TRINITY VALLEY COMMUNITY COLLEGE
PERINATAL ASSIGNMENT PART IIIB
NEWBORN ASSESSMENT
Student’s Name
Sex
Pt’s Initials
HR
Resp
Temp
Head
GestationalAge
by dates
Chest
Abd
Length
Birth Wt
Current Wt
Feeding
PRESENT PREGNANCY
o Maternal O2 in delivery
o BMV ventilation
o Infant O2 at delivery
o Stimulation
:o
Breast
o Bottle
o Suctioning
Date/Time of Delivery: _______________________
Length of Labor: ___________________________
Infant meds given after delivery:________________________
_________________________________________________
TYPE OF DELIVERY
o Spontaneous
Augmentation
o Induction
o SROM
o Prostaglandin
o Pitocin
o
Complications of Labor & Delivery (Infant or maternal) _________
_________________________________________________
o AROM
o Cytotec
PSYCHOSOCIAL
o Father/partner present during labor and/or delivery
o Vaginal o Episiotomy o Forceps
o Vacuum extraction
o Cesarean Section
o Primary o Repeat
Reason__________________________________
Presentation: o Vertex o Breech Other________
Position : o LOA o ROA o LOP o ROP
Other________________
Anesthesia Used: o Epidural o Spinal o General
o Pudendal Other___________
Medications Used: ___________________________
__________________________________________
Abnormal Labs ______________________________
1
5
APGAR Scoring
min
mins
Heart Rate
2 – over 100
1 – slow,  100
0 – absent
Respiratory Effort
2 – good, strong cry
1 – slow, irregular weak cry
0 – absent
Muscle Tone
2 – well flexed
1 – some flexion of extremities
0 – flaccid
Reflex Irritability
2 – cry
1 – grimace
0 – no response
Color
2 – completely pink
1 – body pink, extremities blue
0 – blue, pale
TOTAL
When did the mother first see & touch the infant? __________
_________________________________________________
When did the father first see and touch the infant? _________
_________________________________________________
Rooming In : o Yes
o No
Describe first interactions with the infant: _________________
__________________________________________________
Comments: ________________________________________
DIAGNOSTIC TESTS
Normal
Values
Hemoglobin
Hematocrit
Coombs
Bilirubin
Infant Blood Type & Rh
N/A
Maternal Type & Rh
N/A
Blood Glucose
OTHER
Patient
Values
NEWBORN PHYSICAL ASSESSMENT
NEUROLOGIC
o Alert
o Active
o Lethargic
o PERRLA
o Strong cry o Weak cry
Fontanelles
o Flat
o Bulging
o Depressed o Pulsating
Anterior: o Open o Closed
Posterior: o Open o Closed
o Molding
o Sutures Overlapping
RESPIRATORY cont’
Retractions
o Subcostal
oIntracostal
o Suprasternal o Sternal
o Supraclavicular
Breath Sounds
Left
Right
UL LL UL ML LL 
ooooo
Clear
ooooo
Crackles
ooooo
Wheezing
ooooo
Rhonchi
ooooo
Diminshed
ooooo
Absent
Ears/Nose
o Low Ear Placement
o Responds to noise
o Nose Patency
o Nasal discharge/Describe
_____________________
Mouth
Palate Intact: o Soft o Hard
o Epstein’s Pearls
Neck
o Full Range of motion
o Clavicles Intact
Reflexes
o
o
o
o
Moro
o Sucking
Rooting
o Gagging
Swallowing o Stepping
Babinski

COMMENTS ______________
_________________________
_____RESPIRATORY____

o Unlabored o Labored
o Regular
o Irregular
o Deep
o Shallow
o Stridor
o Grunting
o Nasal Flaring o Apnea
o Emesis o Constipation
o Diarrhea

Abdomen
o Soft
o Flat
o Rigid
o Distended
o Masses _____________
Bowel Sounds
Left
Right
UQ LQ UQ LQ
o o
o
o
o o
o
o
Apical Heart Rate _____/min.
o PMI lt. of sternum
o o
o
o
CRT _______
o o
o
o
Eyes
Lt____ Pupil Size Rt _____
o Lt
React
o Rt
o Bright and clear
o Ability to follow object
o Drainage
oEdema
o Strabismus
o Subconjunctival Hemorrhage
Color of iris______________
GASTROINTESTINAL
CARDIOVASCULAR____
o Regular
o Irregular
o Strong
o Weak
Peripheral Pulses
o Femoral Strong & Equal
o Brachial Strong & Equal
Heart Sounds
o S1
o S2
o Murmur o Gallop
o Muffled
Chest
o Symmetry of expansion
Breast Tissue:
o Flat
o Engorged
Comments _____________
______________________
GENITOURINARY___
Urinary
o Voiding
Genitalia
Male:
o Hypospadius
o Epispadius
o Dorsal Surface
o Ventral Surface
o Circumcised o Uncircum.
o Rugae Present
Testes Descended:
o Rt
o Lt
o Hydrocele
Female : Labia
o Edematous o Symmetrical
o Vaginal Discharge/Describe
____________________
Comments _______________
________________________
AIRWAY
o Patent
o Obstructed
N/ADN/Spring 09/RNSG 2561 Perinatal Assign Part III B
Normoactive
( 5 – 30 x/min)
Hypoactive
( 5 x/min)
Hyperactive
( 30 x/min)
Absent
( in 5 min)
Umbilical Cord
SKIN cont
o Lanugo
o Vernix
o Petechiae
Location________________
o Milia Location___________
o Mongolian Spots
Location________________
o Erythema Toxicum
Location _______________
o Bruising
Location________________
o Birthmarks
Location_______________
TURGOR
oElastic
Poor
______________________
__MUSCULOSKELETAL__
o
# of fingers ____ toes ____
o
Arms symmetrical
o
Legs symmetrical
o
Simian Creases
# of vessels ______________
o Odor 
o Inflammation o Triple Dye
o Drainage
o Rectum Patency
Stools: o Meconium
o Yellow o Green
POSTURE/MUSCLE TONE
o
Limbs flexed
o
Hypotonic
o
Hypertonic
o
Flaccid
o
Tone equal bilaterally
Appetite
(# of mins. br. feeding or amt. of
formula consumed)___________
Comments
_____________
_______SKIN___________
o
o
o
o
o
o
o
o
o
o
o
Warm
o Cool
Hot
o Cold
Dry
o Moist
Pink
o Diaphoretic
Pale
o Gray
Dusky
oRuddy
Mottled
o Cyanosis
Acrocyanosis
Circumoral Cyanosis
Jaundice
Edema
Location ____________
o
o
o
o
o
o
o
o
ACTIVITY
Spontaneous movement
Active
o Inactive
Jittery
ROM
MAEW
o Full
Limited
Specify_______________
Hips clicks absent
Symmetry of gluteal folds
Spine Straight
SKIN TEXTURE
o
Smooth
o Soft
o
Peeling
o Dry

Comments _______________
________________________
Reviewed 11/08