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Newborn Assessment Critical Thinking Map

A collaborative resource hub for Newborn Assessment Clinical Reasoning Maps, offering templates to document perinatal data, vitals, APGAR scores, feeding plans, and priority findings to guide neonatal nursing care.

Daniel Miller
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4 months ago
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ARIZONA COLLEGENameClinical Reasoning MapDateNewborn Assessment Critical Thinking MapAdmit Date: 6/25/23Gestational Age: 40.1Sex: FemaleAllergies: NKDADav of life#<1Code Status: NAPertinent Secondary Medical Dx: NAStatus on Day of Care(newborn day oflife #1,3 days old term newborn etc.). Whatare the expected findings for this client?Newborn <1 day. The baby was bom on 6/25 at 0847. Most infants become drowsy after being quite awake for the first 24 hours. It iscritical to wake them every 2 to 3 hours to feed them so they become accustomed to the practice and begin eating effectively. If a motheris nursing, this is also the greatest technique to stimulate milk production. In a regular room environment, the newborn should be able tomaintain a constant body temperature. During the newborn period, the pulse rate is generally 120 to 160 beats per minute. Tn thenewborn stage, the isuaLbreathing ratgjs 40 to 60 breaths per minute. ____________________________________________________________Labor/Delivery SummaryG_1 ____T ____P_1 ___A ____L ______EDC6/24/23Type of deliveryVaginal ___Date of delivery ___6/25/23 @_0927 ____Length of Labor _____NA ____Length of Time ROM_11 hours_AROMZ'SROMColor of Amniotic Fluid: _____Clear_________EBL ____765 ___mLNewborn Gest AgeBy Dates:_40xl __By Gest Age Exam: _40.1 ___SGA—AGA--LGAAPGAR Score : 1 Min.:85 Min.: _9_WT 3250_Gms_7 ___Lbs.._l_OzLength_50.5cm (20in)_Breastor BottleFormula Type ___NA ____L&D meds______Penicillin__________________Type of anesthesia:LocalEpiduralSpinalGeneralNoneAntibiotics in labor (Y or N)#doses ___3 _____Fetal monitoring issucs/L&D complications:Following delivery, the mother had some trinkling of blood. The nurseadministered an additional dosage of Pitocin and continued to checkthe mother's blood loss

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ARIZONA COLLEGE'NameClinical Reasoning MapDateTime of 1 “ dose6/24 time NASpecial Request/Birth Plan Wishes:NAVital Signs08001200160036.937.137.0HR140142140RR.54 ____54BP____66/3382/3780/36SpO297%99%98%NIPSFacialexpressions:GrimaceRelaxedRelaxedCry:VigorousNo cryNo cryBreathingPattern:Change in breathing.RelaxedRelaxedArms: Legs:FlexedRelaxedRelaxedArousal State:AwakeSleepingAwake/FussyHighlight the data that is associated with the client's priority concerns.In the event an assessment area belowis not appropriate simply put NA in the box.Neuro :Cry (lusty, weak, ftronjhigh pitched)Cardiac :Pink APale// C o o l /Dry/Respiratory:02 @99%L NC / CPAP / Vent /Room air Other

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ARIZONA COLLEGENameClinical Reasoning MapDateDiaphoretic / OtherNAtime:SI / S2 / S3 / S4 /Cap RefillState (quiet alert,active alert,fussy,drowsy, lethargic, sleeping, inconsolable,hunger cues)Reflexes (are they present, weak, missing,unequal? +=present, - = missing)Moro+Sucking,+BlinkJ-Rooting.+Babinski+Palmar+Plantar+Gag_+Eyes: t’ERRLK/Ictcrus 'Sclerahemorrhages/ ClearRed reflex: Present/Absent()ilateral/OtherFIO2:_NAL:NARoom airBreath Sounds:-TeleIRhythm:Reg / Irreg:Murmur:NAEdema: None / Gen / R L / Bilateral Trace1 + 2 + 3 + Pitting / Non-pittingAuscultatiop. ..|r| Diminished / WheezingICrackles / CoarseR:IDiminished / WheezingICracklesICoarseDepth: Shallow/Deep/Normal)Rhythm: Regular/Irrcgular/Pcriodic/ TachypneaRetractions:Mild/Moderate/Severe/Suprastemal/Substemal/intercostalGrunting: Yes /NoNasal Flaring: Yes / NoTreatments:SVN /Suction:Suction performed upondelivery. Babies was delivered through a vaginal delivery.She baby was suctioned right away.LocationNAPulses:Radial: Strong / WeakINot palpated/Doppler / IqualBrachial: Strong / Weak / Not palpated/DopplerI>qualFemoral: Strong!/ Weak / Not palpated/Doppler / IqualPedal: Radial pulses: Strong]/ Weak / Notpalpated/ Doppler /IqualGenitalia:Female: vaginal tag prcscnt/Yes/ VDischarge: kone'pseudo menstruation/whiteMale: Testes: Descended/Descending/Un-palpable/Bilateral/Other _ N AScrotum: Good rugae/Hydrocele/Edematous/ Little rugaeNA_Head:MS:Tone:jDccrcascd/Flaccid)ROM:Moves all extremities easily/ LimitedClavicles Intact/ Crepitus noted/ EqualbilaterallJ/Not intactFingers and Toes:All digitspresenfSyndactyly/ polydactyly/WebbedAnterior Fontanel:(ipen/Closed/Flat/Bulging/ SunkenPosterior Fontanel:Open/Closcd/Flat/Bulging/SunkenSutures:Separated/ IOverridin|>/Approximated/Mobile/Non-mobile)Urethra location: Tip of the glans/hypospadias/ epispadias_______NA __________________Circumcised: Yes,Hips: Barlow maneuverNoOrtolani maneuverNoCaput (location)CrownCephalohematoma (location)NA
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