Physical examination of the neonate
Student’s Name: ___________________________________ Date: _______________
Number
Neonate’s
Initials
Date of Birth
Place of Birth
Gestation at
Birth
Age at
Assessment
History
Maternal History
Pregnancy History
Family/social history
Labour & Birth history
Immediate neonatal period
(incl. Apgar score)
(i.e. feeding, skin to skin)
Maternal/Neonatal
Laboratory findings
Physical Assessment
General Appearance
Posture/general symmetry
Activity
Responsiveness/Cry
Respiration rate/effort
Heart Rate
Vital Signs
Temperature
Anthropometric Measurements
Weight
Head circumference
Length
Head/facial symmetry
Sutures/ fontanelles
Eyes
Ears
Nose
Mouth
Symmetry/length
Skin folds/masses
Clavicles
Chest symmetry
Respiratory effort
Lung sounds
Heart Sounds
Breasts/nipples
Head
Neck
Range of movement
Chest
Bachelor of Midwifery—University of SA, School of Nursing & Midwifery 2015
Upper extremities
Symmetry/tone
Range of movement
Hands/fingers
Condition
Birthmarks
Shape
Size
Bowel sounds
Muscle tone/masses
Umbilicus
Femoral pulses
Genitalia
Male
Female
Elimination
Urine
Bowels
Symmetry/tone
Range of movement
Feet/toes
Hips
Ortolani’s test
Barlow’s test
Gluteal fold symmetry
Anal patency
Skin
Colour
Abdomen
Lower extremities
(with assistance of experienced
practitioner)
Spine and anus
Spinal integrity
Neurological Examination
Rooting reflex
Sucking reflex
Swallowing reflex
Grasp reflex
Asymmetric tonic neck
reflex
Stepping response
Babinski reflex
Moro reflex
Midwifery
Management
Reflection of learning
RM/MO name, signature &
date
Bachelor of Midwifery—University of SA, School of Nursing & Midwifery 2015