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Newborn_Assessment_12_2007 - Mouth(lips gums palate tongue...

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12/26/2007 DG adapted from AEB SAN JOSE STATE UNIVERSITY SCHOOL OF NURSING NURS 146B NEWBORN ASSESSMENT II-Actual Patient Assessment Date___________________ Student Name_________________________ DELIVERY Mode of Delivery: Apgar Scores at 1 min_____at 5 min_____ Gestational age at birth: Sex______ (complete form and hand in with assessment) Problems/Complications: Vital Signs: HR________Resp_________Temp________Color___________ Measurements: Weight________________gms_____________________lbs Length_____________ Skin (rashes, birthmarks, turgor, texture, milia, lanugo,etc.) General posture (at rest, awake) Head to toe assessment: Head Circumference__________ Shape_______________ Fontanels (anterior & posterior): Sutures (overriding, hematoma, caput): Hair color, amount: Face (symmetry, abrasion, edema, birthmarks); Eyes (color, placement, discharge, strabismus, edema, vision): Ears (placement, shape and size, hearing): Nose (patency, discharge, flaring, congestion):
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Unformatted text preview: Mouth (lips, gums, palate, tongue): Neck (webbing, appearance, movement, clavicles): 1 of 2 12/26/2007 DG adapted from AEB Newborn Assessment (cont.) Thorax (shape, appearance, breast, heart, lungs-characteristics of breathing): Chest circumference___________ Abdomen (shape, bowel sounds, umbilicus): Abdomen circumference______ Back (general appearance, spine): Extremities/Hip (symmetry of arms and legs, ROM, Tone, # of fingers/toes): REFLEXES: State how you elicited the reflexes Moro: Babinski: Grasp: Rooting/Sucking: Tonic Neck: GENITALIA/EXCRETION Female Male ANUS (placement, patency, stools-color, consistency, odor, # per day) Voids (# per day) NUTRITIONAL Breastfeeding Formula feeding/Type of formula Frequency of feedings # of feedings per 24 hours Amount per feeding BEHAVIOR Sleeping Pattern Cry (calming techniques by newborn and others) Bonding Immunizations 2 of 2...
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