Jacalyn Patterson

Physical and Gestational Age Assessment of the Newborn

Childbearing Family and Women’s Health Nursing

March 2, 2017
 My patient gave birth vaginally to her newborn baby girl on February 23, 2017 at

6:39am. The gestational age was 38 weeks and I started my assessment on the newborn when

she was eleven hours old. Her APGAR score was 9/9 and she is being bottle fed with Similac

with iron. The mother of the newborn is 23 years old with a blood type and Rh factor of B+.

This is the mother’s third term newborn with three now living. The length of labor the mother

was in stage one for was 103 minutes, the second stage lasted one minute, and the third stage

lasted ten minutes. The maternal history showed that she smoked cigarettes, did take prenatal

vitamins, was Hepatitis and Rubella immune, and had a medical history of fetal pylectasis.

The newborn’s vitals were blood pressure was 71/45 taken on the right upper arm, her

heart rate was 150, her respiratory rate was 54, and her temperature was 97.7°F. She weighed

six pounds and eight ounces and was 20 inches in length along with a head circumference of

32cm. Her skin was appropriate for her ethnicity and had some xerosis areas and was warm to

touch. Her skin had good elasticity with small amount of lanugo on her shoulders, tops of ears

and on her back. Small amount of vernix caseosa was around her genitalia. She had appropriate

molding, the sutures were open, and her anterior and posterior fontanels were open, flat, and soft.

Her hair was silky with discrete single strands. In her neck there were creases, appeared short

and seems to rest on her shoulders. Her chin rested on her chest and was freely movable. She

had some head control and her sternocleidomastoid muscles were even in length.

The newborn’s eyes were symmetrical in shape and movement. There was symmetry in

her eyes, nose, and ears and she had dark colored eyes. Her corneas were bright and shiny and

her ears were soft, pliable, and well formed with frim cartilage. Her pinna of each ear was

straight in line with her inner and outer canthus of each eye. She responded to sound and sneeze

reflex was intact. Her nose is small, narrow and flattened with no bridge. Both nares are patent
bilaterally with no discharge. Lips are pink, symmetrical, in midline, and sensitive to touch. Her

tongue was pink, smooth, rough texture, and produced adequate saliva. The newborn’s hard

palate was intact and dome shaped. Her gag, sucking, swallow, and rooting reflexes are intact

and coordinated. Her abdomen was soft, rounded, and symmetrical in movement. Bowel sounds

were heard in all four quadrants. The umbilicus was clean, dry, and placed in center of her body.

The umbilical cord had two arteries and one vein at birth.

The newborn’s breast tissue was appropriate with well-spaced nipples. She had a barrel-

shaped chest that was symmetrical and synchronously bilaterally with respiratory movement.

Apical pulse was audible and located laterally to mid-clavicular line in the third to fourth

intercostal space. Her clavicles were straight, intact, had no crepitus, and her shoulders were

symmetrical. Her extremities were fully formed, correctly placed, had full range of motion, and

were freely movable. She maintained a flexed position and her arms and legs were of equal

length with symmetrical skin folds. Her legs appeared bowed and her feet were flat. Brachial,

femoral, and pedal pules were palpable. Her hands and feet were covered with creases and all

digits were present, distinct, and well nailed. Abduction of her thighs was greater than 60° with

a negative result of Ortolani’s maneuver. With her thighs flexed on her hip and abducted the

femoral pulse was palpable over the greater trochanters.

The newborn’s spine was straight, flat, freely movable, flexible, c-shaped, and all

vertebrae were intact with a vertex posture. Her labia majora covered her labia minora and

clitoris. Her urinary meatus was correctly placed. The buttocks and creases are equal and

symmetrical. Meconium was expelled within the first 24-48 hours after birth. No abdominal

distension and her urine was clear, had no odor, and was an appropriate amount.
 Her response is specific to gestational age and state of wakefulness. There was

generalized flexion and full range of motion with strong symmetrical movement bilaterally. She

briefly maintained her head erect when positioned on her stomach. She had coordinated intact

responses such as: Moro, tonic neck, palmer and plantar grasp, Babinski, blink, gag, cough,

sneeze, rooting, suck, and swallow. She moved her eyes in the direction of sound and responded

to high pitched sound by “freezing” then followed by agitation. She responded to low pitched

sounds by relaxation and is soothed by a massage, warmth, cuddling, and weightlessness. She

fed well within 48 hours after birth. Her sleep and wake cycles are within defined limits. Her

social behavioral pattern is also within defined limits by smiling and having a strong cry that is

medium pitched to indicate hunger or attention seeking. The newborn’s labs and diagnostic tests

were not available at time of assessment.