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Chamberlain College of Nursing
NR 327 Maternal-Newborn Nursing
Newborn Assessment
STUDENT NAME: Uriel John Casim DATE: 22Sept2020
Newborn Initials: Date of Birth: Female Gestational Age:
Male
APGAR SCORE Score Score Score
0 1 2
Heart Rate
Respiratory Rate
Muscle Tone
Reflex Irritability
Color
Newborn’s APGAR score: 1min: _____ 5 min: ______ 10 min: _______
Top 3 interventions performed on all babies immediately following delivery with
rationale as to why these are priority:
Cardiorespiratory Status: determine if resuscitation necessary. Respiratory and cardio stats are preformed first and
together because transition changes take place at the same time in both systems. The establishment of respiratory
function with cutting the cord is more critical extra-uterine adjustment as air infiltrates the lungs with first breath. The
3 shunts (ductus arteriosus, ductus venosus, and foramen ovale) functionally close during transition to extra-uterine life
with the flow of oxygenated blood in the lungs and readjustment of arterial blood pressure in the heart.
Periodic breathing: Observe pauses in breathing lasting 5-10 seconds without other changes followed by rapid
respirations for 10-15 seconds.
Apical pulse: 110-160 bpm RR: 40-60 breaths/min
Thermoregulation: prevent heat loss
• Blood vessels are closer to the surface. Less insulation - babies have a thinner layer of subcutaneous fat than adults so
loose heat more readily
• A large surface area to body mass ratio (Newborn has 3x more surface area to body mass) - babies have more area to
lose heat from than adults
• Greater evaporative heat loss - because of immaturity of their skin compared to that of adults, babies can lose a lot of
heat and water through their skin
• Less ability to produce heat through shivering, activity, and changes in position - babies rely on non-shivering
thermogenesis or brown fat metabolism for heat production.
• Less ability to vasoconstrict or dilate to gain or lose heat
• Limited stores of metabolic substrates to use for heat production
• Less control of the regulation of their temperature related to more immature central nervous system.
taken soon after birth while infant is held by mother.
• Assessed: Q30 mins for first 2 hrs; axillary
Presence of anomalies: assess and act upon to promote safety. If abnormalities are present at birth, remain calm,
assess, apply nursing interventions, document.
Revised 9/23/2020 1
, Chamberlain College of Nursing
NR 327 Maternal-Newborn Nursing
Newborn Assessment
PHYSICAL ASSESSMENT
Normal or potential FINDINGS
(textbook) Findings on your infant
POSTURE (p. 556)
At rest Flexion of the extremities with the
extremities closely adducted to the trunk
Breech: extended, stiff legs
Awake Flexed extremities moving freely, resist
extension, return quickly to flexed state.
Hands clenched. Symmetric movements.
Slight tremors on crying
VITAL SIGNS (p. 534-538)
Temperature 36-.5-37.5 (97.7-99.5F) axillary
Pulse(s) Apical pulse: 120-160 bpm
(100 sleeping, 180 crying)
Respirations 30-60 breaths/min
B/P 65-95/30-60 mmHg
Capillary refill <3-4 seconds
MEASUREMENTS (p. 542-
543)
Weight 2,500-4,000 g (5lb, 8oz to 8lbs 13 oz)
Length 48-53 cm (19-21 in)
Head Circumference 32-38 cm (13-15 in)
Chest Circumference 30-36 cm (12-14 in)
SKIN (p. 552-554)
Pink or tan with acrocyanosis. Vernix
Color caseosa in/around creases. Small amt of
lanugo over shoulders, side of face, forehead,
upper back. Skin turgor good with quick
recoil. Some cracking and peeling of skin.
Milia. Skin tags. Erythema tocxicum (flea
bite rash) puncture on scalp. Mongolian
spots.
Clear color division over the body with one
Harlequin Color Change side deep pink/red and the other half
pale/normal color
Lacy, red or blue pattern from dilated blood
Mottling (Cutis Marmorate) vessels under the skin.
(Occurs when infant is exposed to cold,
stressed, or over stimulated)
Thick, white substance provides a protective
Vernix Caseosa covering for the fetal skin in utero. Think
covering may indicate preterm infant and
post-term infant many have none at all.
Fine, soft hair that covers the fetus during
Lanugo intrauterine life. Present on shoulders,
forehead, sides of face, and upper back.
Revised 9/23/2020 2
Chamberlain College of Nursing
NR 327 Maternal-Newborn Nursing
Newborn Assessment
STUDENT NAME: Uriel John Casim DATE: 22Sept2020
Newborn Initials: Date of Birth: Female Gestational Age:
Male
APGAR SCORE Score Score Score
0 1 2
Heart Rate
Respiratory Rate
Muscle Tone
Reflex Irritability
Color
Newborn’s APGAR score: 1min: _____ 5 min: ______ 10 min: _______
Top 3 interventions performed on all babies immediately following delivery with
rationale as to why these are priority:
Cardiorespiratory Status: determine if resuscitation necessary. Respiratory and cardio stats are preformed first and
together because transition changes take place at the same time in both systems. The establishment of respiratory
function with cutting the cord is more critical extra-uterine adjustment as air infiltrates the lungs with first breath. The
3 shunts (ductus arteriosus, ductus venosus, and foramen ovale) functionally close during transition to extra-uterine life
with the flow of oxygenated blood in the lungs and readjustment of arterial blood pressure in the heart.
Periodic breathing: Observe pauses in breathing lasting 5-10 seconds without other changes followed by rapid
respirations for 10-15 seconds.
Apical pulse: 110-160 bpm RR: 40-60 breaths/min
Thermoregulation: prevent heat loss
• Blood vessels are closer to the surface. Less insulation - babies have a thinner layer of subcutaneous fat than adults so
loose heat more readily
• A large surface area to body mass ratio (Newborn has 3x more surface area to body mass) - babies have more area to
lose heat from than adults
• Greater evaporative heat loss - because of immaturity of their skin compared to that of adults, babies can lose a lot of
heat and water through their skin
• Less ability to produce heat through shivering, activity, and changes in position - babies rely on non-shivering
thermogenesis or brown fat metabolism for heat production.
• Less ability to vasoconstrict or dilate to gain or lose heat
• Limited stores of metabolic substrates to use for heat production
• Less control of the regulation of their temperature related to more immature central nervous system.
taken soon after birth while infant is held by mother.
• Assessed: Q30 mins for first 2 hrs; axillary
Presence of anomalies: assess and act upon to promote safety. If abnormalities are present at birth, remain calm,
assess, apply nursing interventions, document.
Revised 9/23/2020 1
, Chamberlain College of Nursing
NR 327 Maternal-Newborn Nursing
Newborn Assessment
PHYSICAL ASSESSMENT
Normal or potential FINDINGS
(textbook) Findings on your infant
POSTURE (p. 556)
At rest Flexion of the extremities with the
extremities closely adducted to the trunk
Breech: extended, stiff legs
Awake Flexed extremities moving freely, resist
extension, return quickly to flexed state.
Hands clenched. Symmetric movements.
Slight tremors on crying
VITAL SIGNS (p. 534-538)
Temperature 36-.5-37.5 (97.7-99.5F) axillary
Pulse(s) Apical pulse: 120-160 bpm
(100 sleeping, 180 crying)
Respirations 30-60 breaths/min
B/P 65-95/30-60 mmHg
Capillary refill <3-4 seconds
MEASUREMENTS (p. 542-
543)
Weight 2,500-4,000 g (5lb, 8oz to 8lbs 13 oz)
Length 48-53 cm (19-21 in)
Head Circumference 32-38 cm (13-15 in)
Chest Circumference 30-36 cm (12-14 in)
SKIN (p. 552-554)
Pink or tan with acrocyanosis. Vernix
Color caseosa in/around creases. Small amt of
lanugo over shoulders, side of face, forehead,
upper back. Skin turgor good with quick
recoil. Some cracking and peeling of skin.
Milia. Skin tags. Erythema tocxicum (flea
bite rash) puncture on scalp. Mongolian
spots.
Clear color division over the body with one
Harlequin Color Change side deep pink/red and the other half
pale/normal color
Lacy, red or blue pattern from dilated blood
Mottling (Cutis Marmorate) vessels under the skin.
(Occurs when infant is exposed to cold,
stressed, or over stimulated)
Thick, white substance provides a protective
Vernix Caseosa covering for the fetal skin in utero. Think
covering may indicate preterm infant and
post-term infant many have none at all.
Fine, soft hair that covers the fetus during
Lanugo intrauterine life. Present on shoulders,
forehead, sides of face, and upper back.
Revised 9/23/2020 2
