Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY

NURS 3731: Childbearing Family and Women’s Health Nursing

PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19

Date of Birth: 3/3/19 Time of Birth: 0040 Male/Female Infants Age (in hours): 8 hours Gestational Age: 38weeks 4 days

AGA/SGA/LGA APGAR (1 & 5 minutes): 9/9 Breast or Bottle feeding (including formula): Breast Feeding

Newborn’s Blood Type/ Rh (If applicable): B/ Positive, Coombs Test: Negative Maternal Blood Type/ Rh: O/ Positive

Prenatal Care (Number of Visits):14 visits Mother’s age: 30 Gravida/ Para: G- 2 T- 2 P- 0 A- 0 L- 2

Type of Delivery: Spontaneous Vaginal, Length of Labor: Stage 1: 10 Hours Stage 2: 2 Hours Stage 3: 5 Hours

Augmentation of Labor: NA/ Pitocin/ Artificial ROM/ Cervical Ripening

Assistive interventions for delivery: None/ Episiotomy/ Vacuum/ Forceps

Maternal use of: Alcohol/ Tobacco/ Caffeine/ Street/ Recreational Drugs/ None

Maternal use of prescribed or over-the-counter medications: Prenatal Vitamins

Maternal exposure to AIDS, Hepatitis, Rubella, TORCH: None

Significant medical history R/T pregnancy, labor, deliver and first 24 hours of life: No abnormalities

Familial history of congenital anomalies, metabolic health deviations: None

Additional factors which may have affected fetal growth or development (low income, single/teenage mother, insufficient support
system, inadequate nutritional intake, pica, no prenatal care, etc. Patient is married with the strong support system of her family.
Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY
NURS 3731: Childbearing Family and Women’s Health Nursing
PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19

For the following general categories, THROUGHLY and COMPLETELY document your assessment data and an
INTERPRETATION of each. Use N2643 Health Assessment and N3731 Course Packet for guidelines and correct documentation of
your assessment data.

VITAL SIGNS: Temperature: 99.0 Respirations: 40 Blood Pressure: 60/41 Heart rate: 142

MEASUREMENTS: Length and Weight: 18” and 6lbs 9oz Head and Chest Circumference: 13.5 inches and 13 inches

SKIN: The skin is consistent with genetic background, pink tinged, smooth, soft, pliable, and warm to touch, good elasticity, small
amounts of vernix present in the folds of the skin. No mottling, Mongolian spots or telangiectasia nevi present.

HEAD: Circumference of head is 13.5 inches. Sutures are open, fontanelles are open, soft, and flat. Hair is silky, lying flat, and grows
toward the face and neck

NECK: Creases present, freely movable, rests on shoulders and the chin appears to rest on the chest

FACE: Symmetrical, checks are full. Eyes- symmetrical in shape and movement, brown color. Sclera has a yellow tint, eyelids are
symmetric with movement, corneas are bright, shiny. Ears- soft, pliable, well-formed cartilage, pinna is in a straight line with the inner
and outer canthus of the eye, responds to sound. Nose- small, nose breather, nares are patent bilaterally, no discharge. Mouth- lips
pink and symmetrical and sensitive to touch, adequate saliva, tongue pink and smooth texture, it is proportionate to the mouth and
moves freely, hard palate intact, sucking, swallowing, gag and rooting reflexes present.

TRUNK AND CHEST: General Characteristics and Clavicle: Cylindrical shaped chest, both sides move symmetrically and
synchronously with abdomen during respirations. Ribs flexible, apical pulse audible. Clavicle: straight intact without crepitus,
shoulders symmetrical
Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY
NURS 3731: Childbearing Family and Women’s Health Nursing
PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19
ABDOMEN: General Characteristics and Umbilicus: Prominent, soft, and rounded. Abdominal respirations with symmetrical
movement, bowel sounds present. Umbilicus: Clean, dry, placed in center of baby’s body, cord has two arteries and one vein at birth

EXTREMITIES: Fully formed, correctly placed, full range of motion and freely movable. Maintains a flexed position, arms and legs
of equal length with symmetrical skin folds, legs symmetrical, feet flat. Brachial, femoral, and pedal pulses palpable, all digits present

HIPS: Abduction of thighs greater than 60 degrees. Negative Ortolani’s maneuver.

SPINE: Normal curvature, straight, flat, freely movable, flexible, vertebrae intact.

POSTURE: Presentation: Vertex. Arms, legs, in moderate flexion, fist clenched

GENITALS: Male: Urinary meatus at tip of glans penis, palpable testes in scrotum, stream adequate on voiding.

BUTTOCKS/ANUS: Buttocks and crease are equal and symmetrical, anus patent and appropriately placed. “Wink” reflexes present.

ELIMINATION: Stools: No abdominal distention, transitional stools, soft, formed, light yellow stool present

Urination: Pale yellow color, about 3-4 times a day

NEUROMUSCULAR: General Characteristics, motor reflexes, hearing, vision, touch, and taste. Brain stem development and
musculoskeletal system intact, response is specific to the gestational age and state of wakefulness. Motor: Generalized flexion, full
range of motion, strong symmetrical movement bilaterally. Reflexes: well-developed bilaterally, coordinated, and intact responses

SENSORY ABILITIES: Hearing: Able to move eyes in the direction of sound, responds to high pitches by freezing, followed by
agitation, and to low pitches by relaxing. Vision: Gazes intently, follows and focuses with eyes, accommodation is limited. Touch: s
 Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY
NURS 3731: Childbearing Family and Women’s Health Nursing
PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19
soothed by massage, warmth, and cuddling.

BEHAVIORAL PATTERNS:

Feeding: Control and responsiveness, variations in interest and hunger, overall feeds well within 48 hours

Sleep-Wake Cycle: transitional period with two periods of reactivity at birth and 6-8 hours later. Stabilizes with wakeful periods every
2-3 hours.

Social: Cry us lusty, strong, medium pitched. Responds with quietness, increased alertness to cuddling voice

Laboratory and Diagnostic Test

Normal Range- List ALL Newborn’s results (if

Test Possible/ Probable Cause
Even if not ordered ordered)

Hgb (g/dL) 15-20 19 Within Normal Limits

RBC (ml/dl) 4.1-7.5 5.0 Within Normal Limits

Hct (%) 43-61 54 Within Normal Limits

Bilirubin, total (mg/dl) 4-6 4 Within Normal Limits

Blood Glucose 40-97 mg/dl Not applicable Within Normal Limits

Urine Pale, acidic, low specific Pale in color Within Normal Limits
Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY
NURS 3731: Childbearing Family and Women’s Health Nursing
PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19
gravity
Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY
NURS 3731: Childbearing Family and Women’s Health Nursing
PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19
Summarize your Gestational Age Assessment

The newborn that I assessed for the gestational age assessment was born at full term (38 weeks and 4 days) and was overall rather

healthy. This was the second pregnancy for this mother who had given birth vaginally to a healthy baby boy two years prior. She

never consumed alcohol, tobacco, prescription drugs, or street drugs during pregnancy. This lead to an overall healthy baby and easy

delivery with no complications. The newborn presented with slight acrocyanosis of the extremities which lead to an APGAR score of

9/9 at one and five minutes. During the gestational age assessment, there were no abnormalities assessed of the newborn. The infant

was born of spontaneous vaginal delivery in the vertex position with no assistive use of anesthesia. The newborn is being breast feed

by the mother every three hours. Overall, the infant is healthy with no notable deficits or underlying abnormalities.
Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY
NURS 3731: Childbearing Family and Women’s Health Nursing
PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19
Student Self Growth

Overall, I would assess myself with being adequately prepared to preform and document this newborn physical and gestational

assessment. I was able to review the clinical packet, my notes from lecture, and any other additional information I was able to gain

from my time spent in clinical to formulate this assessment. The difficulties I experienced during this assessment was acclimating

myself to the feel of assessing a newborn baby. My experience throughout nursing school has been on assessing adults so the shift to

newborns was a new and exciting experience. Overall, I would say I was able to adjust well in order to complete my assessment

without significant difficulties.

Moving forward throughout my nursing career, I would say that I gained a significant amount of knowledge regarding the

assessment and implementation of newborn and postpartum mother care. The skills gained from this clinical experience through my

various assessments and patient care will shine through during all patient care in the future. I will be able to use my skills of vital

assessment, precise assessment, and evaluation of conditions for significance and changes to monitor my patients through all stages of

life.
Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY
NURS 3731: Childbearing Family and Women’s Health Nursing
PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19
Nursing Diagnosis Behavioral Outcome Nursing Interventions Documented Rationales Evaluation Modifications
Objectives
1. Risk for Injury r/t 1. Neonate will 1. Assess infant and 1. Assessment of 1. Consistent
elevated Bilirubin display bilirubin maternal blood maternal and monitoring of
levels below 12 type that could neonatal risk maternal and
mg/dL predispose them to factors (p. 550) infant status using
2. Neonate will not high bilirubin 2. Jaundice is visible screening
manifest signs of levels in the face and modalities
jaundice by the 2. Assess the infant head when levels 2. Effective
end of the first using blood test reach 5-8 mg/dL observation of
week of life then progress to overall skin
3. Neonate will be trunk and coloration and
free of CNS extremities as condition
involvement r/t levels rise (p. 550)
high bilirubin
levels
Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY
NURS 3731: Childbearing Family and Women’s Health Nursing
PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19
Nursing Diagnosis Behavioral Outcome Nursing Interventions Documented Rationales Evaluation Modifications
Objective
1. Risk for Sudden 1. Educate patents 1. Teach parents the 1. Parents viewed
Infant Death 1. Parents will regarding safe need to obtain a SID videos
Syndrome (SIDs) demonstrate sleep practices crib that conforms provided by the
proper positioning 2. Educate parents to the safety hospital. Parents
for handling and on to never sleep standards of the then demonstrated
swaddling the in the same bed Consumer Product back to the nurse
infant with the infant, Safety the safe sleeping
2. Parents will regardless of Commission practices they
demonstrate safe alcohol, (CPSC.) (p. 851) learned
and effective medications, 2. A study of more
measures to smoking, or illicit than 1000 SIDs
decrease the risk drug use cases found that
for SIDs bed sharing with
an infant resulted
in an increased
incidence of SIDs
even without
illicit drugs,
alcohol, or
smoking. (p.851)
Student Name: Hannah Shafer YOUNGSTOWN STATE UNIVERSITY
NURS 3731: Childbearing Family and Women’s Health Nursing
PHYSICAL AND GESTATIONAL AGE ASSESSMENT OF THE NEWBORN Date: 04/02/19

Works Cited
Ackley, B.J. Ladwig, G.B, & Makic, M.B. (2017). Nursing Diagnosis handbook: An evidence-based guide to planning care (9th ed). St. Louis:
Elsevier.