COLLEGE OF NURSING, PHARMACY AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING

NAME: Baby F DATE: Dec 01, 2021

NURSERY ASSESSMENT
Birth Date: November 20, 2021 Time: 2:48 PM Sex: Female Apgar: at 1 minute ___7__
at 5 minutes __9___

Type of Delivery: Vaginal ✓ C- Section: ___ Week of Gestation 39 weeks gestation Complications
of pregnancy None
Birth Weight __3.8 kg__ Length _cm_ Head Circumference _50 cm_ Chest Circumference _32 cm_
Abdominal Circumference _35 cm_

Blood type and Rh: _A +_ Resuscitation: None ✓ Oxygen _____ Bag and Mask ____
Intubation ____ CPR ____

NEWBORN FINDINGS
RESPIRATORY
• Respirations/min 50 cpm
• Character of Respirations: regular with moderate depth and symmetrical
• Describe lung sounds: clear, soft, low-pitched sound , bilateral
• Any signs of respiratory distress: None
• Other observations: None

CIRCULATORY
• Apical pulse 115 bpm Character of each pulse rhythm is
regular with moderate in pace
• Any abnormal heart sounds? None
• BP 65/45 mmHg Other observations none
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COLLEGE OF NURSING
THERMOREGULATION
• Temperature and method 37 °C, taken through rectum
• How is newborn’s thermoregulation being maintained at this time? Left the newborn skin-to-skin on the mother and
keep covered
• Other observations

URINARY/ GENITAL
• Has infant voided? Yes When first 24hrs of life Character of
urine: light-colored and odorless
• Any edema None Describe _________

Male

• Location of urinary meatus? Is infant going to have a circumcision?

• Character of scrotum (rugae, color, hydrocele, etc.)
• Describe the position of testes (are they descend bilaterally)
• Other observations:

Female
• Position of labia majora and minora
• Vaginal discharge _✓ _
• Location of urinary meatus
• Other observations:
labia majora larger than clitoris and labia minora
Character swollen and red, clear, white, or slightly bloody discharge
above the vaginal opening.
None
 COLLEGE OF NURSING, PHARMACY AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
HEAD/NECK
Describe findings if present:
• Caput succedaneum? None. Cephalhematoma? None. Molding? None.
• Anterior fontanelle patent? No. Posterior fontanelle patent? No.
• Is newborn responsive to sounds? Yes. How tested? OAE (Otoacoustic Emissions)
• Do pupils react to light? Yes. Do eyes follow objects? Describe. Baby F starts tracking moving objects with her eyes and
reaching for them.
• Color of eyes (Iris): Light brown Color of sclera: White Strabismus? No.
• Nares patent? Yes. Precocious teeth? None Epstein’s pearls? None
• Hard and soft palate intact? Yes. Describe tongue: It allow for a smooth and uninterrupted swipe underneath the frenulum.
Are features symmetrical? Yes.
Other observations: None.

CHEST
• Describe appearance of chest: Chest is symmetrical.
• Number of nipples: 2 Any accessory nipples: None. Swelling of breast buds: None. Witch’s milk: None.
Other observations: None.
ABDOMEN/GROIN
• Describe appearance of abdomen: Gently rounded and symmetrical
• Umbilical cord vessels: 3 arteries: 2 veins: 1
• Hernias: None.
Other observations: None.

MUSCULOSKELETAL
• Describe infant position: Cephalic presentation
• Polydactyly? None. Syndactyly? None.
• Legs similar in length? Yes. Gluteal folds and thigh creases equal? Yes.
• Clubfoot? None. Spine closed? No. Any “tulf of hair” or pilonidal dimple? None.
Other observations: None.
 COLLEGE OF NURSING, PHARMACY AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
NEUROLOGIC/REFLEXES
Describe findings of the newborn’s reflexes:
• Moro: In response to sound the baby suddenly lifts the arms and legs.
• Startle: In response to sound, the baby cries.
• Palmar and plantar grasp: By touching the baby, she holds onto my hand.
• Rooting: By touching the corner of baby F’s mouth, she turned her head and opened her mouth.
• Sucking: Baby F is sucking her thumb.
• Swallowing: Swallowing reflex is present.
• Tonic neck or fencing: Baby F’s head turns to the right, the right arm stretched out and then the left arm bend at the elbow.
• Babinski: In response to the firm stoke of the sole of the baby’s foot, baby F’s big toe moves upward or toward the top of
the foot and the other toe fans out.
• Stepping: Baby F move her legs as if she is walking or trying to take steps.
• Describe newborn’s cries: Vociferous, shrill, and piercing cry of the newborn.
Other observations: None.
Newborn Assessment 2007

Summary and Other Findings:

✓ Baby F’s temperature is 37.0°C.
✓ Baby F has 7–8 skin pustules on her left arm and upper chest. There is no localized swelling or redness, fluctuant lesions,
generalized edema, or rash on palms or soles.
✓ The baby is wearing soiled clothing and is wrapped in a soiled cloth.
✓ The baby is breastfeeding well and shows no other signs of systemic sepsis as mentioned above.
✓ All other aspects of her physical examination are within normal range.