Newborn Nursing Assessment Form
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1Reproductive
Care Program
of Nova Scotia
NEWBORN NURSING ASSESSMENT
Birth Date Birth Time Sex Birth Wt (g) Head Circ. (cm) Length (cm)
Band #
Blood Group
Feeding
Mother
Baby
Coombs
Breast
Exclusive
With suppl.
Formula
GESTATIONAL AGE ASSESSMENT
< 37 WEEKS (Preterm)
≥ 37 WEEKS (Term)
GESTATIONAL AGE
BREAST TISSUE
≤ 3 mm
> 3 mm
By Dates _____________wks.
PLANTAR CREASES
Smooth, Single Crease
Covering Ant. 1/3 or More
EAR
Relatively Flat, Pliable
Stiff Cartilage, Deep Crease at Outer Aspect
By Assessment _________wks.
TESTES
In Canal
Well Within Scrotum
Erythromycin eye ointment given
NORMAL
ABNORMAL (comment on Abnormalities)
Vitamin K Dose / Route ________________
1.
GENERAL
APPEARANCE
Given by ___________________
2.
SKIN
Bruising
Peeling
DISCHARGE
Weight_________________ g
Petechiae
Jaundice
Newborn
Newborn
Arranged
Mec. Stain
Other
screening
screening done
Edema
discussed
Soft tissue wasting
Moderate
Severe
3.
HEAD
Overriding suture
Molding
Caput
Signature______________________________
Hematoma
Other
Date __________________________________
4.
EENT
Cleft Lip/Palate
Other
Suspected Choanal Atresia
Physician assessment completed
5.
RESP
Grunting
Breath Sounds
Nasal Flaring
Tachypnea
Order for discharge written
Retracting
Other
Feeding
Breast
Exclusive
With suppl.
6.
CVS
Murmur
Central Cyanosis
Formula _______________
Arrhythmia
Abs. Fem. Pulses
Medically indicated
Tachycardia
Other
Well Established
7.
ABDOMEN
Scaphoid
Other
Problems Ongoing
Distended
__________________________
Follow-
8.
UMBILICAL CORD
Mec. Stain
Thin
__________________________
2 Vessels
Other
__________________________
9.
MUSCULOSKELETAL
Spine
Foot abn.
COMMENTS
Hip abn.
Other
Clavicle
10.
GENITORECTAL
Hydrocele
Imperforate anus
Hypospadias
Other
Undescended testes
11.
CNS
Tone
Tone
Other
Abn. Cry
Jittery
Date ___________________________
Time _______________________________
Date __________________
Time _______
Time __________
Signature _________________________________________________________________
Signature ______________________________
RCP/09 – Minor Rev.06/2012
NEWBORN NURSING ASSESSMENT
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