As important changes occur during the second and third days after birth, physical assessment of the newborn is required to be completed within 48 hours of the birth. The following are the norms. Any abnormality is to be noted.
Newborn Physical Assessment and Nursing Diagnosis:
- Sleep – 12 to 16 hours in a day
- Feeding – 8 to 12 breast feedings in 24 hour period
- Urine passing – within 12 to 24 hours after birth. One wet diaper every 8 hours on day 2. This will gradually increase to 6-8 wet diapers in 24 hours on day 5.
- Stool – First stool within 48 hours. Breast fed baby 3-4 stools a day and formula fed baby 1-2 stools a day.
- General health – alertness, cry, respirations, temperature, apical pulse, weight all to be noted
- Movement – Tonic neck reflex and muscle tone and symmetry are to be noted.
- Skin – color and sign of jaundice is to be noted. Hydration
- General appearance - Look for forcep marks, stork bites, strawberry mark, mongolian spots, port wine stain
- Newborn screening
- Head symmetry – minor asymmetry is common and gets equalizes within 4 months. Scalp to be clean.
- Ears – Responds to voice and sound
- Eyes – Bruised and puffy eyelids are normal. Blinking to be observed. Focusing on the line of vision to be noted.
- Nose – Shape. Breathing normally through both nostrils with lips closed. Sneezing is a natural reflex to clear nostrils.
- Facial skin – Smooth pink/white.
- Mouth – Chin development
- Lips – Sucking callus on lips
- Tongue – Mobility
- Neck – Contraction of the shoulder and arm muscles
- Hands – Fingers grasping
- Chest – 2 nipples. Breast may have some enlargement
- Back – Spine straight
- Legs and feet – Legs same length and free movement.
- Umbilicus – Dried cord remnant.
- Genitalia –Male- 2 testes felt in scrotum
- Genitalia –Female – Vaginal discharge
- Moro reflex – Response to sensation of loss of support
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