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Mother’s Age : 34 th
Pregnancy : G5P3A1
Gestational Age : 41 mg
Complications during pregnancy : -
Complications of childbirth :-
Ruptures of the membranes : 3 days before operation, green
Type of Delivery` : Sectio Caesaria
Indication : - ruptures of the membran
- oblique potition of the fetus
NEONATAL STATUS
Date of Baby Born : 04-07-2017
Gender : Boy
Weight : 3800 gr
Lenght : 49 cm
Head circumference : 35 cm
APGAR SCORE
0 1 2 APGAR SKOR 1’ 5’ 10’
12/14/2018
7
Conclussion : large for date, term
PHYSICAL EXAMINATION
A. General Appearance
Heart rate : 144 x/menit
Respiratory Rate : 52 x/menit
temperature : 37,2 ºC
General appearance : Crying Strongly, Active Motion
Skin : - Color : red
- Turgor : Normal
- Tonus : Normal
* Gesture : Flexion
* Reflexes : - Moro : (+) -glabela: (+)
- rooting: (+) - palmar : (+)
- plantar: (+)
- Tonus leher : (+)
* sound : Loud
B. HEAD
Shape : Normochepal
Sutura : Normal, moulage (-)
Fontanela : soft, open sinciput, horizontal
Eyes : Normal, sekret (-)
Nose : Normal, the breath of the nostrils(-)
Ear : Normal
Mouth : Normal
Caput succedaneum :-
Cephal hematom :-
C. Neck : tonus normal
D. Thorax :
- Heart : Bunyi jantung SI= tunggal, SII= split tak
konstan, bising Jantung (-)
- Lung : Vesikuler Sound (+) Normal
E. Stomach : Supel, turgor normal, fresh umbilical cord
F. Genitalia : Normal, testis sudah turun ke skrotum, penis
(+) 3 cm, miksi (+)
G. Anus : (+) Normal, mekonium (-)
H. Ekstremitas : Normal, jumlah jari di keempat ekstremitas
lengkap
I.Tulang punggung : Dalam batas normal
J. Anomali lain : Tidak ditemukan
ASSESMEN