LaGuardia Community College
Practical Nursing Program
SCL 115 Maternity Child Health Nursing
OBSERVATION of the NEWBORN
Direction: Complete this observation chart by writing the appropriate value, observation
and nursing intervention for each of the nursing assessment areas
By
Anaise E. Ikama
Age of Baby: ½ hour
Area of nursing
assessment
Type of Delivery: Vaginal
Normal observation
Describe your
observation
Nursing intervention
The nurse should continuously
assess for muscle tone, pulse,
reflex, skin color and respiration
for any abnormality
APGAR score
10/10
8/9
Cry
A vigorous cry is an important
indicator of the health of the
newborn.
Yes.
Initiate breathing to prevent birth
asphyxia (the failure to initiate and
sustain breathing at birth) to occur
Completely pink
Assess for skin pigmentation 1 and
5 minutes after birth for APGAR
score
Color/skin
Completely pink for light skin.
Absence of cyanosis for dark skin
Cardiac heart rate
Respiratory status
Head
100 beats/min or higher
Did not observe
Spontaneous, with a strong lusty
cry
Did not observe
Moulding shaped head
Moulding shaped head
with no injury
Assess newborn’s heart rate 1 and
5 minutes after birth for APGAR
score
Assess respiration status 1 minute
and 5 minutes after birth for
APGAR score
Assess baby’s head for any
trauma, especially if forceps were
used. Also teach the patient that
this bizarre appearance will go
away over the next several days
Eyes
Buttocks
All newborn are specific eye care
to prevent ophtalmia neonatorum
(caused by neisseria gonorrhea
Preferably pink for normal skin
color
Eyes care was given
within an hour after
delivery
Pink
Cord
Grayish color
Grayish color
Circumcision
Circumcision should be done on
the second day of postpartum.
Did not observe
Feeding: types of
formula, breast
feeding/position
Types of formula: glass or hard
plastic container.
Breast feeding positions for
nursing: cradle hold, football hold
and side-lying position.
Patient denied feeding the
baby for deficiency
knowledge R/T
complication of smoking
“Because of the puffiness of the
newborns eyelids, some infants may
not be able to open their eyes wide
right away. When holding [their]
newborn, you can encourage eye
opening by taking advantage of …
baby's "doll's eye" reflex, which is a
tendency to open the eyes more when
held in an upright position”
(www.kidshealth.org)
Assess for skin pigmentation
Teach client to keep the cord of
their babies clean by gently wiping
around the base of the cord each
day with an alcohol cotton swab.
Teach our patient that the best care
for an uncircumcised penis is by
washing and rinsing the foreskin
of the penis whenever the baby has
a bath.
Teach the mother that storing milk
at room temperature for over 4 hr
can increase bacterial growth.
Clear plastic bottles are considered
safe for storing and freezing milk.
Don’t use microwave to warm
milk, better hold the container
under running lukewarm water.
And suggest a smoking cessation
Reflexes
Prompt response to suction with a
gentle slap to sole of foot
Minimal response to
stimulation
Male or Female
Male
Genitalia: Male/Female
Stools
Neonatal jaundice
Weight/length
Newborn has to pass meconium
No, but urinated ten
(first stool) and urine within 12h to minute after birth in the
24hours after delivery
labor delivery room
“Caused by an excess amount of
bilirubin (yellowish-red pigment)
in the baby's skin. Bilirubin is
formed and released into the
bloodstream when red blood cells
are broken down. The bilirubin is
then carried to the liver where it is
processed and eventually excreted
from the body”
(www.californiawebsites.com/neo).
“Full-term born babies (37 - 40
weeks) weigh between 6 lbs
2ounces to 9 lbs 2 ounces (2,812 4,173 grams). The average length
for a full-term infant usually
ranges from 19 to 21 inches (48 to
53 cm)” (kidshealth.org).
program
Assess for reflexes 1 and 5
minutes after birth for APGAR
score
Genitalia need to be monitored for
any abnormality
If the newborn did not pass any
meconium and urine in the LDR,
the nurse needs to assess for any.
If the stool or urine has been
passed, document immediately.
No neonatal jaundice was
noted, rather a pinkish
buttocks
The nurse will keep observing the
infant and if the jaundice is
noticed, it should be immediately
reported to head nurse.
Weight: 3000g
Length: did not observe
Helps the nurse in determining if
the newborn is under or
overweight