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Physical Examination of The Neonate

This document outlines the assessment of a newborn infant. It includes a checklist of observations and examinations to perform including general appearance, measurements, assessment of head and neck, chest, abdomen, extremities and reflexes. The student is evaluated on their proficiency in performing the assessment and identifying any abnormalities. Their examination is observed and documented by two examiners and includes questions to answer. The aim is to evaluate the newborn's development and adjustment to extrauterine life.

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Alana Caballero
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71 views6 pages

Physical Examination of The Neonate

This document outlines the assessment of a newborn infant. It includes a checklist of observations and examinations to perform including general appearance, measurements, assessment of head and neck, chest, abdomen, extremities and reflexes. The student is evaluated on their proficiency in performing the assessment and identifying any abnormalities. Their examination is observed and documented by two examiners and includes questions to answer. The aim is to evaluate the newborn's development and adjustment to extrauterine life.

Uploaded by

Alana Caballero
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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UNIVERSITY OF TECHNOLOGY

Caribbean School of Nursing

BSM Midwifery

Physical Assessment of the Newborn

Student ID................................. Date and time of exam.....................

1st Examiner................................ 2nd Examiner....................................

Aim: To determine the student’s proficiency in the assessment of the newborn in an effort to
evaluate development and adjustments to extrauterine life.

Intervention Yes No Remarks

Wash hands thoroughly to prevent cross


infection

Gather equipment

Identify client and explain procedure to


mother and gain verbal consent. Establish
rapport.

Ensure privacy

Don clean pair of gloves.

Place receiver on examination table and have


mother place baby on it. (Or student place
baby on)

General Observation
 Colour, presence of jaundice, rashes,
birthmarks and any skin
abnormalities
 Observe neonate in proportion to
maturity
 Muscle tone/ activity
 Drowsiness
 Alertness

Deveree Stewart Caribbean School of Nursing- BSM 2015


Revised by Deveree Stewart 2018 Page 1
 Posture
 Respiratory effort
 Cry of the neonate

Check temperature

Measurements
 Head circumference
 Length
 Weight

Head and Neck


 Symmetry
 Moulding
 Caput
 Haematoma
 Sutures
 Fontanelle, shape, size, fullness or
depression

Eyes
 Shape
 Position
 Size
 Appearance of pupils
 Signs of ophthalmic infection
 Cataracts
 Presence of haemorrhage
 *Blinking and corneal reflex

Ears
 Position
 Shape
 Size
 Patency of external auditory meatus

Nose
 Symmetry
 Septum
 Flaring
 Patency

Mouth
 Mucous membrane
Deveree Stewart Caribbean School of Nursing- BSM 2015
Revised by Deveree Stewart 2018 Page 2
 Palate
 Gums
 Frenulum linguae
 *Sucking reflex
 *Rooting reflex
 *Gag reflex

Neck
 Length
 Mobility
 Relationship to body
 Presence of webbing, skin tags or fat
pads
Skin
 Lanugo
 Vernix
 Meconium staining
 Texture
 Hydration

Chest and abdomen


 Inspect thorax for size, symmetry and
shape
 Palpate clavicle for intactness or
presence of mass
 Auscultate breath sounds
 Check respiratory rate, depth and
pattern
 Auscultate heart sounds and rhythm
 Check apical pulse
 Inspect abdominal shape and girth
 Assess umbilical cord identifying
vessels, signs of infection
 Check for the presence of hernia
around umbilical area
 Gently palpate spleen, liver and
kidneys
 Palpate femoral pulses

Genitals and Anus


 Observe genitals for appropriateness
with stated sex
 Observe female infant for maturation
of labia and vaginal discharge
Deveree Stewart Caribbean School of Nursing- BSM 2015
Revised by Deveree Stewart 2018 Page 3
 For males, check position of urethral
opening
 Check passage of urine
 Check maturation of scrotum and
presence of testes
 Check patency of anus (passage of
meconium)
 Nature/ type of stool

Extremities
Arms and Hands
 Establish if equal in length, shape and
moving normally
 Assess for signs of birth injury e.g.
Erb’s Palsy
 Observe shape of fingers and count
the number of digits: polydactyly,
syndactyly
 Observe palmer creases
 *Check palmer/ grasp reflex
 Palpate brachial and radial pulses for
rate and depth
Legs and Feet
 Check legs are equal in size, shape
and length
 Knee height
 Symmetry of leg creases
 Position of feet
 Digits: polydactyly, syndactyly
 Abduct thighs to bed
 Rotate hips through full range of
motion

The back
 Observe the skin and colour
 Palpate and inspect the spinal column
for intactness, masses and symmetry
of vertebrae
 Observe pilonidal dimple for
intactness

Reflexes
 *Moro

Deveree Stewart Caribbean School of Nursing- BSM 2015


Revised by Deveree Stewart 2018 Page 4
 *Walking/ stepping reflex
 *Traction response
 *Ventral suspension
 *Asymmetric tonic reflex

Dress baby and give back to mother/ parents

Wash hands

Documentation
 Record findings of the examination
 Report any abnormal findings to
midwife, doctor and mother/parents
 Health teaching as appropriate

1.

(5 marks)
2.

(5 marks)
3.

(5 marks)
4.

(5 marks)

Deveree Stewart Caribbean School of Nursing- BSM 2015


Revised by Deveree Stewart 2018 Page 5
Key

Yes = 1 mark each; No = 0 mark; *2 marks each

Total = 110 Maximum points

Questions= 4 Questions= 5 marks each= 20 marks

Grand Total = 130 marks

Student total.........................................

Comments ........................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
.............................................................

Student signature...................................

1st Examiner signature........................................................

2nd Examiner signature......................................................

Deveree Stewart Caribbean School of Nursing- BSM 2015


Revised by Deveree Stewart 2018 Page 6

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