NEWBORN ASSESSMENT HEAD-TO-TOE POST-PARTUM ASSESSMENT

1. General survey – whether baby is stable or not 1. Vitals signs + Pain level
2. Vitals signs – (Respirations: 30-60) (HR: 110-160) (Temp – Axilla: 36.5-37.4)
(Weight: percent wt loss from birth wt (not greater than 10%)) B – Breast/nipples
3. Skin – pink and warm, smooth, good skin turgor, intact (Lanugo, Vernix,
Dryness, flaking, Acrocyanosis, Erythema Toxicum, Birthmarks, Mongolian
spots) Look for bruising, petechiae, rash, lesions, jaundice U – Uterus/Incision
4. Head - round and symmetrical (molding, scratches, cuts, birthmarks) make sure
sutures are present (Look for over‐riding, caput, cephalohematoma) B – Bowel
5. Fontanelles – (Anterior-4‐6 cm, Posterior-1‐2 cm)
6. Face – Symmetrical (Milia), look for bruising and facial nerve paralysis
B – Bladder
7. Eyes – clear and symmetrical (swelling + hemorrhage), observe pupillary reflex
and gaze, red light reflex
8. Ears – soft and pliable and well set, responds to sound (Observe Moro reflex in L – Lochia/legs – rubra, serosa, alba
relation to loud sounds)
9. Mouth – Hard & Soft Palate intact, epstein pearls, sucking blister to lips, suck
reflex, rooting reflex present, midline uvula, free moving tongue, mucous E – Episiotomy/emotions
membranes pink and moist (look for Tongue tie)
10. Nose – size, symmetry, position, sneezing
11. Neck – moves freely (any growths, webbing)
12. Shoulders & Arms – Clavicles intact, moves equal bilateral, 5 fingers, palmar
creases, grasp reflex
13. Chest – round + symmetrical movement and nipples may be swollen, breath
sounds + bilateral (look for retractions, indrawing, amount of breast tissue, lung
and heart sounds)
14. Abdomen – protuberant and soft with bowel sounds, cord-2 arteries and 1 vein,
light palpation for masses, skin turgor and perfusion adequate. Cord-clean and
dry, 2 arteries, 1 vein (larger)
15. Genitalia – Void and meconium within 24 hrs
Females: labia formation, pseudomenses, swelling
Males: urethral position, Testes descended,
16. Hips & Legs – femoral pulses, congenital hip, 5 toes, creases, plantar reflex,
babinski Reflex,
17. Back – spine straight, Base of spine, folds of buttocks/legs, Moro reflex, Tonic
Neck Reflex
Bladder
Lochia/legs-rubra, serosa, alba Episiotomy/emotions