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 __Lynette Hosier___________  	 Instructor _Mindy Herrin____________	

Maternal information: age, GTPAL, significant prenatal history
Mother is twenty one years old. She is G 3, T 1, P 0, A 1, L 1. She was admitted on 9/18/12 for a scheduled C-section due to possible fetal arrhythmia. She was taking prenatal vitamins at home and went through all the recommended tests and visits. At her last prenatal appointment, an echocardiogram was done and it was thought that there was a fetal arrhythmia present. Upon admission on September 18 however, no arrhythmia was found. 
Birth history: Type of delivery, Medications during labor, FHR patterns.
The mother had a C-section at 1404 on 9/18/12. She was given one bag of antibiotics (ancef) because the mother was GBS positive. She was given one ibuprofen since the surgery and is taking prenatal vitamins still due to breast-feeding. The baby was born with the umbilical cord wrapped around her neck, but it was loose enough that it did not cause any permanent damage. The mother is O negative so she was automatically given rhogam to prevent the possibility of Rh incompatibility. 
Method of feeding, how often, amount. Any problems feeding?
The mother chose to breast feed. She says there are no problems, her nipples are slightly sore but there is no noticeable redness, excoriation, or bleeding. She said she fed pretty continuously yesterday, but today she feeds her baby about once every two to three hours. There is clear mom-baby attachment.
Measurements:				
Length (cm)__50_______       (inches) _19.69_______ 
Head (cm)___35__ ___       (inches)___13.78_______	
Chest(cm)__33______         (inches)__12.99________	
Birth weight.(gm)_3062_____(lb.)__6__ (oz.)_12____    
Today’s weight.(gm) 2971___(lb.)_6___ (oz.)_8.8____
Percentage of weight loss (Show calculations even if the baby has lost no weight). __3________%       What is normal weight loss?  Between 7-10% weight loss is considered normal._      
Is this neonate's wt. loss within normal limits? Yes, this is well within normal limits._________

 Vital Signs:
Birth:				At time of your care:
T__97.6_____			T __98.5_______
P__160_____			P __152_______
R__60_____			R __61_______

Age (in hours) of first void_7 hours of life______________ 
Voiding patterns: (color, # of times/24 hours)
She typically voids around six times a day. There is no noticeable odor or irregularity about her voids. Color is yellow.
Age (in hours) of first stool_2 hours of life________________
Stools: (type, color, consistency)
Her first stools were dark black and tarry. Now her stools are more of a light brown color and seedy which is consistent with a baby who is breastfed.

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
	This was not ordered for this baby because she is not LGA nor was she born to a diabetic mother. 	Does not apply.	Blood glucose of less than 40 mg/dL is considered hypoglycemic. 	Does not apply. 	
Blood type and Rh factor
	This was done because the mother is O negative so there is a strong likelihood of there being Rh incompatibility especially with this being her second child. 	The baby has A negative. I think this is done automatically if the mother has blood type O or Rh negative. 	Varies. 	There is no presence of ABO incompatibility. And both the mother and baby have Rh negative blood, so there is no Rh incompatibility. 	
Bilirubin

	This is standard for all babies on the floor. Bilirubin levels are tested every 12 hours.
It is done for this baby because the mother is Rh negative. Also the mother is blood type O and the baby is blood type A. 	6.7 	A newborn has twice as much bilirubin as an adult. Total bilirubin levels greater than 13 to 15 mg/dL indicate hyperbilirubinemia. 	This neonate does not have hyperbilirubinemia. 	
Coomb’s test

	This was not done for this patient. 	Does not apply. 	Indirect Coombs’ determines the presence of maternal antibodies in maternal blood. Direct Coombs’ determines presence of maternal Rh antibodies in fetal blood; cord blood is usually used. 	Does not apply. 	

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)
1.0 mg IM should be given by 2 hours of age.	This is given to all newborns to prevent hemorrhagic disease. It is required for hepatic synthesis of blood coagulation factors II, VII, IX, and X. 	Erythema, pain, and swelling at injection site. 	Monitor leg for side effects. Vitamin K is usually given on the left leg and intramuscular immunizations are given on the right leg so we can tell what is causing a reaction. 	
Illotycin (Erythromycin ointment)
Ointment placed into both eyes by one hour of age. 
	This is given to all newborns immediately after birth to prevent the possibility of eye infections from Chlamydia, Gonorrhea, or other bacterial infections of the mother.	Periorbital edema and blurred vision.  	Monitor the neonate’s eyes for any swelling, redness, drainage, odor, or discomfort. 	
NEWBORN ASSESSMENT

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

98.5

152

61

Not taken on floor.	
97.5-99
120-160
30-60
50-75/30-45 mm Hg	She is within normal ranges for everything except respiration rate. She was breathing slightly more frequently than is normal, but she was agitated when we did the exam. 	
Measurements
      Head Circ
      Length
      Chest	
35 cm
50 cm
33 cm	
33-35 cm
45-53 cm
30.5-33cm	Head circumference below the 10th percentile indicates microcephaly which is related to congenial malformation, maternal drug or alcohol use, or maternal infection during pregnancy. Head circumference greater than the 90th percentile indicates macrocephaly which can be related to hydrocephalus. 
Neonates shorter than 45 cm should be assessed for causes of intrauterine growth restriction or prematurity. 	
Color	Consistent with ethnicity. 

	Skin should normally be pink with acrocyanosis. 	No jaundice or pallor was noted. 	
Muscle tone/
Posture	Normal. 
Tense. As to be expected with term babies.
	Extremities should be flexed. Extension of extremities often are related to prematurity, medications given during labor, birth injuries, hypothermia, or hypoglycemia. 	Muscle tone and posture are as to be expected with a term baby. 	
Cry
	Normal. Not high-pitched. 

	H	Cry is as to be expected. 	
Activity level	Very active. 

	There should be a period of reactivity from 30-60 minutes after birth where they are awake and alert. Next the neonate should have a period of inactivity when the newborn sleeps for a few minutes to a few hours and will be difficult to awaken. Then the neonate will enter another period of reactivity lasting four to six hours. 	Activity level is as to be expected for this age. 	
Skin:     
     Lanugo/
     vernix
     Rashes	Fine, dark, downy lanugo present on forehead, arms, legs, and on back above the buttocks. Sparse areas without. 
No vernix or rashes present. 
Milia is present on the nose.	Milia is present on the bridge of the nose and chin. Lanugo is present on the back shoulders, and forehead which will decreases with advancing gestation. Peeling or cracking is often noted on infants over 40 weeks gestation. 
Hemangiomas (stork bites) are developmental vascular abnormalities. 	No vernix was present due to age after birth. She did not have an abundance of lanugo which would indicate prematurity. 
Erythema Toxicum (newborn rash) although normal, was not seen on this neonate. 	
Head 
	Normocephalic. No molding. No caput succedaneum or cephalohematoma present.  

	Molding is a common finding for vaginal births. 
When molding is present, there may be overriding sutures. 	She was delivered via cesarean so no molding was present. 
Bruises or lacerations at the site of the fetal electrode or vacuum extractor are abnormal findings. 	
Fontanels
	Both are open and normotensive. Not bulging or concave. The posterior fontanel is small and hard to find but still slightly open. 	Fontanels should be open, soft, intact, and slightly depressed. They may bulge with crying. The anterior fontanel is diamond shaped approximately 2.5-4 cm and closes by age 18 months. The posterior fontanel is a triangle shape approximately 0.5-1 cm. It closes between 2-4 months.	Fontanels that are firm and bulging not related to crying is an indication of increased intracranial pressure. Depressed fontanels indicate dehydration. 	
Face
	No abnormalities. 

	Face should be proportional to the rest of the head, no obvious growths or abnormalities. 	The face is as to be expected. 	
Eyes
	Eyes are equal in size, symmetrical. Sclera is white, iris is brown. Positive blink reflex and pupil reaction to light. 

	Eyes should be equal and symmetrical in size and placement. 
The neonate is able to follow objects within 12 inches of the visual field. 
The iris should be blue-gray or brown. 
Subconjuctival hemorrhages may be present due to birth trauma. 
Pupils should be equally reactive to light and have a positive red light reflex and blink reflex. Tear production does not occur until two months old. 	Absent red  light reflex indicates cataracts. 
Unequal pupil reactions indicate neurological trauma. 
Blue sclera indicates osteogenesis imperfect.  	
Nose
	Nares patent. No extra cartilage or abnormalities. Baby breathes through nose easily. No bruising or flattening. 

	The nose may be flattened or bruised related to the birth process. Nares should be patent. Small amount of mucus should be present. Neonates primarily breathe through their nose. 	Large amounts of mucus drainage can lead to respiratory distress. 
A flat nasal bridge is seen with Down’s syndrome. 
Nasal flaring is a sign of respiratory distress.	
Mouth

	Lips, gums, tongue, palate, and mucus membranes intact, pink, and moist. No abnormalities such as hare lip. No teeth present.  Reflexes present.

	Lips, gums, tongue, palate, and mucus membranes are intact, pink, and moist. Reflexes are positive. Epstein’s pearls are present. 	Natal teeth, which can be benign or related to congenital abnormalities. Thrush, a fungal infection can be contracted during vaginal birth. It appears as white patches on the mucus membranes of the mouth. 
Cleft lip and/or palate, which is a congenital abnormality in which the lip and/or palate does not completely fuse.	
Ears

	Patent. Elastic recoil. No extra cartilage. Symmetrical. Pinna level with outer canthus of eyes. 

	Top of the pinna is aligned with external cantus of the eye. Pinna should be without deformities, well formed, and flexible. Hearing becomes more acute as Eustachian tubes clear. 	Low-set ears indicate genetic disorders such as Down’s syndrome. Absent startle reflex indicates possible hearing loss. 	
Neck	Trachea midline. 
	The neck should be short with skin folds. There should be a positive tonic neck reflex. 	Webbing indicates genetic disorders. Absent tonic neck reflex indicates nerve injury. None of these are present for this neonate. 	
Chest	Expands symmetrically with breaths. No discharge present. Breast buds are 1-2 centimeters. 

	The chest is barrel shaped and symmetrical. Breast engorgement is present in both male and female neonates related to maternal hormones. This resolves in a few weeks. Clear or milky fluid from nipples related to maternal hormones .
	Funnel chest is a congenital abnormality. Pigeon chest can obstruct respirations. Chest retractions are a sign of respiratory distress. 	
Breath sounds

	Clear, short, shallow, and rapid. Irregular due to sucking on pacifier. Clear lungs, no adventitious breath sounds. 	Lung sounds should be clear and equal. Scattered crackles may be detected during the first few hours after birth due to retained amniotic fluid which will be absorbed through the lymphatics.	Persistent crackles, wheezes, stridor, grunting, paradoxical breathing, decreased breath sounds, and/or prolonged periods of apnea (more than 15-20 seconds) are signs of respiratory distress. 
Decreased or absent breath sounds are often related to meconium aspiration or pneumothorax. 	
Heart sounds

	Regular rate and rhythm for the most part. Accelerates with sucking, decelerates with relaxation as to be expected. 	Point of maximal impulse is at the 3rd or 4th ICS. S1 and S2 are present. There is a normal rhythm with variation related to respiratory changes. Murmurs occur in 30% of neonates but disappear within 2 days of birth. 	Dextrocardia: heart on the right side of the chest. Displaced PMI occurs with cardiomegaly. Persistent murmurs indicate persistent fetal circulation or congenital heart defects. 	
Abdomen

	Soft, non-tender, protuberant, symmetrical abdomen. She has diastasis recti. 	The abdomen id soft, round, protuberant, and symmetrical 	Asymmetrical abdomen indicates a possible abdominal mass. 
Hernias or diastasis recti are more common in African-American neonates and usually resolve on their own within the first year.	
Bowel sounds

	Hypoactive bowels due to recent bowel movement. 	Bowel sounds are present but may be hypoactive for the first few days. Passage of meconium stool within 48 hours post-birth.	Failure to pass meconium stool is often associated with imperforated anus or meconium ileus. 	
Umbilical cord

	Unclamped. No signs of infection. Clear with black crusty parts. No odor or redness. 	The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton’s jelly. The cord becomes dry and darker in color within 24 hours post-birth and detaches from the body within 2 weeks.	One umbilical artery and vein is often associated with heart or kidney malformation. 	
Female Genitals
     Vagina
      Labia
      Pseudo-
      menses	Has dark Brown spots due to her ethnicity. Smegma is present. The labia majora covers the clítoris and labia minora. 
No pseudo-menses present. 	Labia majora covers labia minora and clítoris. Labia majora and minora may be edematous.
Blood-tinged vaginal discharge related to abrupt decrease of maternal hormones is a normal finding. 	Prominant clítoris and small labia minora are often present in preterm neonates. Ambiguous genitalia may require genetic testing to determine sex. 	
Anus

	Patent and intact. 	The anus should be patent. Passage of stool within 24 hours. 	Imperforated anus requires immediate surgery. Anal fissures or fistulas are abnormal findings. 	
Arms and hands

	Acrocyanosis of hands present. Five non-webbed fingers on each hand. 	Arms are symmetrical in length and equal in strength. Should be 10 fingers. No clicking at the joints. 	Polydactyly: extra digits may indicate a genetic disorder. Syndactyly: webbed digits may indicate a genetic disorder. 	
Legs and feet

	Acrocyanosis of the feet present. Five toes on each foot. 	Legs should be symmetrical in length and equal in strength. Full range of motion of all extremities. No clicks at the joints. Should be 10 toes. 	Hypotonia: floppy, limp extremities indicate possible nerve injury. 
Hypertonia: tightly flexed arms and stiffly extended legs with quivering indicate possible drug withdrawal. 	
Back	No dimpling of the spine. Mongolian spots near the bottom present. 	There should be a C curve of the spine with no dimpling. 	No pilonidal dimple was noted. 	
Variations of normal and meanings of normal found at Chapman & Durham, 2010, p. 290-296.
NEWBORN REFLEXES

REFLEX	YOUR ASSESSMENT	EXPECTED FINDINGS	AGE WHEN REFLEX SHOULD DISAPPEAR
	
Rooting

	Present. 	The neonate turns her head toward the direction of the stimulus (rubbing the side of a cheek near the corner of the mouth) and opens her mouth. 	Disappears between 3-6 months. 	
Sucking

	Present. 	Place a gloved finger in the neonate’s mouth and a sucking motion should occur. 	Disappears at 10-12 months. 	
Swallowing

	Present. 	When something is placed in the mouth, the baby should swallow it. 	The baby will never lose this. 	
Pupillary

	Present. 	When a bright light is shined in the baby’s eyes, the pupil should constrict. 	The baby will never lose this. 	
Moro

	Present. 	With sudden extension of the head, the arms abduct and move upward and the hands form a “C.” If you drop the baby’s head back, it should extend out legs and arms. 	It disappears by 4 months. 	
Startle

	Present but delayed. 	This is similar to the Moro reflex. When you make a loud noise the baby should abduct arms and legs and typically cries. 	It disappears by 4 months. 	
Palmar grasp

	Present. 	Place a finger in the palm of the neonate’s hand. The neonate grasps the finger tightly. If the neonate grasps the examiner’s fingers with both hands, the neonate can be pulled to a sitting position. 	Disappears at 3-4 months. 	
Planter grasp

	Present.	Place a thumb firmly against the ball of the infant’s foot. Toes should flex tightly down in a grasping motion.	Disappears at 3-4 months. 	
Tonic neck

	Not present.	With the neonate in a supine position, turn the head to the side so that the chin is over the shoulder. The neonate assumes a “fencing” position with arms and legs extended in the direction head is turned. 	Present between birth and 6 weeks. Disappears by 4-6 months. 	
Stepping

	Present.	Hold the neonate upright with feet touching a flat surface. The neonate steps up and down in place. 	Disappears at 3-4 weeks. 	
Blinking

	Present. 	When the eye begins to dry out, the baby should blink to protect the eye. If wind is blown into the baby’s face, it should blink to protect the eye. 	You should never lose this. 	
Trunk incurvation

	Present. 	Newborn lies prone and when one side of spine is stroked, it causes pelvis to flex toward stimulated side. 	 This usually disappears at 12 months.   	
Babinski

	Present. 	Stroke the lateral surface of the sole in an upward motion. The neonate should hyperextend and fan the toes. 	Disappears at one year. 	

Discuss the clinical significance of the findings from your physical assessment.
There were no significant findings from the physical assessment. The neonate appears healthy, has no abnormal growths or visible abnormalities. 
GESTATIONAL AGE EXAMINATION 
What is your estimate of the neonate's gestational age from your assessment? ____40 weeks_________ (Hand in Ballard sheet with this assignment)   
Does your assessment agree with the gestational age by LMP?  (Discuss) 
Not entirely. She delivered at 39 weeks and the Ballard scale indicates that the neonate is 40 weeks. However, because the Ballard assessment was done more than 24 hours after birth, the results are not entirely accurate. 
Is this infant SGA, AGA or LGA? ___AGA________
Are there any complications expected for a baby in this classification?  (Discuss)
_No complications expected for this baby. ____________

Risk for infection related to umbilical cord opening as evidence by unclamped, black and crusty umbilical cord. 

Lakeview College of Nursing
N305 Newborn Assessment Grading Grid
STUDENT'S NAME ___Lynette Hosier____________  Date of Care _September 20, 2012__________
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