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Newborn Assessment

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Running head: NEWBORN ASSESSMENT

Newborn Assessment
College of Southern Nevada
Nurs 247

Newborn Assessment

Student Name: Date: November 21st, 2009

Infant Sex: Male Age at Exam: 6 hours old Gestational Age: 40 weeks Diet: Formula

Features of Pregnancy, Labor & Delivery: Data obtained from Prenatal History, L&D Record, and Verbal Report:

The patient is a 27 year old female that was a G3 P2. The patient did not receive any prenatal care with this pregnancy or previous pregnancy. The patient stated that this pregnancy went very fast as she didn’t realize how far along she was until her water broke at home on 10/9/09. The patient stated that she did not have much pain and did not receive any pain medication. When the patient arrived, she was 10cm, 100% and +2. The patient gave birth to the baby vaginally within 15 minutes of arriving to the hospital and stated she only pushed 3 times. The patient lost approximately 200mL of blood during birth and the patient had lab work drawn the morning of the interview however no results were available. The patient reports no known diseases or illnesses.

|Assessment |Textbook Normals |Finding |
|Posture |Vertex: arms and legs in moderate flexion; fists clenched |Flexion of arms and legs. Fists |
| |Normal spontaneous movement bilaterally asynchronous but equal extension in all |clenched closely to chest. |
| |extremities | |
| |Frank breech: legs straighter and stiff | |
|Vital Signs | |Apical pulse of 115 when lying |
|Heart Rate and Pulses |Visible pulsations in left midclavicular line, 5th intercostals space |quietly. S1 and S2 were sharp and |
| |Apical pulse, 4th intercostals space 100-160 beats/min, 80-100 bpm (sleeping), up|clear. at rest. S1 & S2 sharp and |
| |to 180 bpm (crying) |clear. |
| |Quality: first sound (closure of mitral and tricuspid valves) and second sound | |
| |(closure of aortic and pulmonic vales) sharp and clear | |
| |Possible murmur | |
| |Peripheral pulses equal and strong | |
| |Femoral pulses equal and strong |Femoral and brachial pulse was |
|Peripheral pulses: | |equal and strong. |
|Femoral, brachial, poplitieal, post.| | |
|Tibial |Axillary: 36.5(C to 37.2(C |Axillary temp: 98.2 F |
| |Temperature stabilized by 8-10 hr of age | |
|Temperature |30-60 breaths/min |Respiratory Rate: 42 |
| |Shallow and irregular in rate, rhythm, and depth while infant is awake. Breath |Breath sounds were shallow, |
|Respiratory Rate |sounds loud, clear, near |irregular and no crackles were |
|(Count respirations for full minute)|Crackles may be heard after birth |present. |
| | | |
| | |87/42 |
| |80-90s/40-50s | |
|B/P | | |
|Apgar Score (Describe) |Evaluation made 1-5 min after birth. Scores 0-3 indicate severe distress; 4-6 |1 Minute: 9/9 |
| |indicate moderate difficulty; 7-10 indicate no difficulty adjusting to |5 Minute: 9/9 |
| |extrauterine life. | |
| | | |
| | | |
| | | |
|Heart Rate | | |
|Respiratory Rate | | |
|Muscle Tone | | |
|Reflex irritability | | |
|Color | | |
| |0 |1 |2 | |
| |Absent |Slow (100 | |
| |Absent |Slow, weak cry |Good cry | |
| |Flaccid |Some flexion |Well flexed | |
| |No Response |Grimace |Cry | |
| |Blue, Pale |Body pink, extremities |Completely pink | |
| | |blue | | |
|Weight today |2500-4000g |2880g |
| |Acceptable weight loss: ( 10% | |
|Head Circumference |32-36.8 cm |34cm |
|Chest Circumference |2-3 cm less than head circumference, avg. 30-33cm |31cm |
|Abd Circumference |Same size as chest |31cm |
|Length |45-55 cm |44cm |
|Skin color |Generally pink, varying with ethnic origin, acrocyanosis (if chilled), mottling, |Pink coloring all over |
| |harlequin sign, plethora, telangiectases, erythema toxicum or neonatorum, milia, | |
| |petechiae, ecchymoses | |
|Birthmarks |Mongolian spot |N/A |
|Lanugo |Over shoulders, pinnas of ears, forehead |Minimal lanugo around ears and |
| | |forehead. |
|Fontanels | | |
|Anterior |5cm diamond, increasing as molding resolves |Normal |
|Posterior |Triangle, smaller than anterior |Normal |
|Eyes |Both present, equal size, round, firm, Symmetric, blink reflex, no discharge, |Both eyes present, round firm and |
| |pupils (PERRLA), Eyeball movement random, jerky, uneven, focus possible briefly, |of equal size. Symmetric shape |
| |following to midline, transient strabismus or nystagmus until third or fourth |noted. |
| |month | |
|Nose |Midline, some mucus but no drainage, preferential nose breather, sneezing to |Located midline, minimal mucus, no|
| |clear nose, slight deformity (flat or deviated to one side) from passage of birth|drainage. |
| |canal | |
|Ears |Correct placement (line drawn through inner and outer canthus of eyes should |Correct placement noted. Cartilage|
| |reach to notch of ears) |well formed. Responds to noise. |
| |Well formed, firm cartilage | |
| |Responds to voice and other sounds | |
| |State (eg. alert, asleep) influences response | |
|Mouth | Symmetry of lip movement; buccal mucosa pink dry or moist, pink gums; tongue not|Buccal mucosa pink and moist. |
| |protruding, freely movable, symmetric in shape; sucking pads inside cheek; soft |Tongue moving freely, not |
| |and hard palates intact; uvula in midline; distinct chin; moist mouth; rooting, |protruding and soft/hard palate |
| |sucking, extrusion reflexes present |intact. |
|Chest |
|Symmetry |Circular, barrel shaped; clavicles intact; rib cage symmetric and intact; nipples|Circular, barrel shaped. Rib cage |
| |prominent and symmetrically placed |symmetric and intact. Nipple |
| | |placement symmetrical. |
|Breast Tissue |breast nodule 3-10mm, secretion of witch’s milk |N/A |
|Lungs |symmetric chest movement, chest and abdominal movements synchronized during |Symmetric chest movement, |
| |respirations; occasional retractions, especially when crying |retractions seen when crying. |
|Heart Sounds |Quality: first sound (closure of mitral and tricuspid valves) and second sound |S1 and S2 sharp and clear. No |
| |(closure of aortic and pulmonic vales) sharp and clear |murmur auscultated. |
| |Possible murmur | |
|Abdomen |Rounded, prominent, dome shaped, some diastsis of abdominal musculature, liver |No distension and bowel sounds |
| |possibly palpable 1-2 cm below right costal margin, no other masses palpable, no |present. |
| |distention; bowel sounds present within minutes after birth | |
|Umbilical Cord |Two arteries, one vein, whitish gray, definite demarcation between cord and skin,|Dry around base, odorless with |
| |no intestinal structures within cord, dry around base, drying, odorless, cord |cord clamp. |
| |clamp in place for 24hr, reducible umbilical hernia | |
|Stool |Meconium stool passing within 24-48hr after birth, meconium followed by |N/A |
| |transitional and soft yellow stools | |
|Genitals | | |
|Female |Female genitals | |
|Male |Male genitals |Male genitals, meatus visible at |
|Meatus |Meatus at tip of penis |tip of penis and testes palpable |
|Testes |Palpable on each side |when squeezed on each side. |
|Urination |Voiding within 24 hr, stream and amount adequate |N/A |
|Extremities |Full ROM, possible slight tremors, some acrocyanosis |Full ROM |
|Fingers/Toes |5 fingers on each hand, fist often clenched with thumb under fingers, 5 toes on |5 fingers/toes on each hand/foot. |
| |each foot | |
|Back/Spine |Spine straight and easily flexed |Spine straight and easily flexed. |
|Anus |One anus with good sphincter tone, passage of meconium within 24-48 hr after |One anus with good sphincter tone.|
| |birth, good “wink” reflex of anal sphincter | |
|Pulses |Peripheral pulses equal and strong |Femoral and brachial pulses equal |
| |Femoral pulses equal and strong |and strong. |
|Mother’s ABO & RH | |B (+) |
|Infant ABO & RH | |O |
|Infant Lab Values |Hemoglobin |14-24 gm/dl |Labs were drawn but results not |
| |Hematocrit |44%-64% |available at time of assessment. |
| |Glucose |46-65 mg/dl | |
| |Leukocytes (white blood cells) |9,000-30,000/mm3 | |
| |Bilirubin, total serum |( 2.0 mg/dl | |
| |Blood gases | | |
| |Arterial |pH 7.32-7.49 | |
| | |PCO2 26-41 mm Hg | |
| | |PO2 60-70 mm Hg | |
| |Base excess |-10 to –2 mEq/L | |
| |Bicarbonate, serum |21-28 (arterial) | |
| |Anion gap |7-16 mEq/L | |
| |Venous |pH 7.31-7.41 | |
| | |PCO2 40-50 mm Hg | |
| | |PO2 40-50 mm Hg | |
|Medications/Purpose | |N/A |
|Erythromycin ophthalmic ointment 5mg|To prevent ophthalmia neonatorum in newborns of mothers who are infected with |Placed in eyes at birth. |
|in each eye after birth |gonorrhea, conjunctivitis, and Chlamydia. | |
|Vitamin K 0.5mg IM |Vitamin K is used for prevention and treatment of hemorrhagic disease in the |Administered at birth. |
| |newborn. | |
| | | |
| | | |
| | | |

Reflexes- Test at least 5 – Learn these: Describe how to test each and the interpretation:

|Reflex |Eliciting the reflex |Characteristic Response |Interpretation |
|Sucking and rooting |Touch infant’s lip, cheek, or corner of mouth|Infant turns hear toward stimulus; opens |Infant turned head towards finger |
| |with nipple |mouth, takes hold, and sucks |when cheek rubbed. |
|Swallowing |Feed infant; swallowing usually follows |Swallowing is usually coordinated with |Infant able to suck effectively and |
| |sucking and obtaining fluids |sucking and usually occurs without gagging, |swallow formula. |
| | |coughing, or vomiting | |
|Grasp | |Infant’s fingers curl around examiner’s |Infant curled finger and toes when |
|Palmar |Place finger in palm of hand |fingers, toes curl downward |finger placed near fingers/toes. |
|Plantar |Place finger at base of toes | | |
|Crawling |Place newborn on abdomen |Newborn makes crawling movements with arms |Infant failed arms/legs when placed |
| | |and legs |on abdomen. |
|Glabellar (Myerson) |Tap over forehead, bridge of nose, or maxilla|Newborn blinks for first four or five taps |Infant blink 4 times when tapped 4 |
| |or newborn whose eyes are open | |times on forehead. |

Mother- Infant Interaction:

The interaction between the mother and infant was observed and the mother was very gentle and loving towards her baby. She stated that she missed her other children being this small and that this time was one of her favorite times as a mother. Infant did not cry and went to sleep in mothers arms.

Nursing evaluation of any abnormal or unusual findings:

Nursing evaluation of mother/baby interaction was normal and newborn assessment findings were all within normal ranges.…...

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Knowledge and Conformance on Essential Newborn Care

...Knowledge and Conformance of Delivery Room Staff on Essential Newborn Care Protocol A Thesis Proposal Presented to the Faculty of the Graduate School of University of the Visayas Cebu City, Philippines In Partial Fulfillment of the Requirements for the Degree of Masters of Arts in Nursing Major in Maternal and Child Health Nursing by MAY PRINCES T. ABUCEJO, RN August, 2012 THE PROBLEM AND ITS SCOPE INTRODUCTION Rationale of the Study The Child Survival Strategy published by the Department of Health has emphasized the need to strengthen health services of children throughout the stages. The neonatal period has been identified as one of the most crucial phases in the survival and development of the child. The Millennium Development Goal Number four (4) of reducing under five child mortality can be achieved by the Philippines, however, if the neonatal mortality rates are not addressed from its non-moving trend of decline, MDG 4 might not be achieved (http://www.doh.gov.ph/node/2664). Based on health statistics, the Philippines is one of the 42 countries that account for 90% of under-five mortality worldwide. Eighty two thousand (82,000) Filipino children under five years old die every year. Thirty seven percent (37%) or 40,000 of them are newborn. Majority of them (3/4) die within the first two days of life, mostly from preventable causes. The high mortality and morbidity rates in newborn are directly related to inappropriate hospital and community......

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