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
Contributor
4.5
39
2 months ago
Preview (3 of 10)
Sign in to access the full document!
ARIZONA COLLEGE
Name Clinical Reasoning Map Date
Newborn Assessment Critical Thinking Map
Admit Date: 6/25/23 Gestational Age: 40.1 Sex: Female
Allergies: NKDA Dav of life# <1 Code Status: NA
Pertinent Secondary Medical Dx: NA
Status on Day of Care (newborn day of
life #1,3 days old term newborn etc.). What
are 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 is
critical to wake them every 2 to 3 hours to feed them so they become accustomed to the practice and begin eating effectively. If a mother
is nursing, this is also the greatest technique to stimulate milk production. In a regular room environment, the newborn should be able to
maintain a constant body temperature. During the newborn period, the pulse rate is generally 120 to 160 beats per minute. Tn the
newborn stage, the isuaLbreathing ratgjs 40 to 60 breaths per minute. ____________________________________________________________
Labor/Delivery Summary
G_1 ____ T ____ P_1 ___ A ____ L ______ EDC 6/24/23
Type of delivery Vaginal ___ Date of delivery ___6/25/23 @
_0927 ____
Length of Labor _____NA ____ Length of Time ROM_11 hours_
AROM Z
'SROM
Color of Amniotic Fluid: _____Clear _________
EBL ____765 ___mL
Newborn Gest Age By Dates: _40x l __By Gest Age Exam: _40.1 ___
SGA—AGA-- LGA
APGAR Score : 1 Min.: 8 5 Min.: _9_
WT 3250_Gms_7 ___Lbs.._l_Oz Length_50.5cm (20in)_
Breast or Bottle Formula Type ___NA ____
L&D meds ______Penicillin __________________
Type of anesthesia: Local Epidural Spinal General None
Antibiotics in labor (Y or N) #doses ___3 _____
Fetal monitoring issucs/L&D complications:
Following delivery, the mother had some trinkling of blood. The nurse
administered an additional dosage of Pitocin and continued to check
the mother's blood loss
Name Clinical Reasoning Map Date
Newborn Assessment Critical Thinking Map
Admit Date: 6/25/23 Gestational Age: 40.1 Sex: Female
Allergies: NKDA Dav of life# <1 Code Status: NA
Pertinent Secondary Medical Dx: NA
Status on Day of Care (newborn day of
life #1,3 days old term newborn etc.). What
are 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 is
critical to wake them every 2 to 3 hours to feed them so they become accustomed to the practice and begin eating effectively. If a mother
is nursing, this is also the greatest technique to stimulate milk production. In a regular room environment, the newborn should be able to
maintain a constant body temperature. During the newborn period, the pulse rate is generally 120 to 160 beats per minute. Tn the
newborn stage, the isuaLbreathing ratgjs 40 to 60 breaths per minute. ____________________________________________________________
Labor/Delivery Summary
G_1 ____ T ____ P_1 ___ A ____ L ______ EDC 6/24/23
Type of delivery Vaginal ___ Date of delivery ___6/25/23 @
_0927 ____
Length of Labor _____NA ____ Length of Time ROM_11 hours_
AROM Z
'SROM
Color of Amniotic Fluid: _____Clear _________
EBL ____765 ___mL
Newborn Gest Age By Dates: _40x l __By Gest Age Exam: _40.1 ___
SGA—AGA-- LGA
APGAR Score : 1 Min.: 8 5 Min.: _9_
WT 3250_Gms_7 ___Lbs.._l_Oz Length_50.5cm (20in)_
Breast or Bottle Formula Type ___NA ____
L&D meds ______Penicillin __________________
Type of anesthesia: Local Epidural Spinal General None
Antibiotics in labor (Y or N) #doses ___3 _____
Fetal monitoring issucs/L&D complications:
Following delivery, the mother had some trinkling of blood. The nurse
administered an additional dosage of Pitocin and continued to check
the mother's blood loss
ARIZONA COLLEGE'
Name Clinical Reasoning Map Date
Time of 1 “ dose 6/24 time NA Special Request/Birth Plan Wishes:
NA
Vital Signs 0800 1200 1600
36.9 37.1 37.0
HR 140 142 140
RR .54 ____ 54
BP
____
66/33 82/37 80/36
SpO2 97% 99% 98%
NIPS
Facial
expressions: Grimace Relaxed Relaxed
Cry: Vigorous No cry No cry
Breathing
Pattern: Change in breathing. Relaxed Relaxed
Arms: Legs: Flexed Relaxed Relaxed
Arousal State: Awake Sleeping Awake/Fussy
Highlight the data that is associated with the client's priority concerns. In the event an assessment area below
is not appropriate simply put NA in the box.
Neuro :
Cry (lusty, weak, ftronj high pitched)
Cardiac :
Pink APale/ / C o o l / Dry/
Respiratory:
02 @ 99% L NC / CPAP / Vent /Room air Other
Name Clinical Reasoning Map Date
Time of 1 “ dose 6/24 time NA Special Request/Birth Plan Wishes:
NA
Vital Signs 0800 1200 1600
36.9 37.1 37.0
HR 140 142 140
RR .54 ____ 54
BP
____
66/33 82/37 80/36
SpO2 97% 99% 98%
NIPS
Facial
expressions: Grimace Relaxed Relaxed
Cry: Vigorous No cry No cry
Breathing
Pattern: Change in breathing. Relaxed Relaxed
Arms: Legs: Flexed Relaxed Relaxed
Arousal State: Awake Sleeping Awake/Fussy
Highlight the data that is associated with the client's priority concerns. In the event an assessment area below
is not appropriate simply put NA in the box.
Neuro :
Cry (lusty, weak, ftronj high pitched)
Cardiac :
Pink APale/ / C o o l / Dry/
Respiratory:
02 @ 99% L NC / CPAP / Vent /Room air Other
ARIZONA COLLEGE
Name Clinical Reasoning Map Date
Diaphoretic / Other NA
time:
SI / S2 / S3 / S4 /
Cap Refill
State (quiet alert, active alert, fussy,
drowsy, lethargic, sleeping, inconsolable,
hunger cues)
Reflexes (are they present, weak, missing,
unequal? +=present, - = missing)
Moro + Sucking ,+
Blink J- Rooting .+
Babinski + Palmar +
Plantar + Gag _+
Eyes: t’ERRLK/Ictcrus 'Sclera
hemorrhages/ Clear
Red reflex: Present/ Absent()ilateral/
Other
FIO2: _NA L: NA Room air
Breath Sounds:
-Tele I Rhythm:
Reg / Irreg:
Murmur: NA
Edema: None / Gen / R L / Bilateral Trace
1 + 2 + 3 + Pitting / Non-pitting
Auscultatiop. . .|r | Diminished / Wheezing I Crackles / Coarse
R: I Diminished / Wheezing I Crackles I Coarse
Depth: Shallow/Deep/ Normal)
Rhythm: Regular/Irrcgular/Pcriodic/ Tachypnea
Retractions:
Mild/Moderate/Severe/Suprastemal/Substemal/interc
ostal
Grunting: Yes /No
Nasal Flaring: Yes / No
Treatments: SVN / Suction: Suction performed upon
delivery. Babies was delivered through a vaginal delivery.
She baby was suctioned right away.
Location NA
Pulses:
Radial: Strong / Weak I Not palpated/
Doppler / Iqual
Brachial: Strong / Weak / Not palpated/
Doppler I >qual
Femoral: Strong!/ Weak / Not palpated/
Doppler / Iqual
Pedal: Radial pulses: Strong]/ Weak / Not
palpated/ Doppler / Iqual
Genitalia:
Female: vaginal tag prcscnt/Yes/ V
Discharge: kone'pseudo menstruation/white
Male: Testes: Descended/Descending/Un-
palpable/Bilateral/Other _ N A
Scrotum: Good rugae/Hydrocele/Edematous/ Little rugae
NA_
Head: MS:
Tone: jDccrcascd/Flaccid)
ROM:Moves all extremities easily/ Limited
Clavicles Intact/ Crepitus noted/ Equal
bilaterallJ/Not intact
Fingers and Toes: All digits
presenfSyndactyly/ polydactyly/Webbed
Anterior Fontanel:
(ipen/Closed/Flat/Bulging/ Sunken
Posterior Fontanel:
Open/Closcd/Flat/Bulging/
Sunken
Sutures:
Separated/ IOverridin|>/Approximated/
Mobile/Non-mobile) Urethra location: Tip of the glans/hypospadias/ epispadias_
______NA __________________
Circumcised: Yes,
Hips: Barlow maneuver No
Ortolani maneuver No
Caput (location) Crown
Cephalohematoma (location) NA
Name Clinical Reasoning Map Date
Diaphoretic / Other NA
time:
SI / S2 / S3 / S4 /
Cap Refill
State (quiet alert, active alert, fussy,
drowsy, lethargic, sleeping, inconsolable,
hunger cues)
Reflexes (are they present, weak, missing,
unequal? +=present, - = missing)
Moro + Sucking ,+
Blink J- Rooting .+
Babinski + Palmar +
Plantar + Gag _+
Eyes: t’ERRLK/Ictcrus 'Sclera
hemorrhages/ Clear
Red reflex: Present/ Absent()ilateral/
Other
FIO2: _NA L: NA Room air
Breath Sounds:
-Tele I Rhythm:
Reg / Irreg:
Murmur: NA
Edema: None / Gen / R L / Bilateral Trace
1 + 2 + 3 + Pitting / Non-pitting
Auscultatiop. . .|r | Diminished / Wheezing I Crackles / Coarse
R: I Diminished / Wheezing I Crackles I Coarse
Depth: Shallow/Deep/ Normal)
Rhythm: Regular/Irrcgular/Pcriodic/ Tachypnea
Retractions:
Mild/Moderate/Severe/Suprastemal/Substemal/interc
ostal
Grunting: Yes /No
Nasal Flaring: Yes / No
Treatments: SVN / Suction: Suction performed upon
delivery. Babies was delivered through a vaginal delivery.
She baby was suctioned right away.
Location NA
Pulses:
Radial: Strong / Weak I Not palpated/
Doppler / Iqual
Brachial: Strong / Weak / Not palpated/
Doppler I >qual
Femoral: Strong!/ Weak / Not palpated/
Doppler / Iqual
Pedal: Radial pulses: Strong]/ Weak / Not
palpated/ Doppler / Iqual
Genitalia:
Female: vaginal tag prcscnt/Yes/ V
Discharge: kone'pseudo menstruation/white
Male: Testes: Descended/Descending/Un-
palpable/Bilateral/Other _ N A
Scrotum: Good rugae/Hydrocele/Edematous/ Little rugae
NA_
Head: MS:
Tone: jDccrcascd/Flaccid)
ROM:Moves all extremities easily/ Limited
Clavicles Intact/ Crepitus noted/ Equal
bilaterallJ/Not intact
Fingers and Toes: All digits
presenfSyndactyly/ polydactyly/Webbed
Anterior Fontanel:
(ipen/Closed/Flat/Bulging/ Sunken
Posterior Fontanel:
Open/Closcd/Flat/Bulging/
Sunken
Sutures:
Separated/ IOverridin|>/Approximated/
Mobile/Non-mobile) Urethra location: Tip of the glans/hypospadias/ epispadias_
______NA __________________
Circumcised: Yes,
Hips: Barlow maneuver No
Ortolani maneuver No
Caput (location) Crown
Cephalohematoma (location) NA
Preview Mode
Sign in to access the full document!
100%