BLOOMFIELD COLLEGE

Frances M. McLaughlin Division of Nursing

NUR 351 Maternal and Pediatric Nursing SPRING
2010
Newborn Assessment Tool

Student Name: Karlyn Martinez

Clinical Objectives for the newborn nursery experience

1. Identify the normal characteristics of the neonate.

2. Identify the physiologic adaptive responses of the neonate.
3. Implement nursing care of the neonate including cord care, bath, vital signs, weights, circumcision care,
and feeding.
4. Perform correct holding and burping techniques.
5. Assess gestational age.
6. Collect newborn assessment data.
7. Document care and assessments accurately.
8. Demonstrate use of techniques to maintain neutral thermal environment.
9. Accompany the neonate to the mother on the postpartum unit.
10. Apply principles of safety and medical asepsis in administering care.

I. Maternal History - Briefly describe the history of the mother as stated on the
chart. Include pertinent data regarding labor and delivery.

Mother was a 28 year old woman gravid=1, para= 0. She began receiving
prenatal care at 5 months of pregnancy; in total she had 9 prenatal visits.
During the course of her pregnancy she gained approximately 25lbs. She has
a history of kidney stones. Her blood type is B negative. She presented to the
hospital at 40 weeks gestation for an with an epidural. She labored for 19
hours before it was decided that a Cesarean section will be best.

II. Apgar Scoring – Discuss the newborn’s Apgar score at birth – 1 minute, 5
minutes and during your observation period.

The apgar score is a methods for rapid evaluation of the infants cardio
respiratory adaptation after birth. The nurse scores the infant at 1 minute
and 5 minutes in each of five areas. The assessments are arranged from most
important (heart rate) to least important (color). The infant is assigned a
score of 0 to 2 in each of five areas and the scores are totaled. Newborn
resuscitation should not delayed until the 1 minute score is obtained.
However, general guidelines for the infant’s care are based on three ranges
of 1 minute scores.
 APGAR SCORING
1 minute after 5 minutes after At time of
birth birth observation
Heart Rate 2 2 2
Respirations 2 2 2
Muscle Tone 2 2 2
Reflexes 2 2 2
Color 1 1 2
Total 9 9 10
III. History of Newborn –

Gestational age: 40 Sex: Male

Weight: 3708 grams/ 8 lbs 2 oz Date of birth: 2/3/10
Length: 20 ½ Time of birth: 13:21

IV. General Description of the Newborn –

Posture:
Color: Pink
Temperature: 98.4 F Apical rate: 146 Pulses: 146 Respiratory rate: 38 Effort:

V. Detailed Assessment – Describe findings in detail. If you are unable to obtain any of the
information or the finding is not present, use your book and write what you would expect to see.
Place an asterisk “*” next to this information.****

Integument:

Color: Infant’s skin was pink overall

Birthmarks: No birthmarks or skin discolorations noted

Mongolian spots: None ***Mongolian spots are bluish black marks that resemble bruises on
the sacrum, buttocks, arms, shoulders, or other areas. They occur most frequently in
newborns with dark skin and usually disappear after the first few years of life. Some
continue into adulthood.

Condition: Skin is intact with no cracks or peeling noted

Hydration: Good skin turgor with quick recoil

Milia:***Milia are cysts, 1 to 2 mm in size caused by distention of sebaceous glands. They

occur on the face over the forehead, nose, and chin and disappear within the first weeks
without treatment**** No milia present.

Lanugo: **Lanugo is fine hair that covers the fetus during intrauterine life. ** No lanugo
present.

Vernix caseosa: **Vernix, a thick white substance, resembles cream cheese and provides a
protective covering for the fetal skin in utero. ** No vernix caseosa observed.
 Erythema toxicum: The nurse assesses the newborn for the presence of erythema toxicum,
which are red blotchy areas that may have white or yellow papules in the center.** No
erythema toxicum present.

Neonatal jaundice: **The nurse assesses the infant for jaundice at least every 8 to 12 hours
and is particularly watchful with infants with increased risk factors. Jaundice begins at the
head and moves down the body and the areas of the body involved should be documented**
No jaundice was noted.

Head:

Shape: Infant’s head is large in proportion in comparison with rest of body. Sutures are
palpable with small separation between each. Hair is smooth, silky and clean.

Molding: No caput succedaneum or cephalhematoma present. **A caput succedaneum often

appears over the vertex of the newborn’s head as a result of pressure against the mother’s
cervix that causes localized edema. Caput also may occur when a vacuum extractor is used
to assist birth and corresponds to the area where the extractor was placed on the skull. A
cephalhematoma is characterized by bleeding between the bone and its covering, the
periosteum. **

Size-circumference: **Infant’s head circumference should be around 32-38 cm (13-25 in).

Head approximately one fourth infant’s length. **

Hair: Hair color is blonde. Hair is smooth, silky and clean. Hair pattern consistent
throughout scalp.

Condition of scalp: Scalp is smooth with palpable fontanels.

Caput succedaneum: None present (Please see “molding”)

Cephalhematoma: None present (Please see “molding”)

Fontanels: **The anterior fontanel is a diamond shaped area where the frontal and parietal
bones meet. It measures 4 to 5 cm from bone to bone, although it varies because of molding
and individual differences, The fontanel closes by the 18 months of age. The anterior
fontanel should be soft and even with the surrounding bones or only slightly depressed. The
posterior fontanel is triangular area where the occipital and parietal bones meet. It is much
smaller than the anterior fontanel, measuring .5 cm to 1 cm. This fontanel closes by the time
the infant is 2 to 4 months of age. **

Symmetry of facial features: Facial features are symmetrical with no abnormalities.

Eyes: Eyes appear blue in color, symmetric and clear. Pupils equal and react to light. Tears
present during crying periods.
 Ears: Ears are well formed and complete. Skin cartilage is stiff. The ears are set even with
the outer canthus of the eye. Infant’s responds to loud noise. Infant passed hearing
screening for both ears.

Nose: Both nostrils are open with no blockage present. No flaring or mucus noted.

Neck and Shoulders:

Check for symmetry and range of motion: Neck turns easily from side to side. Clavicles are in
intact and symmetrical. No creptitus or crying upon palpation noted.

Chest and Abdomen:

Chest circumference: **The chest is measured at the level of the nipples. It is usually 2 to 3
cm smaller than the head. The normal circumferences of the chest 30 to 36 cm (12 to 14
inches).

Breast engorgement: Nipples are present and located properly. No discharge or

engorgement present.

Umbilicus: Umbilicus midline with no sign of infection. Clamp is on tight and cord is
showing signs of drying.

Gastrointestinal Tract:

Epstein’s pearls: No Epstein pearls present.

Regurgitation: Mother reports no sign of regurgitation after feedings. None observed during
assessment.

Vomiting: Mother reports no sign of vomiting after feedings. None observed during
assessment.

Anus: Anus is present without any discoloration or pain upon palpation.

Describe stools ** Stools should be assessed for type color, and consistency. **

Meconium: Infant has passed meconium within the 1st day of birth.

Genitourinary Tract:

Describe urinary output: ** Most newborns void within 12 to 24 hours of birth. The
newborn’s urine may contain uric acid crystals that cause a reddish or pink stain on the
diaper.**

Genitalia: The infant’s scrotum is pendulous and is darker in color in regards to rest of skin
color. Rugae are present over scrotum. Both testes are palpated in the scrotum. The meatus
is at the tip of the glans penis with no abnormalities noted.
 Circumcision: Infant is not circumcised.

Hymenal tag: NOT APPLICABLE. **Hymenal or vaginal tags are small pieces of tissue at
the vaginal orifice. These are normal and disappear in a few weeks.

Extremities:

Describe positions: The upper and lower extremities remain flexed at the elbow and resisted
extension during examination.

Simian line: **The hands are examined for a simian crease or line. This is a single crease
parallel with the base of the fingers that crosses the palm without a break. It may be seen
with incurving of the little finger in Down syndrome.

Range of motion: Equal and bilateral movement of upper and lower extremities. No
crepitus, redness, lumps or swelling observed.

Neuromuscular:

Sucking reflex: Sucking reflex was observed when gloved finger was placed in mouth against
the palate. Sucking action was strong.

Swallowing: **Infant swallows fluid. It should be coordinated with sucking.**

Rooting: Rooting reflex present when cheek was gently stroked.

Crying: Infant has a loud, strong cry.

Startle/Moro: ** The Moro reflex is the most dramatic reflex. It occurs when the infant’s
head and trunk are allowed to drop back 30 degrees when the infant is in the slightly raised
position. The infant’s arms and legs extend and abduct with the fingers fanning open and
thumbs and forefingers forming a C position. The arms then return to their normally
fixated state with an embracing motion. The legs may also extend then flex. **

Babinski: Positive Babinski reflex.

Grasp-palmar: Positive palmar grasp reflex.

Plantar: Positive planter reflex.

Tonic-neck: Positive neck reflex.

V. Nutritional assessment:

A. Feeding - Formula/ type and amount or Breastfeeding/how often/number of wet

diapers
Mother is currently breastfeeding as well as formula feeding. Last feed was
at 11 am. With one wet diaper since 8 am.