Scores 0 Scores 1 Scores 2

Heart rate Absent <100 >100bpm

Respiratory rate Absent Slow, irregular Good lusty cry
Reflex irritability No response Grimace, some motion Cry, cough
Muscle tone Flaccid, limp Flexion of extremities Active flexion
Color Cyanotic, pale Pink body acrocynosis Pink. Pink extremities

APGAR SCORE Normal findings Abnormal findings

Assign Apgar scores at 1 and at 5 The score is 8-10 A score of less 8 may indicate a
minutes after delivery . he Apgar poor transition from intrauterine
score is an assessment of to extrauterine life.
infant;s ability to adapt to
extrauterine life. Assess the
following:

Auscultate apical pulse The pulse is less than 100 bpm Pulse I greater than 100 bpm
indicating bradycardia, absent
heartbeat indicated fetal
demise.

Inspect chest and abdomen for The newborn is crying The newborn has absent, slow
respiratory effort. and irregular respirations.

Inspect muscle tone by The extremities are flexed, an Delayed neurologic function may
extending legs and arms. you note active movement be seen in grimace, no response.
Observe degree of flexion and
resistance in extremities.

Inspect body and extremities for The full body should be pink The newborn is cyanotic, pale
skin color (acrocynosis)

VITAL SIGNS Normal findings Abnormal findings

Monitor axillary temperature Temperature is 97.5 to 99 F A temperature of less than 97.5
(36.4 to 37.2 C) F ndicated hypothermia which
may suggest sepsis.

A temperature of greater than

37.2 Cindicates hyperthermia.
(consider infection or improper
monitoring of temperature
probe).

Inspect and auscultae lung Breathing is easy and Labored breathing, nasal falring,
sounds nonlabored. The lungs are clear rhonci, rale sretarcitons ang
bilaterally grunting
Monitor respiratory rate
Auscultate apical pulse
MEASUREMENTS
Weigh the newborn using a
newborn scale
Measure length
Measure head circumference
Measure chest circumference.
Place tape measure at nipple
line and wrap around th infant
GESTATIONAL AGE
To asses neuromuscular (with
the newborn in supine position)
Inspect posture (with the
newborn undisturbed)
Assess for square
Assess for recoil. Bilaterally flex
elbow up
Rate is 30 to 60 breaths/min
Pulse is regular and within
range of 120 to 140 beats/min
while at rest. The rate may rise
to 180 beats/min when crying
or fall to 100 beats/min when
sleeping.
Normal findings
The newborn weighs between
2500 to 4000g
The newborn is 44 to 55 cm
Circumference is 33 to 35.5 cm
Circumference is 30 to 33 cm
(1 to 2cm less than head)
Normal findings
Arms ang legs are flexed
Angle is 0 to 30
A rate less than 30 or greater
than 60 breaths/min is seen
with respiratory distress
Pulse is irregular or the rate is
above 180 beats/min while
crying: below 100 beats/min
while sleeping may indicate
cardiac abnormalities
Abnormal findings
Weiht is less than 2500 or
greater than 4000g
Length is less than 44 or greater
than 55 cm
Circumference is less than 33 cm
or greater than 35.5. this may
indicate microcephaly, improper
bran growth, premature closing
of the sutures, intrauterine
infection, or chromosomal
defect
Circumference less than 29 cm
or greater than 34 cm
Abnormal findings
In premature children the
newborns arms and legs may
be limp and extend away from
the body
In premature children, may
have a square window
measurement of less than 30

Assess popliteal angle. Flex
thigh on the top of abdomen;
push behind the ankle and
extend the lower leg up
towards the head until
resistance is met. Measure the
angle behind the knee
Assess for scar sign. Lift the arm
across the chest toward the
opposite shoulder until
resisteance is met; note
location of elbow in relation to
midline of chest
Perform
SKIN, HAIR, and NAILS
Assess for skin colr, odor, and
lesions
Elbow anle is less than 90 and
the arm rapidly recoils to a
flexed state.
The angle should be less than
100
Elbow position is less than
midline of chest
Normal findings
Skin color ranges rom pale
white with pink, yellow, brown
or olive tones to dark brown or
black. No strong odor should be
evident, and the skin should be
lesion free.
Skin should be soft, warm,
slightly moist with good turgor
and without edema or lesions.
Common newborn skin
variations include
Physiologic jaundice
Birthmarks
Milia
Erythema toxicum
Telangiectatic nevi (
stork bites)
Another common variation in
harlequin sign (one side of the
bosy turns red: the other side is
Elbow angle may be geater than
110 and delayed recoil may be
seen
Premature children may have o
popliteal angle of greater than
100
In premature children, elbow
position is at midline of chest or
greater
Abnormal findings
Yeloow skin may indicate
jaundice or passage of
meconium in utero secondary
to fetal distress. Jaundice within
24 hours after birth is
pathologic and may indicate
haemolytic disease of the
newborn. Blue skin suggest
cyanosis, pallor suggest anemia
and redness suggest fever,
irritation.

Palpate for texture,
temperature, moisture, turgor
and edema.
Inspect and palpate hair.
Observe for distribution,
characteristics, and presence of
any unusual hair in the body.
Inspect and palpate nails. Note
color, texture, shape and
condition of nails
.
pale). There is a distinct color
line separation at middle. The
cause is unknown.
Dark skinned newborns have
lighter skin color than their
parents. Their color darkens
with age. Bluish pigmented
areas called Mongolian spots
may be noted on the sacral
areas of Asian, black, native
American, and Mexican-
Americam infants.
Skin is warm and slightly moist. Ecchymoses in various stages or
Vernix caseona (cheesy, white in unusual location or circular
substance that is found on the burn areas suggest child abuse
skin, especially in skin folds) is a although bruising or burning
common finding; it eventually may also be from cultural
absorbs into the skin. practices such as cupping or
coining. Petechiae, leisons or
rashes may indicate serious
disorders.
Hair is normally lustrous, silky, Dirty, matted hair may indicate
strong and elastic. Fine, downy neglect.
hair covers the body.
Dark skinned children have Blue nailsbeds may indicate
deeper nail pigment,. Nails cyanosis, yellow nailbeds
extend to end of fingers or indicate jaundice. Blue-black
beyond ,are well formed. nail beds suggest a nailbed
hemmorhage.
 BICOL UNIVERSITY

COLLEGE OF NURSING

LEGASPI CITY

NURSING AUDIT HOMEWORKS

Submitted by

Jessica Louise D. M erluza

BSN IV-C

Submitted to

Esther Valladolid RN, MAN