Newborn Assessment
Scenario: The nurse is caring for a 2-day-old, male, newborn rooming in with the mother. The nurse has
an order to complete a newborn assessment.
History: Vaginal delivery, 15-hour labor, AHR-148 bpm, RR-36 bpm, Temp.-97.6, Birth weight: 7lbs. 2 oz.,
and 21 inches long, HC: 36 cm, CC: 34cm
Today’s weight: 6 lbs. 12 oz.
1. What should the nurse do upon entering the couplet care room of the mother and newborn?
(IWIPES)
2. The nurse begins by assessing the newborn’s vital signs. The nurse documents below.
Why does the nurse assess the vital signs first?
The nurse notes that the newborn is quietly sleeping in a relaxed facial expression and position, with no
signs of respiratory distress.
AHR Normal range:
What is the nurse listening for and for how long?
Place an x on the place where the nurse will place the stethoscope.
The nurse documents 148 bpm. Is this WNL?
1
, RR Normal range:
What is the nurse listening for and for how long? What are signs of respiratory distress in the newborn
that the nurse should be observing for?
Place an x on the place where the nurse will place the stethoscope for breath sounds.
Draw a picture of the posterior torso beside the anterior torso and mark an x where the nurse will place
the stethoscope on the posterior surface for breath sounds.
Describe how the nurse will listen for breath sounds.
The nurse documents 36 bpm. Is this normal?
Place an x on the abdomen where the nurse listens for bowel sounds.
Describe how the nurse will listen for bowel sounds.
What are normal findings for bowel sounds?
The nurse checks for newborn reflexes. What are the reflexes that will be checked?
2
Scenario: The nurse is caring for a 2-day-old, male, newborn rooming in with the mother. The nurse has
an order to complete a newborn assessment.
History: Vaginal delivery, 15-hour labor, AHR-148 bpm, RR-36 bpm, Temp.-97.6, Birth weight: 7lbs. 2 oz.,
and 21 inches long, HC: 36 cm, CC: 34cm
Today’s weight: 6 lbs. 12 oz.
1. What should the nurse do upon entering the couplet care room of the mother and newborn?
(IWIPES)
2. The nurse begins by assessing the newborn’s vital signs. The nurse documents below.
Why does the nurse assess the vital signs first?
The nurse notes that the newborn is quietly sleeping in a relaxed facial expression and position, with no
signs of respiratory distress.
AHR Normal range:
What is the nurse listening for and for how long?
Place an x on the place where the nurse will place the stethoscope.
The nurse documents 148 bpm. Is this WNL?
1
, RR Normal range:
What is the nurse listening for and for how long? What are signs of respiratory distress in the newborn
that the nurse should be observing for?
Place an x on the place where the nurse will place the stethoscope for breath sounds.
Draw a picture of the posterior torso beside the anterior torso and mark an x where the nurse will place
the stethoscope on the posterior surface for breath sounds.
Describe how the nurse will listen for breath sounds.
The nurse documents 36 bpm. Is this normal?
Place an x on the abdomen where the nurse listens for bowel sounds.
Describe how the nurse will listen for bowel sounds.
What are normal findings for bowel sounds?
The nurse checks for newborn reflexes. What are the reflexes that will be checked?
2
