CHIPOLA COLLEGE

NURSING PROGRAM

NEWBORN ASSESSMENT

Birth Data

Gestational Age____________ Male/Female

Weight_____________ Vital Signs: T _____

Length_____________ P_____

Head Circumference__________ R_____

Chest Circumference__________

Apgars: 1 minute________ 5 minutes_________

Supportive Data

Complications of Pregnancy_________________________________________________

Preexisting Maternal Condition______________________________________________

Prenatal care: yes/no

Maternal Age_______

Maternal smoking/alcohol/drugs (circle and explain)

Anesthesia used during labor and delivery______________________________________

Length of labor________

Length of membrane rupture__________

Amniotic Fluid clear/meconium stained

Complications of labor_____________________________________________________

Presentation_________

Type of delivery: Vaginal/C-section

Resuscitation measures____________________________________________________

Physical Assessment

Skin (Color, Appearance, Turgor, Birthmarks) ________________________________________________________________________

________________________________________________________________________

Head/Scalp (Fontanels, Molding, Cephalohematoma, Caput Succedaneum):___________

________________________________________________________________________

Eyes (Reactivity/Discharge):________________________________________________

Mouth and Throat:________________________________________________________ _______________________________________________________________________
Chest (Quality of Respirations, Lung Sounds, Effort, Retractions, Grunting):__________ _______________________________________________________________________

________________________________________________________________________

Heart (Apical Rate & Rhythm, Heart Sounds, Pulses):____________________________

________________________________________________________________________

Abdomen (Shape, Umbilicus, Hernia, Bowel Sounds):___________________________

________________________________________________________________________

Anogenital (Anal Patency, Stool Type, Genital Swelling):_________________________

_______________________________________________________________________

Reflexes (Moro, Tonic Neck, Palmar grasp, Step, Babinski, Rooting, Sucking):________

_______________________________________________________________________

_______________________________________________________________________

Extremities (Symmetry, Polydactyly or Syndactyly):_____________________________

________________________________________________________________________