e
Student name ,LQ),;‘Q{LC—VQ{]_D\ o Date lQ] 18
NURSING ASSESSMENT OF THE NEWBORN
5t
NEWBORN: 82 _Gender £
Initials Age 3%.|
Apgars @imin 4§ @ 5 min_Q_
Weeks Gestation via Dubowitz/Ballard (maturity rating)_Zj‘fi
Weeks Gestation via LMP 53- |
(\P3 $02.
Birth weight &@M Weight today (g‘bfi Blood type/RhL
Developmental percentile (AGA, SGA, or LGA)_AGA
L
Fetal delivery presentation Cefna\iC — Ve ctexX
Complications of birth/early neonatal period N/a
Date/time of first feed 10/1% @5:20
Breast or bottle feed Brenst
3F
~/A
Date/time of first void_\0/ 1% 1523 Date/time of first stool
Congenital anomalies_N/A
Gravida 5_ Para 3 Term 3 Preterm O Ab | Lc3
MOTHER:
Age 30 Race 3 335
Deliveryaa%e 19/\%~ 8 Type of Delivery voginal
i6 \
If ¢/s or(inductiop, reason/indication:
Length of time membranes ruptured_28 min
Length of labor & b
Maternal Temp prior to birth
Anesthesia £piduron Meds in labor €8 Ampiciim, Prdctin
Tron, Prenakal
Meds during pregnancy firnfig« bby Asdivin, Procacdicng0my, viramin
Blood type/RhAY__ Group|B strep Postrve
started .
Date/Trimester prenatal ca
Creatadsonat piapetes
;
| Antepartum risk factors
Genetic concerns (\1 estobkinnol Drabcrea
Complications of past pregnancies Positive (129, Obeaity, Crestoronon
g
\d+W Dioberes
Chronit
|
, pate
na me _{ QA re ny C EOTFA— Assessment
tudent Newborn ignificall
ce- N or
A
instruc(i
ons on
ng s — S ee
Cues/Findirengsplan of all 2 di
——ctual ma Discuss significance
ing@.filej M)..
ls Sfor ca
* flgé/:;;u:r
flfl g, fig fli flv mfl hfl fl
AetARRRESES
S Li,,,C ern RE ”37:5-“"" -
G
- Ne wb
»/ orm cerm
Lfg:hta//ww — — Ae G
e — ok wah
| gzt R > o .
I
—
}—
quality) |~ —————
Respirations
| (count for 1 full m inute, note rate & Aveay
["Apical Pulse | \o- S——— — .= _ al-as 7
1 full min
| (count fort arm ute) _ ©-
pomor2 zInos L PR s R
eV — +he normort
& right leg —
pre/post ductal) Aa/uys
B Nf;rma\-
“BP (righ bl |
AT 2 eretes
i,
al)
~02 Saturation (pre/post duct res.5\bs
e oW, a tod wowld
w{m
;ov—mox\‘ enor
%07 — ks S
L\ PR
t
e7 g ~No rma|-N0“W‘“" - — -
boway a.2% ih (i
e A
on PACK N
| Length YT S ey
e B;thor\‘— UAIS ~ b5
|
-
Colev B PoTMAL Pod =N
| (inches) Skin v, Mo — N
[ skin Terure 15 o e 59015
Color for vace,
i meneo kel (N)
rgor ceCoils | any recoiled
< Texture Sm ocme Tuen
h, rar
otgd
Tr
% no ecerra
o ovnd 3y (ND
Turgor Present,
a Divhhmocy
— Sk Wi
veeniy¥ aQ,a
Sa = \tth— D)
[*Baby hos o
Lanugo =
SN nevr tack “wo rask ~(N)
sPoiS on
s vosinosboeondsa
Rashes
° Slate gray ‘
Mongolian butets
Spots |
9oliCt
on‘
QW
n
SPors |
|
|- vetly @ c
Vernix
o by
Caseosa
Socol Ve TelteYes
Reflexes
re\'\c) PuUPlls are
< Blink
\ght |
| ALWUE to
% Pupillary reflex
sessment with h cocoversheet, meds_ Revised spring
spring 2023
set -Newborn Physical A 2(
UV UBE T YRR TR NS S FIeS TR
Student name ,LQ),;‘Q{LC—VQ{]_D\ o Date lQ] 18
NURSING ASSESSMENT OF THE NEWBORN
5t
NEWBORN: 82 _Gender £
Initials Age 3%.|
Apgars @imin 4§ @ 5 min_Q_
Weeks Gestation via Dubowitz/Ballard (maturity rating)_Zj‘fi
Weeks Gestation via LMP 53- |
(\P3 $02.
Birth weight &@M Weight today (g‘bfi Blood type/RhL
Developmental percentile (AGA, SGA, or LGA)_AGA
L
Fetal delivery presentation Cefna\iC — Ve ctexX
Complications of birth/early neonatal period N/a
Date/time of first feed 10/1% @5:20
Breast or bottle feed Brenst
3F
~/A
Date/time of first void_\0/ 1% 1523 Date/time of first stool
Congenital anomalies_N/A
Gravida 5_ Para 3 Term 3 Preterm O Ab | Lc3
MOTHER:
Age 30 Race 3 335
Deliveryaa%e 19/\%~ 8 Type of Delivery voginal
i6 \
If ¢/s or(inductiop, reason/indication:
Length of time membranes ruptured_28 min
Length of labor & b
Maternal Temp prior to birth
Anesthesia £piduron Meds in labor €8 Ampiciim, Prdctin
Tron, Prenakal
Meds during pregnancy firnfig« bby Asdivin, Procacdicng0my, viramin
Blood type/RhAY__ Group|B strep Postrve
started .
Date/Trimester prenatal ca
Creatadsonat piapetes
;
| Antepartum risk factors
Genetic concerns (\1 estobkinnol Drabcrea
Complications of past pregnancies Positive (129, Obeaity, Crestoronon
g
\d+W Dioberes
Chronit
|
, pate
na me _{ QA re ny C EOTFA— Assessment
tudent Newborn ignificall
ce- N or
A
instruc(i
ons on
ng s — S ee
Cues/Findirengsplan of all 2 di
——ctual ma Discuss significance
ing@.filej M)..
ls Sfor ca
* flgé/:;;u:r
flfl g, fig fli flv mfl hfl fl
AetARRRESES
S Li,,,C ern RE ”37:5-“"" -
G
- Ne wb
»/ orm cerm
Lfg:hta//ww — — Ae G
e — ok wah
| gzt R > o .
I
—
}—
quality) |~ —————
Respirations
| (count for 1 full m inute, note rate & Aveay
["Apical Pulse | \o- S——— — .= _ al-as 7
1 full min
| (count fort arm ute) _ ©-
pomor2 zInos L PR s R
eV — +he normort
& right leg —
pre/post ductal) Aa/uys
B Nf;rma\-
“BP (righ bl |
AT 2 eretes
i,
al)
~02 Saturation (pre/post duct res.5\bs
e oW, a tod wowld
w{m
;ov—mox\‘ enor
%07 — ks S
L\ PR
t
e7 g ~No rma|-N0“W‘“" - — -
boway a.2% ih (i
e A
on PACK N
| Length YT S ey
e B;thor\‘— UAIS ~ b5
|
-
Colev B PoTMAL Pod =N
| (inches) Skin v, Mo — N
[ skin Terure 15 o e 59015
Color for vace,
i meneo kel (N)
rgor ceCoils | any recoiled
< Texture Sm ocme Tuen
h, rar
otgd
Tr
% no ecerra
o ovnd 3y (ND
Turgor Present,
a Divhhmocy
— Sk Wi
veeniy¥ aQ,a
Sa = \tth— D)
[*Baby hos o
Lanugo =
SN nevr tack “wo rask ~(N)
sPoiS on
s vosinosboeondsa
Rashes
° Slate gray ‘
Mongolian butets
Spots |
9oliCt
on‘
QW
n
SPors |
|
|- vetly @ c
Vernix
o by
Caseosa
Socol Ve TelteYes
Reflexes
re\'\c) PuUPlls are
< Blink
\ght |
| ALWUE to
% Pupillary reflex
sessment with h cocoversheet, meds_ Revised spring
spring 2023
set -Newborn Physical A 2(
UV UBE T YRR TR NS S FIeS TR
