Newborn Assessment

Posture is flexed, normal spontaneous movement bilaterally asynchronous. Apical HR is 120-140 bpm (80/100- 180 bpm in the norm range). PP equal and strong. Axillary temperature (36.5-37.2 C).RR 40 breaths/min; shallow and irregular rate and rhythm. Crackles may be present. BP at birth.. 60-80/40-50… 10 days later 95-100/45-75. Weight F 3400 g/ M 3500 g. Length 45-55 cm. HC 32-36.8 cm.

Head is round, soft, with no laceration or bruising noted. A/P fontanels are flat, and free of depression. Sutures aligned. Ears are symmetrical with bilateral recoil. Passed L/R/B hearing test. Pt responsive to voice. Eyes are aligned, symmetrical. Pupils are present, equal in size, reactive to light. Eyelid edema. GLABELLAR reflex present. Nose is in midline, free of discharge, some mucous, preferential nose breather. TONIC NECK reflex present. Mouth palate was formed, no teeth, pink, moist. Positive SWALLOWING, SUCKING , and ROOTING reflex. Skin is pink; acrocyanosis present. No jaundice present. Vernix caseosa may be present on skin… white, cheesy, odorless. Lanugo present over shoulders, pinnae of ears, forehead.Throat and neck had full ROM, neck short, thick, surrounded by skin folds, no webbing noted. Chest circular. Lungs CTA. HR 135 bmp and regular rhythm. Clavicles intact. Breast tissue present, nodule approximately 6 mm. Abdomen is rounded, prominent, dome shaped, non-distended. Umbilical cord is dry around base, odorless, with cord clamp in place. Bowel sounds normoactive x4. Meconium was passed 0800. Urinary meatus at tip of penis, foreskin covers glans (if uncircumsized). Scrotum large, edematous, pendulous covered with rugae. Palpable on each side. Pt has voided (should void w/I first 24 hours), stream and amt adequate. MORO reflex present. Full ROM extremities X4. Five fingers on each hand, no webbing present. PALMAR/PLANTAR grasp reflex present. Five toes on each foot no webbing noted. BABINSKI reflex present....