Lakeview College of Nursing
N305 – NURSING OF THE CHILDBEARING FAMILY
Newborn Assessment/Case History
Note: This assignment is to be completed after you complete your newborn assessment.
STUDENT'S NAME __Gregory Cahill_________  	 
Instructor __Mindy Herrin______________________	

Maternal information: age, GTPAL, significant prenatal history
__age: 25, G=6, P=3, T=3, Pt=0, SAB=2, IAB=1, L=3, has fiancé, chlamydia 10 years ago, 2 prior cesareans, genital herpes, toxoplasmosis   _______________________________________________________________________________________________________________________________________________________________________________
Birth history: Type of delivery, Medications during labor, FHR patterns.
_elective cesarean, lower uterine transverse incision, epidural, no labor, apgar of 8 & 9 at 1/5 minutes _______________________________________________________________________________________________________________________________________________________
Method of feeding, how often, amount. Any problems feeding?
__Bottle fed- 30-60 ml every 2-3 hours, no problems feeding _____________________________________________________
Measurements:				
Length (cm)__48.3 cm__       (inches) ___19 in._ 
Head (cm)___35.0 cm___       (inches)__13.5________	
Chest(cm)___33.5_         (inches)____13.0______	
Birth weight.(gm)_3395_____(lb.)_7___ (oz.)___8__    
Today’s weight.(gm)_3395_(lb.)__7_ (oz.)__8_
Percentage of weight loss (Show calculations even if the baby has lost no weight). (3395-3395)/3395= 0%       What is normal weight loss? ___5-10%______      
Is this neonate's wt. loss within normal limits?___yes____

 Vital Signs:
Birth:				At time of your care:
T___99ºF____			T ____98.4º F_____
P___140 bpm____			P __138 bpm_______
R_40______			R ____63_____

Age (in hours) of first void________________ 
Voiding patterns: (color, # of times/24 hours)
__________________________________________________________________________________________________________________________________________________________
Age (in hours) of first stool__________________
Stools: (type, color, consistency)
__________________________________________________________________________________________________________________________________________________________

NEWBORN LABS AND DIAGNOSTICS TESTS

Name of test
(Date)	Why was this test ordered for this client?
	Client’s results	Expected
 results	Interpretation of this client’s results	
Blood glucose level
	LGA
Mom has DM	na		Test ordered when risk factors are present to monitor for hypoglycemia	
Blood type and Rh factor
	To determine risk factors 				
Bilirubin

	Neonates produce more bilirubin than adults and this is a standard test	5.0	Under 6-7 mg/dL	Bilirubin is within normal limits	
Coomb’s test

	Mother has Rh- blood and the baby has Rh+ blood				
Newborn Screen

					

NEWBORN MEDICATIONS

Physician’s order
(medication, dosage, route, frequency)	Why was this medication ordered for this client?
	Common side effects	Nursing interventions for this client	
Aquamephyton 
(Vitamin K)
	To promote blood clotting in the newborn			
Illotycin (Erythromycin ointment)-1/4 inch bead of ointment to lower eyelid of each eye

	Prophylactic antibiotic for gonococcal or chlamydial eye infections		Assess for edema and inflammation of eyelids	
Hep-B vaccine

	To immunize against hep-B			
NEWBORN ASSESSMENT

Area	Your Assessment
	Variations of Normal Findings 	Clinical Significance of Your Assessment Findings & Variations of Normal	
Vital Signs
      Temp
      Heart Rate
      Resp. Rate
      BP	

98.4ºF

138 bpm

63	
97.7-99.4ºF
110-160 bpm

30-60 rpm
80-60/45-40 mmHg	
Vitals are within normal limits	
Measurements
      Head Circ
      Length
      Chest	
13.5 inches
19 in.
13.0 in.	
12.5-14.5 in.
18-22 in
12-14 in	
Measurements are within normal limits	
Color	pink

Muscle tone/
Posture	

Cry
	loud

Activity level	alert

Skin:     
     Lanugo/
     vernix
     Rashes	Normal for ethnicity
none
none
Mongolian spots on buttocks 			
Head 
	normocephalic

Fontanels
	Anterior & posterior=
Measurements are within normal limitsnormotensive

Face
	Symmetric with no gross deformities

Eyes
	Pupillary reflex normal

Nose
	patent

Mouth

	No teeth, gag reflex present

Ears

	Symmetrical, passed hearing test

Neck	Trachea midline, clavicles intact 
			
Chest	Symmetrical, appears to have an extra nipple under left nipple

		
Breath sounds

	Clear, no adventitious sounds			
Heart sounds

	S1, S2present, no murmurs head			
Abdomen

	Soft, symetrical			
Bowel sounds

	Active x4			
Umbilical cord

	normal			
Male Genitals:
Penis
	Circumcised, 			
Scrotum/Testes
	Deep rugae 			
Female Genitals
     Vagina
      Labia
      Pseudo-
      menses				
Anus

	patent			
Arms and hands

Legs and feet

Back				

NEWBORN REFLEXES

REFLEX	YOUR ASSESSMENT	EXPECTED FINDINGS	AGE WHEN REFLEX SHOULD DISAPPEAR
Start-end	
Rooting

	present	Neonate turns head toward the direction of a stimulus and opens his mouth	Birth-3/6 months	
Sucking

	present	Baby makes sucking motion when something is placed in their mouth	Birth-10/12 months	
Swallowing

	present			
Pupillary

	present			
Moro

	present	Symmetrical abduction and extension of arms and legs, and legs flex up against truck	Birth- 6 months	
Startle

	present	Symmetrical abduction and extension of arms and legs, and legs flex up against truck	Birth- 4 months old	
Palmar grasp

	present	Neonate grasps fingers placed in their hands	Birth-3/4 months	
Planter grasp

	present	Toes flex tightly down in a grasping motion	Birth-3/4 months	
Tonic neck

	present	“fencing” position, arms and legs extend in the direction the head is turned	Birth/6weeks-4/6 months	
Stepping

	Not present	Neonate steps up and down when held upright with feet touching a flat surface.	Birth-3/4 weeks	
Blinking

	present			
Trunk incurvation

	present			
Babinski

	present	Hyperextension and fanning of toes when the sole of foot is stroked laterally	Birth-1 year old	

Discuss the clinical significance of the findings from your physical assessment.
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
GESTATIONAL AGE EXAMINATION 
What is your estimate of the neonate's gestational age from your assessment? _____39+ weeks gestation______________ (Hand in Ballard sheet with this assignment)   
Does your assessment agree with the gestational age by LMP? (Discuss)___The newborn scored a 39 on the Ballard scale, which would put him between 38 & 40 weeks gestation (closer to 40 weeks).  Gestation was estimated at 38.0 weeks.  The gestational age by LMP is close but slightly under the estimated gestation of the Ballard scale __________________________________________________ 
Is this infant SGA, AGA or LGA? ______AGA________
Are there any complications expected for a baby in this classification?  (Discussion)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Priority Nursing Diagnosis:

Lakeview College of Nursing
N305 Newborn Assessment Grading Grid
STUDENT'S NAME __________________________  Date of Care ______________________
INSTRUCTOR _Mindy Herrin, MSN, RN                   Date of Submission ________________
	Possible Points	Points Given
	
Demonstrations of Physical 
Assessment 
	20		
Newborn Assessment Write-Up	20		
Appropriate Priority Nursing Dx Determined	10		
Medications and Labs	5		
History and Physical Assessment	25		
Expected Findings
	10		
Clinical Significance
	5		
Gestational Age Assessment
(submit completed form)
	5		
Total
	100