NEWBORN PHYSICAL ASSESSMENT

Parent’s Initials __________________ Today’s Date _______________ Sex of Baby _______________

Date & Time of Birth ___________________ Gestational Age __________ determined by_____________________

Number of Vessels in cord __________ Delivery Room Resuscitation ___________________________________

Method of Feeding ___________________ Baby’s Blood Type & Rh ____________ Baby’s Coombs____________

Mother’s Blood Type & Rh ___________ Candidate for which type of Newborn Jaundice ___________________

Birth Weight ___________ Today’s Weight _________ Total Wt. Loss

_________ % Weight Loss ________

APGAR 1 minute 5 minutes

Heart Rate
Respiratory Rate
Muscle Tone
Reflex
Color
TOTAL:
1. Vital Signs:

_______________________________________________________________________________________

2. RESPIRATORY EFFORT: Retractions _______________ Grunting ______________ Quality of Cry

_____________

3. AUSCULATE FOR: Heart sounds ________________________________ Heart Rhythm

________________________

4. BOWEL SOUNDS: Character ____________________________________ Location of abnormality

_________________

5. SKIN: Color ____________________ Texture _________________________ Turgor

_________________________

Lanugo ______________ Vernix _____________ Mongolian spots _____________ Rashes

________________

Other Breaks or Marks

________________________________________________________________________

6. MEASUREMENTS: Head (FOC) _______________cms. Chest _______________cms. Length_____________cms

7. HEAD: Hair Texture __________________________ ANTERIOR FONTANEL: size _______ cms X ________cms

Tension ____________________________ POSTERIOR FONTANEL: size _______ cms X

________cms

Molding _______________________ Caput ______________________ Cephalhematoma

____________

8. EYES: Position ____________________ Pupils _________________ Iris ____________

Sclera__________________

Ophthalmoscopic exam ________________________________ Presence of Hemorrhage

___________________

9. EARS: Placement ________________________ Pinna ______________________ Hearing

______________________
10. NOSE: Symmetry ______________________________________ Patency

____________________________________

11. MOUTH: Color _______________ Mucous Membranes ______________ Tongue _____________ Teeth

___________

Hard, soft palates _______________________________________ Uvula

_____________________________

12. NECK: Shape _______________ Mobility _________________ Masses ____________ Lymph nodes___________

13. CLAVICLES: Integrity

_____________________________________________________________________________

14. CHEST: Shape ______________________ Breast Engorgement __________________ Nipple

Size_______________

15. ABDOMEN: Shape ________________ # of cord vessels ______________ Umbilical cord

appearance______________

16. FEMORALPULSES:

_______________________________________________________________________________

17. GENITALIA: Female: Labie majora ____________________________ Urethra

________________________________

Vagina ____________________________ Vaginal Discharge

____________________________

Male: Position of urethral opening __________________________ Presence of

testes________________

Maturation of Scrotum

______________________________________________________________

18. ELIMINATION: Urine: Color ____________________# of times in last 24 hrs.

_________________________________

Stool: Color ___________________ Type _____________________ # in last 24 hrs

________________________

19. ANUS: Determine Patency _____________________________________ Anal Reflex

___________________________

20. HIPS: Range of motion

_____________________________________________________________________________
21. SPINE: ____________________________ Scapula ______________________ Gluteal folds

_____________________

Observe pilonidal dimple for intactness:

_____________________________________________________________

22. EXTREMITIES: Appearance of Hands _____________________________ Of Feet

_____________________________

Hands: # of digits RT. _________ LT __________ Polydactyly _______________ Syndactyly

________________

Feet: # of digits RT. _________ LT __________ Polydactyly ________________ Syndactyly

_________________

23. REFLEXES: Moro (Startle) ____________________________ Rooting

__________________________________

Palmar grasp _____________________________ Sucking

__________________________________

Plantar grasp _____________________________ Stepping (dancing)

_________________________

Diagnostic/Laboratory Date
Date Test Results Normal Value Significant for This Patient

Meds Given Since Birth

Generic or Trade Name Recommended Dosage Classification & Purposes Nursing Measures &
Range & Ordered Dose for this patient Adverse Reactions

Vitamin K

Erythromycin
Ophthalmic ointment

MATERNAL ASSESSMENT/DATE SHEET

CIRCLE ANY ABNORMAL DATA

Date_____________________

Patients Initials __________ Age ____________ EDC ___________________ GTPAL ____________________

Admission Date _____________ Delivery Date _____________ C-Section ______________ Vaginal Delivery

___________

Episiotomy Type _______________________ Tubal Ligation _____________________ Date

___________________

Induction _______________________ Type _____________________________ Time Begun

________________

Date and Time of Rupture of Membranes ________________________________ AROM or SROM (Please

Circle)

Nature of Amniotic Fluid ____________________________________________________

Type of Anesthetic _________________________________________________ Time Administered

___________________

Weight Gain During Pregnancy _________________________________ BP Range During Pregnancy

________________

Medications During Pregnancy

__________________________________________________________________________

Complications During Pregnancy

_________________________________________________________________________

DIAGNOSTIC AND/OR LABORATORY DATA (Circle any abnormal data)

PRIOR TO LABOR

DATE TEST RESULTS NORMAL VALUE SIGNIFIANCE FOR THIS PATIENT

Hepatitis Screening
Ultrasound
Blood Type Rh
Hgb
Hct
 Amniocentesis

DONE UPON ADMISSION

DATE TEST RESULTS NORMAL VALUE SIGNIFIANCE FOR THIS PATIENT
WBC
RBC
Hgb
Hct
Platelets
Urinalysis
Other Significant

LABOR SUMMARY

FIRST STAGE OF LABOR

YOUR PATIENT

Date & Time Labor Began ___________________________________________

Time at 4 to 5 cm Dilated ____________________________________________
Time at 10 cm Dilated _______________________________________________
Total First Stage ___________________________________________________

SECOND STAGE OF LABOR

Time at 10 cm Dilated ____________________________________________

Time of Baby’s Delivery ___________________________________________
Total of Second Stage _____________________________________________

THIRD STAGE OF LABOR

Time of Baby’s Delivery ___________________________________________

Time of Placenta’s Delivery_________________________________________
Total of Third Stage ___________________________________________________

Total Time of Labor ________________________________________________

Total Blood Loss __________________________________________________cc