Newborn Assessment Tool NURS273
OCC School of Nursing
Newborn Newborn
Demographics/General Information Note any significant labs and the normal
range in the newborn with attention to:
Name:(use only first initial of last name and gender assigned at birth, for example, S., baby Explain the significance.
girl): __AC, Baby boy______________________________________________________ WBC___not indicated____
Age (in days/or hours if under 24 hours old.) _1-hour old_____________
Birth weight (lbs., oz) __9lb 8.4 oz______________Birth wt(gms)____4320 g_____________ H&H____not indicated____
Birth Length __52 cm__________________________________________________________
Prenatal Care yes/no ___________Yes______________________________ Coombs____not indicated___
Significant maternal history__repeat cesarean section and bilateral tubal C-reactive protein____not indicated____
ligation__________
Complication during delivery? __none_______________________________________ Accucheck__43 mg/dL (normal range in 1st
Medication crossing the placenta prior to delivery? ___none__________________________ hour of life is <45 mg/dL per hospital
Apgar 1 min/5min ___8______/_____9__________Resuscitation required? Yes/No Describe policy). Infant monitored due to LGA
resuscitation efforts if performed_suction and tactile stimulation_____________________ status__
T__98.6_ [Route] _axillary_ Apical P___148___R___40___BP(if applicable)___n/a_______ Hep B Vaccine __given 9/23/25 at 0842___
sPO2____100%___pain___0___ [how assessed] ____NIPS scale_____
PKU/Newborn Screening____pending___
Newborn Nutritional Requirements Hearing Screening__not yet done____
Results ____not yet done______
First Feeding time___1015_____
Transcutaneous Bili____not indicated____
Type of Feeding? (choose one) Breast/formula/combination
Vitamin K _____given 9/23/25 at 0842____
Breastfed time per feeding on average___34 minutes____
Eye Prophylaxis-
LATCH Evaluation ____not done_____
Medication: erythromycin
Lactation Consultant utilized? ______no_______
Route: ophthalmologic
Date of Administration: 9/23/25 at 0842
SS 1/25
OCC School of Nursing
Newborn Newborn
Demographics/General Information Note any significant labs and the normal
range in the newborn with attention to:
Name:(use only first initial of last name and gender assigned at birth, for example, S., baby Explain the significance.
girl): __AC, Baby boy______________________________________________________ WBC___not indicated____
Age (in days/or hours if under 24 hours old.) _1-hour old_____________
Birth weight (lbs., oz) __9lb 8.4 oz______________Birth wt(gms)____4320 g_____________ H&H____not indicated____
Birth Length __52 cm__________________________________________________________
Prenatal Care yes/no ___________Yes______________________________ Coombs____not indicated___
Significant maternal history__repeat cesarean section and bilateral tubal C-reactive protein____not indicated____
ligation__________
Complication during delivery? __none_______________________________________ Accucheck__43 mg/dL (normal range in 1st
Medication crossing the placenta prior to delivery? ___none__________________________ hour of life is <45 mg/dL per hospital
Apgar 1 min/5min ___8______/_____9__________Resuscitation required? Yes/No Describe policy). Infant monitored due to LGA
resuscitation efforts if performed_suction and tactile stimulation_____________________ status__
T__98.6_ [Route] _axillary_ Apical P___148___R___40___BP(if applicable)___n/a_______ Hep B Vaccine __given 9/23/25 at 0842___
sPO2____100%___pain___0___ [how assessed] ____NIPS scale_____
PKU/Newborn Screening____pending___
Newborn Nutritional Requirements Hearing Screening__not yet done____
Results ____not yet done______
First Feeding time___1015_____
Transcutaneous Bili____not indicated____
Type of Feeding? (choose one) Breast/formula/combination
Vitamin K _____given 9/23/25 at 0842____
Breastfed time per feeding on average___34 minutes____
Eye Prophylaxis-
LATCH Evaluation ____not done_____
Medication: erythromycin
Lactation Consultant utilized? ______no_______
Route: ophthalmologic
Date of Administration: 9/23/25 at 0842
SS 1/25
