Newborn Assessment Demographic Data: The clients name is Mark Conejos, a male Filipino citizen at Umboy St.

Labac, Naic, Cavite. The date of birth is May 16, 2011. His weight is 10 pounds. I. Vital Signs: The clients temperature is 36.6o Celsius. His pulse rate is 124 bpm and his respiratory rate is 35 cpm. II. Anthropometric Measurements: The clients head circumference is 38 centimeters. His chest circumference is 39 centimeters. His abdominal circumference is 44 centimeters. The length of the client is 59 centimeters and his recent weight is 10 pounds. III. Physical Weight: A. Integument The clients color is pinkish. He has one dark pigmented birthmark on his right leg. His skin intact is smooth. He has no presence of vernix caseosa and lanugo. B. EENT The clients eyes is slate gray, no tears, can do blink reflex, has a distinct eyebrows, cornea is bright. There

is fixation at times and the pupils are equal and active to light. The clients ears have flexible pinna with cartilage present and the pinna top on horizontal line with outer canthus of eye. The loud noise elicits startle reflex. The clients nose can obligate nose breaths, has no nasal discharge, nostrils patent bilaterally, sneezes to clear nostrils, bridge appears absent and has a thin and white nasal mucus discharge. The clients throat has minimal salivation. The mucosa is moist, palate high arched, uvula at the midline, tongue moves freely, has well developed fats pads and can execute different reflex such as: sucking reflex, rooting reflex and extrusion reflex. C. Chest The clients chest has equal anteroposterior and lateral diameter. Has bilateral chest movements, evident xiphoid process and has enlarged nipples. The heart rate is 124 bpm with no faint sounds and presence of murmurs. The breath sounds is 35 cpm and has a bilateral bronchial breath sounds and presence of moist breath sounds. D. Abdomen The client has a contour dome shaped abdomen that is soft to palpate and has presence of abdominal respirations. The bowel sounds is present and can be auscultate. The umbilical cord is dry at base and it is now healed. There is no presence of distention.

E. Genitals The clients general appearance of his genitalia has increased pigmentation, smegma at prepuce which is covering the urinary meatus. The urinary meatus is at the tip of the glans penis. The penis has palpable testes in the scrotum with rugae and can be erected. F. Extremities y Arms

The clients arms can maintain the posture of flexion which is 180o and is full range of motion in all joints including his fingers and toes. The muscle tone has equal and bilateral movement. The number of fingers is 10 and its skin color is pinkish. y Legs

The clients legs are pinkish in color. The length of the legs in relation with the arms is almost touches the knees. The flexion of the femur is 180o which is a full range of motion. The legs appeared bowed while the feet appeared flat and the number of toes 10.

H. REFLEXES REFLEXES SUCKING AND ROOTINGREFLEX ADMINISTER TO BABY Touching the skin at one corner of the infants mouth; touches the lips of the infant by the nipple of the bottle. SWALLOWING EXTRUSION Baby give a bottle of milk to drink Let the baby to suck the nipple of the bottle without milk TONIC NECK REFLEX Placing the infant into supine and rotate the head to one side RESPONSE Infants head turn toward the side touches; infant wean or suck the nipple Infant drink and swallow the milk. Infant protrude outward the nipple of the bottle Infant extend the leg and arms which the jaw is turned. The opposite arm and leg will flex PALMAR Touches the palm of the infant Infant fingers flex and grasp the examiners finger PLANTAR Holding one foot of the infant and touches the sole MORO OR STARTLE Having the infant lying on a flat surface and hit loudly the floor to startle the infant BABINSKI The plantar surface of the infants foot is stroked from the lateral heel area upward Infant foot toes fan out Infant doesnt react Infants toes flex downward

STEPPING OR WALKING

Infant is held under the arms with the feet placed on flat surface

Infant is too young for these reflex

LANDAU

Let the infant lay down with the hands under the abdomen; Infant skin stroke on the one side of the spine

Infant is in swimming position; shoulder and pelvis turn toward the stimulated side

Remarks: The client is now 3 months old. The baby cannot execute the rooting reflex which could be disappeared at the 6th week of age of the neonate. The baby is healthy as it could be based on the assessments but there is a possible threat which is fall hazards, incomplete immunization and ineffective health maintenance.

GENERAL APPEARANCE

The newborn's body height and weight is proportionate. He is relaxed and his movement is well coordinated to his body. He is clean and well-groomed, he has no body and breathe odor. No distress noted because he is only a few months old. He can response by the used of different reflexes.

VISION A premier university in historic Cavite recognized for excellence in the development of morally upright and globally competitive individuals.

MISSION Cavite State University shall provide excellent, equitable and relevant educational opportunities in the arts, science and technology through quality instruction and relevant research and development activities. It shall produce professional, skilled and morally upright individuals for global competitiveness.

Republic of the Philippines CAVITE STATE UNIVERSITY (CvSU) DON SEVERINO DE LAS ALAS CAMPUS Indang, Cavite

College of Nursing

Initial Data Base for Pregnant Nursing Practice

Presented by: GROUP 1 BSN 2 2 Presented to: Mrs. Chua, RN Clinical Instructor, Level II October 21, 2011

In Partial Fulfillment of the Requirement in NURS 50 for the Degree Bachelor of Science in Nursing