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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.

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    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: _40 x 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

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    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

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    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

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