBORN ASSESSMENT C
Rig0t ;e4t
S,mmetr, S,mmetri" S,mmetri"
Mo6ement @le=ed @le=ed
+igits 1num#er2 D toes/4ingers Dtoes/4ingers
@le=ion "reases + +
Palmar "reases
Sole "reases
-i(s#
7nta"t +islo"ated/su#lu=ation
Rig0t + not dislo"ated
;e4t + not dislo"ated
Neuro'muscular# Tone: Normal + ;et0argi"
Rigid Tremors
Re4le=es:
Re4le=: +es"ri#e /0at ,ou
o#ser6ed
+es"ri#e t0e !ro"edures +es"ri#e normal res!onses
Rooting: #a#, turned
to/ards t0e side o4 t0e 0ead
7 stro.ed&
;ig0tl, stro.e t0e side o4
t0e #a#ies 4a"e to see i4
#a#, turns 0ead t0at /a,
Ba#, /ill turn 0ead to/ards
t0e side t0at /as stro.ed&
Su".ing: W0en 7 !la"ed m,
!in.,- /0i"0 /as glo6ed-
t0e #a#, #egan su".ing&
Stimulate t0e #a#,8s mout0
#, !la"ing a 4inger inside-
or e6en a #in.,- and see i4
t0e #a#, #egins to su".&
Ba#ies /ill #egin su".ing
on 4inger /0en stimulated- a
su".ing motion o""urs&
Moro: Ba#, tensed/4le=ed
u! /0en 7 "la!!ed&
Ma.e a loud sound- su"0 as
"la!!ing and see 0o/ #a#,
res!onds& Ba#, s0ould
startle&
A loud noise /ill startle t0e
#a#, and "ause t0en to tense
u!/4le=&
Ste!!ing: 7 0eld t0e #a#, u!
and t0e #a#, started
Hold t0e #a#, u! so t0at
t0e 4eet are 9ust tou"0ing a
Holding t0e #a#, u! so t0at
t0e 4oot tou"0es a sur4a"e
NEWBORN ASSESSMENT D
ste!!ing li.e it /as /al.ing
in air&
sur4a"e and o#ser6e i4 t0e
#a#, is ste!!ing- /0i"0 is
t0e 4le=ing and e=tension o4
t0e legs&
/ill "ause t0e #a#, to 4le=
and e=tend t0e leg& T0is
mimi"s /al.ing&
>ras!/0and: 7 !ut m, !in.,
gentl, on t0e #a#ies 0and
and t0e #a#, gra##ed m,
!in.,&
>entl, tou"0 t0e #a#ies
0and to see i4 t0eir re4le=
/ill "ause t0em to gra#
,our !in.,&
Ba#, /ill gras! /0ate6er is
!ut in t0eir 0and- su"0 as a
4inger&
>ras!/4oot: 7 tou"0ed t0e
#a#ies 4oot and s0e "urled
0er toes as i4 tr,ing to 0old
m, !in.,&
>entl, tou"0 t0e #a#ies
4oot to see i4 #a#, rea"ts
and tries to gras! 4inger&
Ba#, /ill tr, to gras! /it0
t0eir 4oot /0ate6er is
tou"0ing t0eir 4oot&
W0at is ,our o6erall assessment an" !rognosis 4or t0is in4ant 1do not sa, EgoodF2
T0e #a#, seems to #e 4un"tioning normal 4or a ne/#orn& T0e #a#, is 6er, "alm and
doesn8t "r, mu"0& T0e #a#, seemed to #e most "om4orta#le /0en s/addled and #eing
0eld #, mom& T0e #a#, 0as t0e desire to #reast 4eed e6en t0oug0 it 0as 0ad a little
di44i"ult,- and /ill #e a#le to #etter lat"0 on a4ter a little /0ile& T0e #a#, 0as no
noti"ea#le a#normalities t0at "an #e seen& T0e #a#, a!!ears to #e 6er, 0ealt0, and 0as
t0e a!!ro!riate re4le=es t0at s0ould #e !resent in a ne/#orn& T0e #a#, is not "r,ing as
mu"0- t0e #a#, is more a/are o4 its surroundings outside t0e /om# and a!!ears to #e
ada!ting 6er, /ell& Mom and dad seem to #e ad9usting to !arenting as /ell&
NEWBORN ASSESSMENT (
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! 7ia!nosis Necessary
AssessmentsA%nterventions
Rationale
%neective
thermore!ulation RA,
immature com(ensation
or chan!es in
environmental
tem(erature5
15 Parents Ce(t taCin! o the
babies hat) ha" to teach them
that it8s im(ortant to Cee(
their hea" covere" so they
"on8t lose heat that way5
25 Promote wellness o the baby
by checCin! vital si!ns such
as tem(erature to maCe sure
the baby is stayin! warm)
checC or hy(o!lycemia5
35 Place baby un"er warmer or
use a layer o li!htwei!ht
blanCets5
45 ,each (arents im(ortance o
maCin! sure the baby stays
warm5
.abies have a har" time Cee(in! their tem(eratures
re!ulate"5 4e have to assist them by Cee(in! them warm)
an" (uttin! a hat on their hea" so that heat "oesn8t esca(e
that way5 +1isitor) 1HIH;5 A baby loses control over their
tem(erature at ni!ht so we nee" to maCe sure the (arents are
e"ucate" on this matter so that they can taCe care o their
baby5 Swa""lin! the babies not only comorts them) but is
hel(s re"uce the risC o heat loss an" lessens thermal stress
they may eG(erience when slee(in!5
NEWBORN ASSESSMENT B
%mbalance" nutrition#
less than bo"y
reJuirements RA, (oor
inant ee"in! behaviors
15 Assist an" show the new
mother on how to (ro(erly
breast ee" her newborn5
25 @onitor inants wei!ht to
maCe sure the inant is taCin!
in enou!h nutrients +intaCe
an" out(ut;
35 Assess the baby to maCe sure
the baby has the (ro(er
sucCin! techniJue) an" it
latchin! on correctly5
45 ,each the mother what she
can "o) an" "iscuss her
eelin!s about !ivin! the baby
ormula i she is havin! a
har" time breastee"in!5
Newborns nee" to be monitore" closely5 .y Cee(in! tracC o
intaCe an" out(ut we are able to maCe sure that the baby is
!ainin! the a((ro(riate amount o wei!ht an" receivin!
a"eJuate nutrition5 .y su((ortin! the mother throu!h
breastee"in! we are able to hel( her an" assist her i she has
Juestions5 +-olmes) 2013;5 Plans can be constructe" an"
reconstructe" to hel( im(rove the breastee"in! (rocess5 .y
"iscussin! with the mom we can "etermine i she is havin!
issues breastee"in! an" i she woul" (reer to !ive the baby
ormula5
NEWBORN ASSESSMENT %
Reerences
An"erson) ?5) 4ailoo) @5) 6 Petersen) S5 +1HIH;5 2ee(in! babies warm# have we !ot it ri!htK5 -ealth 1isitor) L2+12;) 3M25
-olmes) A5 +2013;5 >stablishin! successul breastee"in! in the newborn (erio"5 Pe"iatric ?linics < North America) L0+1;) 14M'1LI5
"oi#105101LAF5(cl5201250H5013
NEWBORN ASSESSMENT *
>RA+7N> RGBR7: @OR OB OR NEWBORN ASSESSMENT
.elow >G(ectations Nee"s %m(rovement @eets >G(ectations >Gce(tional
A5 Assessment 11D !oints2
Assessment 0as H1' #lan.
s!a"es- 0as !oor anal,sis
1') !oints2
Assessment 0as *1' #lan.s
1'D !oints2
Assessment 0as D% #lan.
s!a"es- anal,sis need to #e more
in de!t0
1$) !oints2
Assessment 0as no #lan. s!a"es
and e="e!tional anal,sis
.5 Nursin! "ia!nosis 1) !oints2
+oes not "om!lete t0e "are !lan
11D !oints2
:0ooses ina!!ro!riate nursing
diagnoses #ased on t0e
assessment
11B !oints2
:0ooses 1' a!!ro!riate nursing
diagnoses #ased on t0e
assessment
1') !oints2
:0ooses $ a!!ro!riate nursing
diagnoses #ased on t0e
assessment
?5 %nterventions 1) !oints2
+oes not 0a6e an, inter6entions
11D !oints2
Has "0osen ina!!ro!riate nursing
inter6entions
11B !oints2
:0ooses '$ a!!ro!riate nursing
inter6entions 4or ea"0 diagnosis
1') !oints2
:0ooses C or more a!!ro!riate
nursing inter6entions 4or ea"0
nursing diagnosis
75 Rationale or interventions 1) !oints2
+oes not 0a6e an, rationales 4or
inter6entions
11D !oints2
Stated ina!!ro!riate rationales
4or nursing inter6entions
11B !oints2
Stated a!!ro!riate rationales 4or
nursing inter6entions 4or ea"0
diagnosis
1') !oints2
7nde!t0 dis"ussion o4 t0e
nursing inter6entions 4or ea"0
diagnosis /it0 e6iden"e#ased
su!!ort outside o4 te=t#oo.s
>5 /rammar) s(ellin!) 6
clarity o i"eas
1' !oints2
H1) errors in grammar or
s!ellingI ideas are not "learl,
!resented
1D !oints2
J1) errors in grammar or
s!ellingI ideas are almost al/a,s
"learl, !resented
1B !oints2
JD errors in grammar or s!ellingI
ideas are "learl, !resented
11) !oints2
APA 4ormat is e="ellentI no
errors in grammar or s!ellingI
ideas are "learl, !resented