So, for this procedure we will need our PA forms and papers which we can write our notes

on a pen and
the gloves for the PPE. We're now here at our client’s crib so, we're going to verify the client's name first
on the crib tag and on the baby's hospital tag. Usually, it is on the wrist or on the ankle so let us check...
NAME born on DATE and SEX. So, we have the right patient. PROVIDE PRIVACY AND HAND HYGIENE

I’m going to put on my gloves, this will protect the baby and us from any cross-contamination and
remember we're handling newborns and they're very fragile. We have now removed the blanket or the
wrapping of the baby in order for us to assess him much more thoroughly and effectively. We're going to
start by assessing the client's vital signs. Let's start with the respiratory rate. The normal is usually 30 to
60 breaths per minute. We're going to assess for any respiratory distress. We can see that if the baby is
having nasal flaring. There is no presence of that and there are also no chest retractions. We're going
assess the breathing. We're going to count it for a whole minute. Unlike in adults which we can do it for
30 seconds and multiply it by two, in babies we have to actually watch the rise and fall in order for us to
get it properly because their breathing varies from the adult. Now we're going to look at the rise and fall
of the baby's chest and we're going to count it for one minute. The baby's breath is 38 respirations per
minute.

Now we're going to assess the baby's heart rate. The normal is 110 to 160 beats per minute so when a
baby cries it actually varies. We're going to use a stethoscope and specifically the bell. I'm assuming that
this is for the infant so the infant size is usually smaller. We're going to use the apical pulse in order to
count the heart rate of the baby. We're going to locate first the fourth intercostal space from the baby's
clavicle. We're going to go down one two three and four and we're going to go lateral and just below the
nipple and we're going to start listening for a whole minute. The baby's heart rate is 142. Now we are
going to check the baby's temperature using our digital thermometer. The usual is 36.4 to 37.4 degrees
Celsius. We're going to take the axillary we're just going to turn on the thermometer and we're going to
place it in the axillary and make sure to put the arm down while doing so. The baby's temperature is
36.8. Now we're going to weigh the baby assuming that this is a baby scale we've also removed the
infant's clothing makes sure that the diaper isn't soiled and we're going to weigh the baby. The baby
weighs eight pounds and we're now going to take the length of the baby. We have laid him in a flat
surface that's lined and this is clean.

We're going to mark the ends of the baby from the toes to the baby's head. We're going to need a pen
and the tape measure. We're going to hold the baby's head down midline and we're going to mark that
and then we're also going to hold the one foot of the baby down and we're also going to mark that.
After marking the ends we're going to use our measuring tape to measure the length of the baby. The
usual length is 18 to 22 inches and our baby is approximately 19 inches. Now we're going to assess the
baby's head and head circumference the normal is 33 to 38 centimeters. We're going to start by lifting
the head slightly just for us to put down our tape measure and we're going to measure it. Our baby's
head circumference is 35 cm. Now we're going to assess the baby's chest and get the chest
circumference. We're going to put the tape measure beneath the baby and we're going to use the nipple
of the baby as a guide. The usual chest circumference is one to two cm less than the baby's head. The
baby's head is 35 cm and this baby's chest circumference is actually 33 centimeters. The baby's chest
does not have any obvious deformities.

Now we are going to assess the baby using the apgar scoring. We're going to start with the heart rate.
We assessed it earlier and it was 142, it's greater than a hundred so it's two and the respiratory effort is
good and strong that's also a two. The muscle tone of the baby is active and he was moving around just
now. The reflex irritability or the grimace is crying and vigorous. Earlier, the color of the baby is pink in
the body and a bit bluish on the extremities which means there's presence of acrocyanosis which is
perfectly normal for a newborn like NAME. The overall the score of the baby is 9 which is within the
normal range. The baby's gestational age is 38 weeks and he is a term baby and the weight is also
assessed earlier, he is eight pounds approximately three thousand six hundred grams.

Now we're going to assess the baby's skin. First, let's start with the color. It's normal and also the tone.
We're going to also check the body for any birth marks There's one here and that's normal. Also, the
Vernix caseosa is present since it's a newborn, it's not supposed to be removed. The lanugo is also
present so there's a moderate amount. There's also disclamation or the flakes and peeling. It's also
normal with a newborn. There's also presence of milia especially on the nose, the white spots. We also
have erythema toxicum. It's present but it will go away and eventually it will disappear. There is no
forcep mark, no lesion and the baby's skin turgor is good.

Now we're going to assess our baby's Head. Let's start with the fontanelles. It's still open, suture lines
are appreciated. The suture lines and the fontanelles will disappear with time. There is also presence of
molding. This is also normal. No presence of swelling and no cephalohematoma. Now for the baby's
eyes we're going to examine the external and internal structures. All structures seem to be present and
no problem and no abnormalities. We can see the pupil and the sclera and there's no signs and
symptoms of infection or any bleeding. The baby's ears seem to be in good skin condition, it's normal.
There are no skin tags on the infant. For the baby's nose, there is the presence of milia, the white spots,
we're going to check for choanal atresia or any blockage in the nostrils. We're going to occlude one
nostril and let the baby breathe through the other and the other side. Okay, the baby was able to
breathe through both nostrils. There's no signs and symptoms of distress now.

We're going to assess the baby's mouth. We're going to start by looking if one side curves when the
baby cries or opens his mouth. It suggests that the baby has facial nerve injury if one side curves. The
mouth should open symmetrically. We're also going to inspect the tongue if it's short, normal or tongue
tied. Our baby’s tongue is normal. We're also going to inspect the palette. It is intact, there is epstein
pearls which is perfectly normal and will disappear with time. Now we're going to assess the infant's
neck. It is normal and creased, it is also short which is usual in newborns. The head rotates freely. If it is
rigid, it indicates that there is injury to the sternocleidomastoid muscle during delivery. The head control
is also present. Upon earlier inspection, the chest is actually 33 centimeters, it is 1 to 2 cm less than the
baby's head. The infant does not have a super numerary nipple or a third nipple, it is usually found in
line with the nipple. It is symmetrical and the clavicles are smooth and straight. We've also assessed the
respiration; it was 38 the normal is 30 to 60 and no presence of retraction.

Now for the baby’s abdomen, it appears normal and not sunken or scaphoid. It appears protuberant.
We're also going to auscultate for bowel sounds, it should be present within an hour after delivery.
We're going to start and we're going to do the same way as we do in adults but for a whole minute.
We're going to do it counter clockwise, starting at the upper right quadrant. The bowel sound is
appreciated. No abnormal bowel sounds heard. We're also going to palpate the baby's liver on the
baby's right side. Now I’m on the left side and we're just going to palpate it, it's usually one to two cm
below the coastal margin. We're also going to palpate for the baby's spleen. It's also one to two cm
below the coastal margin. Now we're going to inspect for the baby's umbilical cord. Remember that the
baby should have two arteries and one vein which is present. We're also going to assess for any bleeding
of the cord at the base. There is none and it should not be wet because if it is moist and with odor, it
indicates infection.

We're also going to check the diaper if the baby has voided. The kidney function is normal. We're now
going to palpate for the baby's kidneys. We're going to do deep palpation on the right side first, it should
not be too small and not too big and the other side, Okay. If the baby's kidney is too small, it may
indicate poor functioning of the kidney and if it's too big it might be pulling of the urine due to urethral
obstruction. Now we're going to elicit abdominal reflex and we're going to do that by stroking each
quadrant with our finger. The umbilicus should move towards the direction of our finger and where we
stroked it. It actually moved towards the direction of our finger. This is the superficial abdominal reflex it
indicates the spinal nerves T8 and T10. Now we're going to assess the client's genitalia we're going to
assume first that he is a male so we're going to put down the diaper. Now we're going to assess if the
meconium has passed through. It has a penis which should be approximately 2 cm. The urethral opening
is at the tip of the glands, it's normal so we're going to slide the foreskin to inspect. The scrotum is a bit
edematous, it's normal because he is a newborn. We're going to palpate the inguinal ring, okay and then
the baby’s testis. We're going to now elicit chromosteric reflex by stroking the internal side of the thigh.
As I stroke the inner thigh, the baby's testis should move upward, so the testis moved upward as i
stroked.

Now we're going to assume that our baby is a female. So, for a female we're going to inspect the vulva.
The vulva is normal. There is presence of swelling but that's perfectly normal. We're going to assess also
for vaginal secretions. Pseudo menstruation is normal, it is blood tinged. It is due to the maternal
hormone and disappears usually one to two days after birth. Now we're going to inspect or assess the
baby's back. I'm just going to turn him to the side making sure that I am assisting him. The baby's spine
appears to be flat in the lumbar and sacral area and there is no pinpoint opening, no dimpling and no
sinus tract. A sinus tract could be an indication of dermal sinus or spina bifida.

Now for the baby's extremities, we're going to inspect the arms and the legs of the baby. It is usually
short and proportional to the trunk of the baby. The hands are plumped and clenched and that's normal.
The fingernails are soft and smooth, it's also extended over the fingertips on both hands. Now we're
going to unflex the arm to test the muscle tone of the baby. We're going to unflex it for five seconds and
as I hold it down and release it, the baby should flex it back because it's their normal reflex. The baby
flexed back his arms. We're going to hold the baby's arm again downward and we're going to assess the
length of the arm. The fingertips of the baby should at least go as far as the middle of the thigh or the
mid-thigh. This baby’s arm, goes as far as the mid-thigh and it’s normal. Short arms are an indication of
achondroplasia dwarfism.

Now we're going to observe the curvature of the baby's finger on both sides and it is normal. We're also
going to assess if there is presence of simian crease or the single polymer crease, there is none single
palmar crease is an indication that the baby may have down syndrome. Now we're going to assess the
baby's fingers for webbing. It's not stuck together so there's no webbing and there is also no presence of
syndactyly or polydactyly or extra fingers. The fingers are not fused together so that's perfect and
normal.

We're also going to assess the movement of the arms and the legs, both left and right, for symmetry. If
it's symmetrical, there might be an injury to the baby's clavicle or brachial or cervical plexus or even
fracture to the long bones. It is symmetrical the arms and the legs. The legs are also short and bowed
and that's normal for a baby. The sole is flat, this is due to the extra padding of fat. There's also the
presence of crisscross lines on the soles of the feet. We're also going to move the baby's ankle to see the
range of motion. The baby's heel cord is not unusually tight.

Now we're going to assess the baby's Ankle clonus and the normal result is that the baby should try and
counter flex his foot because I’m going to dorsiflex it for a few seconds. It should be rapid alternating
contraction as I push it up. There is contraction and the baby is trying to go against the force and also on
the other side. The abnormal finding is if the baby relaxes or does not have any contraction with the
dorsiflexion of the foot. It may be an indication of neurologic or calcium deficit. Our baby was actually
contracting as we pushed the ankle up. There is various deviation and it's perfectly normal and the feet
is turned in. Now we're going to test or inspect the femur of the baby to see if the hip is situated in the
hip socket. We're going to first, flex both hips and then we're going to abduct it. We're going to look if
the legs are abducting at the same time, so they both are. There's no popping sound heard so it's a
negative Barlow and Ortolani test. There's also no missing toes or extra toes so the spacing is also
normal.

After the assessment and inspection of the baby, we have to wrapped him back again and we're placed
him back in the right crib. After the procedure is done, we're going to validate the data for accuracy and
completeness. Every finding during the procedure came out as normal and there were no abnormalities
and mostly the findings were aligned with the age of the baby and the state of the baby. We will now
discard our PPE and throw it in the proper bin and we're going to do hand washing. After the procedure
we're now going to interpret the results to identify if there's any abnormalities or any results that came
out as not normal. Mostly, all the findings were of normal levels and were correlated to the baby's age
weight length. Everything was aligned and normal. We do not need to report any significant findings
because all findings were normal in a newborn. Now we're going to document all the data and the
findings during the assessment.