OB CLINICAL PERFORMANCE APPRAISAL TOOL

The students should complete during the clinical period the following assignments:

1) Daily clinical log: Students will keep a daily clinical log on the provided form. Summary of strengths,
weaknesses, areas for improvement, and overall impression of the day may be discussed. These will be TYPED
and turned in during the semester to the clinical instructor. *This is a portfolio requirement. It should be
completed and returned to the clinical instructor for a total of five clinical days (see page 3)
2) Patient teaching: The teaching plan should be done during the 6th week of the clinical experience or by
2/27/09 (see page 4 for instructions)
3) Clinical Care Plans: There are two care plans required during the semester. The first care plan will be
completed and posted on your clinical blackboard assignments by 3/27/09. The second care plan will be
completed and posted on your clinical blackboard assignments by 4/17/09 (see page 5-9 for instructions
and scoring)
4) Labor and Delivery, Postpartum and Newborn Assessments. Complete one assessment in each of the
three areas. This information may be used to assist you in developing your first care plan. Complete and
post on your clinical blackboard assignment links. (see page 11-32 for instructions)

STUDENT RESPONSIBILITIES:

1. Assignments will be given for each unit by the clinical instructor.

2. Students are expected to arrive on the unit 15 minutes before the start of the experience and be ready to receive
the assignment from the instructor.

3. Each student will be prepared for random oral inquiry regarding all facets of the assigned client's care utilizing the
nursing process, during the clinical experience:

a. nursing history and diagnosis

b. family history
c. physiological process
d. nursing assessment
e. planned nursing objectives and interventions
f. significant laboratory findings
g. client's medications: Each student is held responsible for verbalizing actions, indications, side
effects, contraindications, and nursing implications for all medications the client is to receive before
administering medications. No medications are to be given unless discussed with instructor. Drug
cards are recommended to facilitate the verbalization of medication information. The instructor will
accompany each student, initially, during the preparation and administration of medications.
Students are allowed to administer medications utilizing all routes with the exception of "IV push"
medications.
h. specific nursing treatments: identify scientific principles and rationale, procedures (according to
hospital policy), and needed equipment. If a student comes to clinical unprepared, the student will
be asked to leave the unit and it will be counted as a missed clinical day.

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4. A daily clinical log will be required for each student, for five of your clinical weeks. It may also include your
thoughts of the day, assignment, etc. The log will be turned in throughout the semester for discussion with your
clinical instructor. Completing the five logs at the end of the clinical will be unacceptable in passing the clinical
experience.

5. Patient teaching the clients usually experience an array of new experiences during their hospital stay. The more
knowledge and understanding of the various client experiences the student possess, the better the students ability
will be to teach the client.

6. Clinical evaluations will be done at mid experience and at the end of the clinical experience. The clinical
instructor will provide a sign-up sheet. Students are expected to come to the clinical evaluation session with a list
of their strengths and a list of areas needing improvement.

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 DAILY CLINICAL LOG (Format)

Student Name: Date:

Clinical Site: Instructor/Course:

Patient Information
Initials:
Diagnosis:
Age/Sex:

Summary of strengths/weaknesses, areas for improvement, and overall impression of the day.

Skills acquired and activities participated in today.

List specific competencies attained from this clinical experience/Consider all 8 curricular objectives (behaviors).

Give examples of how you attained these competencies. Do not say “I met the culture competency today.” Explain
how you attained it.

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4
TEACHING PLAN (Format)

Purpose: Since much of maternal/child health is achieved by the process of education, the student must appreciate &
practice health teaching both in & out of the hospital.

TEACHING PLAN FORMAT

I. TITLE:
Topic to be taught

II. ASSESSMENT of the LEARNER:

Who you’re teaching & why they need the information.
Discuss significance of the topic taught.

III. CONTENT:
What information will be taught!
List in outline form of ALL you plan to teach.
Cite content; book, lecture, other sources.

IV. METHODOLOGY:
What teaching strategies used? = How information is presented, i.e., discussion,
demonstration, etc.

V. EVALUATION:
How you know learner understood information =return demonstration, asked
questions to clarify, etc.

POSTPARTUM DISCHARGE Client Education

• Teaching Plan - Postpartum Discharge: The information is limited only to the MOTHER’S PHYSICAL
changes/needs for the postpartum period at home: What the woman needs to recognize to call her caregiver!
The information for the mother should be concise, comprehensive, & limited to 20 minutes.

•You must include teaching related to:

♦ the two primary physical risks for a postpartum mother:
1. Infection sites
2. Bleeding: normal vs abnormal
♦ one psychological risk: discuss postpartum depression r/t the key symptom to
recognize.
♦ instruction for primary prevention related to the mother’s
urogenital gynecologic health: discuss Kegel exercise, wipe perineum
front to back, an No douching.
Presentation of the postpartum discharge information will be done during the clinical rotation with the instructor
observing.

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CLINICAL CARE PLAN INSTRUCTIONS

1. Purpose: This activity enables the student to conduct an assessment of a childbearing woman and
plan nursing care specific to that client, based on nursing research and Standards of Care. The
assessment will include the physiologic, psychological, social, cultural, and environmental influences
pertaining to the client and her family.

2. For the first care plan, the student will select a patient who has a medical diagnosis of either:

Gestational Diabetes Hypertensive Disorder Depression

Preterm Labor
Dysfunctional Labor
Postpartum infection
Abuse
Adolescent pregnancy
hyperbilirubinemia
Neonatal anomalies
Neonatal trauma
Postpartum Hemorrhage Cesarean Section
Postterm labor and birth Intrapartum Infection
Thromboembolic disease Maternal Substance
Neonatal infection Neonatal
Postterm neonate SGA or LGA infant
Preterm neonate

The second care plan will be developed from a simulation case study which will include priority
nursing diagnoses and plan of care for labor, immediate postpartum and transition of neonate.
(See Simulation Blackboard Site)

3. Select and list three NANDA nursing diagnoses based upon assessment data

4. Nursing assessments must include both subjective and objective data which supports the nursing
diagnoses

Examples of data include current pregnancy, past pregnancy history, gynecological history,
medical history, intrapartum course, delivery summary, postpartum status, condition of the
newborn and social/cultural beliefs, values, behaviors and traditions.

5. Select the one priority nursing diagnosis from your list of nursing diagnoses and formulate a plan
of care for your first care plan. Three priority nursing diagnoses for the second care plan. See
enclosed Nursing Care Plan Format.

6. Develop patient focused objectives that are realistic, measurable & written as client behaviors

7. Interventions must be guided by standards of care and comprehensive in meeting your objectives
such as frequency of monitoring, medications used or anticipated use, therapies such as perineal
care, breast milk pumping, sitz baths, and to include a minimum of one teaching intervention.

(Standards of Care are throughout your textbook titled “Expected Outcomes of Care, Protocols for
Care, Plan of Care or Care Paths”). Examples are seen on pages 253, 254, 272, 276, 362, 383,384,
389, 406, 418, 420 etc. (Lowerdemilk & Perry, 2006)

8. Sources for rationale include current literature from maternity textbooks and professional journals
(not magazines or websites). Two nursing journals must be included in your citations using APA
format. One article must be a nursing research article. If you have any questions regarding your
choice of articles please see your clinical instructor for approval.

9. Evaluation indicates how objectives were or will be achieved; including alternative recommendations
if objectives are not achieved.
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10. Must be typed. Do not use client’s name—assign a number to represent the client.

11. **The most points fall under nursing interventions and rationales. This is the most important part of
your care plan. Information in these sections must be detailed and in-depth!!!

12. Points will be deducted for not following APA format for grammar, spelling, sentence structure, font,
citations and bibliography as this is a strong indication of a student’s ability to follow directions.

9. Your care plan must include:

1. Clinical subjective and objective assessments (See labor and delivery,

postpartum or newborn assessments for content)
2. Priority Nursing Diagnosis
3. Patient Objectives
4. Comprehensive nursing interventions including a teaching intervention
for one nursing diagnosis (minimum of 10 interventions)
5. Rationale supported by literature citations (Author, date)
6. Evaluation results or anticipated achievement of plan
7. References using APA format

10. Submit complete care plan to your clinical instructor as directed in print or safe assignment.
Example:

• Nursing Diagnosis – sleep pattern disturbance related to anxiety about safety of fetus & outcome
of pregnancy as evidenced by facial grimacing, crying, inability to initiate self care.

• Patient Objectives-
[STG] – After teaching, patient demonstrates relaxation techniques
[LTG] – By discharge, patient sleeps for uninterrupted periods of time

• Nursing Intervention (one teaching plan example given; your plan will include more interventions
including a teaching plan)
1. RN will teach relaxation techniques;
a. Slow-chest breathing
b. Imagery

• Rationale - Using relaxation techniques release tension from the mind and body and are
beneficial in enhancing regular rest periods to promote uterine and fetal oxygenation (Lowdermilk
& Perry, 2006).

• Evaluation – Patient states this “helps me sleep!” or should relax patient to sleep 3-4 hours
uninterrupted.

• References

Lowdermilk, D., & Perry, S. (2006). Maternity nursing (7th ed.). St. Louis: Mosby.

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Running head: SAMPLE TITLE PAGE

Header should be 1"from top edge of paper.

Running head description should be flush at the
margin and two lines below the header.

Center and begin

approximately
4-inches from top
edge of paper.

Title of Paper

Student Full Name

Student ID#

Site (if appropriate)

Center and begin

approximately
8-inches from the top
edge of paper.

Submitted in partial fulfillment of the requirements in the course

Course NUR 318: Clinical Management of the Childbearing Family

Spring 2009

MATERNITY PATIENT CARE PLAN

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 ASSESSMENT: Client Objectives NURSING RATIONALE FOR EVALUATION
Significant Client Data INTERVENTIONS INTERVENTIONS
Subjective: Short term: (Need to be specific to the Short Term:
maternity client.)

Objective:

Long term:

Long Term:

1. Priority Nursing Diagnosis (NANDA) :__________________________________

2. Nursing Diagnosis: __________________________________________________________
3. Nursing Diagnosis:___________________________________________________________
___________

Grade Sheet for Care Plan

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Student Total
Score Possible

________ 5 1. Subjective Assessment Data

Age, Gravida/Para, obstetrical history, gynecological history, prenatal history, past medical
history, surgical history, family history, labor and delivery summary including date & time
psychosocial and cultural history, allergies, medications, ETOH, drugs, smoking, concerns,
discomforts, knowledge deficits

________ 5 2. Objective Assessment Data

Vital signs, laboratory data, physical assessment findings, fetal monitoring if indicated

3. Nursing Diagnosis (3)

2 A. Appropriate for assessment data

3 B. Prioritizes significant diagnosis

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5. Objectives

5 A. Realistic, measurable & written as client behaviors

6. Nursing Interventions

_________ 10 A. Adheres to Standards of Care

__________ 15 B. Comprehensive including teaching outline

___________ 15 C. Individualized & specific to the nursing diagnosis

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7. Rationale

_______ 10 A. Current Literature focused upon the childbearing family

______ 10 B. Relevant to interventions
______ 5 C. Includes relevant research and nursing journal articles
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_______ 10 8. Evaluation of how objectives were met or expected and alternative recommendations if not

completed.

9. Grammar, spelling, citations,

5 Bibliography (APA format)

________ Total

COMMON OB DRUGS

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 PITOCIN GENTAMYCIN

METHERGINE AMPICILLIN

TERBUTALINE AZITHROMYCIN

NIFEDIPINE DOXYCYCLINE

MAGNESIUM SULFATE BENZATHINE PENICILLIN G

DEMEROL ACYCLOVIR

NUBAIN METRONIDAZOLE

STADOL MICONAZOLE

PHENERGAN ERYTHROMYCIN EYE OINTMENT

BUPIVICAINE NARCAN

XYLOCAINE PROSTIN GEL

FENTANYL BETAMETHAZONE

MORPHINE DURAMORPH

PERCOCET / TYLOX RhoGAM

IBUPROPHEN RUBELLA VACCINE

TYLENOL HEPATITIS B VACCINE

COLACE ASPIRIN

TUCKS CYTOTEC

AMERICAINE/DERMAPLAST SPRAY VARIOUS ANTACIDS

PRENATAL VITAMINS VITAMIN K

ALDOMET PROCARDIA

PROCTOFOAM ZOFRAN

VICODIN TORADOL

*You must know the actions and side effects, doses and administration forms of these drugs prior
to your clinical experience.*

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 CLINICAL WORKSHEET GUIDELINES FOR ASSESSMENT OF
THE LABORING WOMAN
Student Name: Date:
Intrapartum Summary:

Labor began (contractions 10 min. apart and regular):

Date/Time________________________________________________________

Membranes ruptured: Date/Time______________  SROM AROM

Amniotic fluid:  Clear  Light meconium-stained  Thick meconium-stained

 Polyhydramnios  Oligiohydramnios  Foul-smelling

Induction  Augmentation  Method used:__________________________________

External □ or Internal Fetal Monitoring □ or Both □
Fetal Heart Rate
Fetal Heart Variability
FHR Periodic Rate Changes
FHR Accelerations
FHR Early Decelerations
FHR Late Decelerations
FHR Variable Decelerations
Nursing Interventions for Periodic
Rate Changes
Uterine Contraction Pattern
Frequency/Duration/Intensity
Latent Phase
Frequency/Duration/Intensity
Active Phase
Frequency/Duration/Intensity
Transition Phase
Identify actual or potential problems related to above data and state why

Stage II and III Delivery Summary

Delivery Date and Time: ______________________________________
Delivery Method:
Spontaneous □ Forceps □ Vacuum Assisted □ Vaginal Birth after Cesarean □
Cesarean Section Classical □ Lower Uterine Segment □
Bilateral Tubal Ligation Yes □ No □

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Reason for Non-Spontaneous
Delivery_______________________________________
__________________________________________________________________
____
Episiotomy None □ ML □ RML □ LML □ Extensions □
Lacerations 1st degree □ 2nd □ 3rd □ 4th □
Estimated Blood Loss (EBL) ________ Fetal Position/Presentation __________
Placenta: Duncan □ Schultz □

Identify actual or potential problems related to above data and state why

Stage IV Labor/Immediate Postpartum

Time to Recovery______ Time to Post Partum
Room______

Time Temp Pulse Resp BP Fundus Lochia Perineum Voiding

Identify actual or potential problems related to above data and state why

Medications During Four Stages of Labor

Drug/Amount/Time Purpose Noted Effect Nursing
Actions
Stage 1
Stage 2
Stage 3
Stage 4

Anesthesia:
Epidural □ Spinal □ General □ Local □

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Identify actual or potential problems related to above data and state why

Infant:
Female □ Male □ Weight ____ Length _______
Anomalies__________________________________
Apgar Score
Apgar Score 1 minute 5 minutes
Heart Rate
Respiratory Effort
Muscle Tone
Reflex Response
Color
Total

Identify actual or potential problems related to above data and state why

Summary of Family Adaptation/Bonding/Initiation of Feeding

Identify actual or potential problems related to above data and state why:

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NURS. 318: POSTPARTUM ASSESSMENT

Student Name_________________________________________Date______________

Client Information

Client Initials________ Age_______

Gravida _______ Term_______ Preterm ________ Abortions________ Living_______

Due Date: (LMP)_______ (Ultrasound)_________ Gestational Age ________ Prenatal Care

Began_____________

Number of prenatal visits___________Childbirth education classes_________________

Marital Status/Significant Other_____________________________________________

Religious Preference_____________________________________________________

Occupation____________________________________________________________

Ethnic/Racial Background_______________Allergies___________________________

Admission Date____________ Admitted from:  home  Dr.’s office Other_________

Past Obstetrical History: Include dates of previous deliveries, Cesarean or vaginal births, forceps or
vacuum extractions, length of labor, analgesia/anesthesia used, term or pre-term, weights of babies,
health of infants at birth, abortions/miscarriages.

Complication(s) of this pregnancy: Include both concurrent medical diagnoses, such as diabetes, as
well as problems directly caused by the pregnancy, such as PIH. Define and describe the
condition(s) and current medical treatment.

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Prenatal Laboratory Findings: Postpartum Medications (Attach drug cards)

Blood type
Rubella titer Name Dosage Route
VDRL/RPR
HBsAg
GBS
HIV
Chlamydia
GC

Pregnancy Laboratory Findings: Postpartum Laboratory Findings:

Hgb Hgb
Hct Hct
WBC WBC
Urine Urine
Other Other

Compare the laboratory findings and describe the changes after birth. Explain if this finding is
normal or abnormal:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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Past Medical/Surgical History: Summarize significant past illnesses, hospitalizations,
surgeries, and/or injuries. Include dates.

PSYCHOSOCIAL ASSESSMENT : Include significant family dynamics, medical/genetic

history, and psychosocial/spiritual stressors. Explain cultural beliefs that may affect the
intrapartum or postpartum experience of this patient.

Ages and relationships of persons living in household:

Pregnancy planned? _________

Alcohol use: Before pregnancy? _______During pregnancy? _________________

If yes: type, frequency, amount_________________________________________
Tobacco use: Before pregnancy? _________ During pregnancy? __________
If yes: Type, frequency, amount (packs per day)__________________________
Illegal drug use: Before pregnancy? _______ During pregnancy? ___________
If yes: type, frequency, amount ________________________________________
Have siblings been prepared for new baby?____How?______________________

Family Dynamics:

Medical/Genetic History:
Stressors:

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Labor/Delivery Summary:

Labor began (contractions 10 min. apart and regular):

Date/Time________________________________________________________

Membranes ruptured: Date/Time______________  SROM AROM

Amniotic fluid:  Clear  Light meconium-stained  Moderate meconium-stained

 Thick meconium-stained  Polyhydramnios  Oligiohydramnios  Foul-smelling

Induction  Augmentation  Method used:__________________________________

Monitoring used:  Ultrasound  Toco  FSE  IUPC  Intermittent auscultation

FHR:  Reassuring  Nonreassuring

Describe FHR characteristics, including baseline rate, variability, periodic changes, and
interventions if nonreassuring:______________________________________________

______________________________________________________________________

Coping mechanisms used during labor:_______________________________________

How was labor tolerated by this client?_______________________________________

Who provided the most support to her during labor?_____________________________

Describe what this person did that was helpful:_________________________________

Analgesia/anesthesia: Include medications, dosages, times, routes of administration,

cervical dilation, effacement, and station when administered (attach cards):

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Delivery: Date________________ Time_________________

Vaginal  VBAC (vaginal birth after cesarean)

Operative Vaginal delivery:  Vacuum  Forceps

 Cesarean Reason:_______________________________________________

Episiotomy:  Yes  No  N/A Lacerations: 1o 2o 3 o 4 oOther: ________

 Male  Female Weight:___________lbs./oz. _____________grams

Length ________________________Head Circumference_______________________

Chest Circumference__________Gestational Age ________ weeks

(circle one): SGA AGA LGA

Apgars: _________ 1 min. ________ 5 min.  Breastfeeding  Bottlefeeding

Complications of labor/delivery:
______________________________________________________________________

Length of labor: 1st Stage ___________2nd Stage___________3rd Stage_____________

Was her labor typical considering her gravida and para?

______________________________________________________________________

POSTPARTUM ASSESSMENT:

MATERNAL PHYSIOLOGIC ASSESSMENT DATA

CARDIOVASCULAR/ RESPIRATORY
Vital signs date & time ______________ T____ P____ R_____ BP_________
Heart sounds ________________ Lungs_______________________________
Color of skin/ mucous membranes
______________________________________________________________

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Pre-pregnant wgt ______ Current wgt ______ Total wgt gain________________
Edema: location & amount____________________________________________
Pedal pulses _______________________________________________________
Capillary refill _______________ seconds
Patient questions or concerns? _______________________________________

Identify actual or potential problems related to above data and state why:

BREASTS
Preferred method of infant feeding: Breast Bottle Undecided
Prior experience with preferred method? Yes No
If yes, describe
_________________________________________________________________
Breast size, symmetry, fullness
_________________________________________________________________
Support bra available? _______ On?___ Breast pump needed? _______________
Measures in use for lactation suppression_________________________________
Presence of: Colostrum _____ Mature milk______ Engorgement __________
If breastfeeding, shape of nipple (erect, flat, inverted). Nipples intact? Y N
Patient questions or concerns?
________________________________________________________________

Identify actual or potential problems related to above data and state why:

UTERUS/ LOCHIA
Location & firmness of fundus_________________________________________
Uterine cramping? Y N
If yes, pain rating (0-10 scale):_________________________________________
Methods used for pain relief & effectiveness______________________________
Lochia: Color ___________ Amount _______________ Odor ________________
# pads saturated in 8 hours _______________________ Any clots?____________
Patient questions or concerns?
__________________________________________________________________

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Identify actual or potential problems related to above data and state why:

INCISION (Cesarean or episiotomy)

Episotomy: type _______________ Other lacerations/ extensions_____________
If C/S, type (location) ___________________ Dressing? Y N
Describe incision using REEDA
Redness ___ Edema ___ Ecchymosis ___ Drainage ___ Approximation______
Pain from incision / episiotomy? Y N
Pain rating on 0- 10 scale __________

Pain relief methods used: Effectiveness:

1. 1.
2 2.
3. 3.
(use additional paper or back of page as needed)
Patient questions or concerns? _______________________________________

Identify actual or potential problems related to above data and state why:

PERINEUM/ ELIMINATION
Any swelling, lesions, venereal warts, condyloma, hemorrhoids, etc.? __________
If yes, describe______________________________________________________
Urine: Color, odor, amount ____________________________________________
Difficulty or discomfort with voiding? Y N
Bladder palpable? Y N

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Interventions to promote voiding Effectiveness
1. 1.
2. 2.
3. 3.

Bowel sounds ____ Flatus ___ Last BM (color/ consistency/ amount)__________

Abdominal tenderness? _____ Abdomen distended?______
Patient questions or concerns? _______________________________________

Identify actual or potential problems related to above data and state why:

LOWER EXTREMITIES
Homan’s Sign: R _______ L ________
DTR’s : R _______ L _______
Clonus: R _______L _______
Antiembolism stockings on? Y N If yes, reason_________________________
Patient questions or concerns? _______________________________________

Identify actual or potential problems related to above data and state why:

NUTRITION/ SLEEP & REST

Diet type _____________
% taken at last meal _______
Patient’s satisfaction with food served _______________________________
Cultural/ ethnic food preferences (what does patient think that a postpartum woman should eat
or not eat?) __________________________________________________________
Any nausea? Y N
Any vomiting? Y N
Fluid intake in last 8 hours: Oral ________ IV _________
Number of hours sleep since delivery ______ Naps? _______ Feel rested?______

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What interrupts sleep?________________________________________________
Patient questions or concerns? _________________________________________

Identify actual or potential problems related to above data and state why:

TEACHING & DISCHARGE PLANNING NEEDS

What specific teaching needs does the mother and/or family have during the hospital stay?

Mother’s or family’s opinion:

Health care provider opinion:

Your opinion:

Observe and describe each family member’s interactions with infant:

Behavior Mother Father Other(Siblings, Grandparent, etc.)

Position while holding:

Response to infant cries:

Infant’s response

Proximity to infant crib:

Response to infant feeding:

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Communication with infant:

Acceptance of sex of infant:

Positive/negative comments about infant:

Evidence of bonding:

Patient concerns or questions:

Identify actual or potential problems related to above data and state why: Describe your findings
as it relates to Maternal Role Attainment Theory):

Learning Needs/Discharge Planning: List three specific priority learning needs of this patient.
Identify a discharge planning need other than teaching/learning:
1.
2.
3.
Discharge Planning Need

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Current Medical Orders (Lists each order excluding medications)
Patient’s order Rationale for this patient

25
 MEDICATION LIST
(Add additional pages as needed for all sections)

Medication Dose Time Route Side Effects Significance for Nursing Implications
client

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IV Therapy

Solution Site Amount Frequency Infusion Significance for

Pump client

LABORATORY AND DIAGNOSTIC TESTS

* Include prenatal labs ** Explain what the result indicates about the client’s condition
Test Date Norms* Pt results Interpretation/Analysis **
Chemistry:
Glucose
BUN
Uric Acid
Liver enzymes:
SGOT
SGPT
LDH
CBC:
Red blood cell
count
Hematocrit *
Hemoglobin *
White blood cell
count:
Differential
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Erythrocyte
Sed rate

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 Test Date Norms* Pt results Interpretation/Analysis **
Drug therapeutic
levels:
Mg SO4
Culture results:
Syphillis-
VDRL/RPR/
Serology *
Chlamydia
GC
Group Beta
STREP
Blood Type/Rh *
Atypical
Antibodies
Urinalysis:

Urine C&S

Ultra-sound:
Biophysical Profile
Fetal breathing
Fetal
movement
Fetal tone
Amniotic fluid
volume/index
(AFV/AFI)
Non-stress test:

28
 Test Date Norms* Pt results Interpretation/Analysis **
Contraction Stress
test

AFP (Alpha-
fetoprotein)
Other
Rubella

Hepatitis B Surface
Antigen

Glucose Screening
1o gtt
3o gtt

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 WELL NEWBORN ASSESSMENT

NORMS INFANT OBSERVATION

1. Cardiovascular
Heart rate

Peripheral pulses

2. Temperature

3. Respiratory
A. Rate

B. Breath sounds

C. Grunting, flaring, retractions

4. Musculoskeletal
General position at rest

Muscle tone

Spinal column

Hips

Clavicles

5. Average length
inches/cm
Average weight
lbs/oz and grams
Normal range of weight loss
within the first week of life:
Head circumference
inches/cms
Chest circumference
inches/cms
6. Head
A. Molding
B. Fontanelles

C. Caput Succedaneum

D. Size-relation to body compared to

adult

77. Eyes
30
 A. Sclera

B. Lacrimal glands

C. Neuromuscular control

D. Reflexes (PERRL – RED)

8. Ears – Position – Cartilage- Skin

Tags

9. Nares

10. Palate – soft & hard

11. Skin integrity

A. Vernix

B. Color

C. Variations r/t gestational age

D. Nevi (birthmarks)

E. Rash

12. Genitourinary
A. Male

B. Female

13. Gastrointestinal
A. Abdomen

B. Bowel sounds

C. Stools

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14. Musculoskeletal

Reflexes present at birth (list five

normal newborn reflexes,
describe how to elicit them
and the expected response
by the newborn)

A.

B.

C.

D.

E.

Reflex Onset Inhibition Stimulus Behavior

Moro Birth Third month Supine Position Stimulation will result in extension
Sudden loud noise of the infant’s extremities, followed
causes rapid or sudden by return to a flexed position
movement of infant’s against the body.
head.
Tonic neck- Birth Sixth month Supine position Extremities on side of body facing
asymmetrical Neck is turned so head head position extend, those on
is facing left or right. side opposite flex.
Tonic neck- Birth Sixth month Supported sitting. Extension or flexion of neck will
symmetrical Flexion or extension of result in extension of arms and
infant’s head. flexion of legs.
Grasping Birth Fourth to Supine position. Stimulation will result in a grasping
sixth month Stimulation of the palm action of the fingers or toes.
of the hand or ball of the
foot.
Babinski Birth Sixth month Supine position. Stimulation will result in extension
Stimulation by stroking of the toes.
the sole of the foot.
Sucking Birth Third month Supine or supported Touching area of mouth will result
sitting. in a sucking action of the lips.
Stimulus applied directly
above or below the lips.

Identify actual or potential problems related to above data and state why

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