AdventHealth University
Department of Nursing - NURS 330
Newborn Clinical Document
Student Information
Student Name:
Date:
Clinical Site:
Basic Patient Information
Baby Gender:
Room #:
Patient Name:
OB Provider:
Delivery Date & Time:
Type of Delivery:
Gestational Age:
Size Classification:
Accuchecks:
Initial Assessments & Vital Signs
Time of 1st Void:
Time of 1st Stool:
Time of Bath:
Feeding Method:
Feeding Times/Notes:
Weight & APGAR Scores
Birth Weight (g):
Today's Weight (g):
% Changed:
APGAR 1 Min:
APGAR 5 Min:
APGAR 10 Min:
Birth Information & Lab Values
Blood Type:
Coombs Test:
Glucose (mg/dL):
ROM Time:
ROM Notes:
Resuscitation/Medications:
Maternal Labs
GBS:
Blood Type:
Hepatitis B:
Rubella:
RPR:
HIV:
Chlamydia:
Gonorrhea:
COVID:
Other:
Maternal Conditions
Conditions:
Allergies:
Gravida/Para:
Blood Loss:
Epidural:
Laceration:
Baby Medications & Screenings
Antibiotics:
Ampicillin:
Gentamycin:
Eye/Thigh Tx:
Hearing:
Cardiac:
Car Seat:
PKU:
Circumcision:
Hep B Vaccine:
HUGS Tag:
Family Interaction
Observed Interactions:
Family Bonding Notes:
NEWBORN FOCUSED ASSESSMENT
Assessment
8 AM
12 Noon
MISC:
bulb syringe in crib, supine positioning, bands verified, wrapped, cap on
Bulb syringe present, lying on back, ID bands match mom, wrapped in blanket, hat on
Same, turned to side after feeding, rewrapped after diaper change
SKIN:
pink/pale/cyanotic/jaundiced, dry/peeling/moist, skin integrity & turgor, mucous membrane color & description, presence of rash, nevi, Mongolian spot, milia, etc.
Pink all over, warm and dry, good turgor, lips pink and moist, some milia on nose
Still pink, no jaundice noted, skin still dry, turgor good
HEAD:
symmetrical, molding, caput, cephalhematoma
FONTANELS:
soft/flat/bulging
FACE:
symmetrical, movement, mouth & palate intact, ear/eye discharge, sclera color
Head round, cephalhematoma on right side - soft swelling, fontanels soft and flat, face equal on both sides, no discharge from eyes/ears, white part of eyes white
Cephalhematoma unchanged, anterior fontanel still soft and flat, eyes clear
CARDIAC:
heart rhythm/rate reg or irreg, murmur, pulses present/equal
Heart sounds regular, rate 140, no murmur heard, pulses felt (unsure)
Heart rate 137, regular rhythm
PULMONARY:
breath sounds present all lobes, respiratory rate reg/irreg, retractions present, grunting
Lungs clear both sides, breathing 45/min, regular pattern, no grunting or pulling
Breathing 48/min, clear lung sounds, no distress
CHEST:
breasts symmetrical, buds
ABDOMEN:
bowel sounds present, distended/non-distended/soft
UMBILICAL CORD:
drying/moist
Chest equal, small breast buds, belly soft, bowel sounds heard, cord clamped and drying
Abdomen still soft, bowel sounds active, cord drying well with clamp on
GENITALIA:
Female: labia majora covers minora/equal size of both, vaginal discharge
Female parts, labia swollen (normal for newborn), no discharge seen
unchanged
NEURO REFLEXES:
grasp, rooting, moro, Babinski, suck
Good grasp when finger placed in palm, turns head when cheek touched, startles with noise, sucks well
unchanged
ACTIVITY:
awake & alert, quiet, lethargic, jittery
CRY:
weak/excessive
Alert during exam, calms with swaddling, strong cry when upset
Quiet alert after feeding, not jittery, cry still strong
Education Provided to Parents/Caregivers
Breastfeeding basics: proper latch, feeding cues, frequency (8-12 times/24 hours) Normal newborn appearance: explained labial swelling is normal and will resolve Cephalhematoma monitoring: what to watch for, that it will resolve in weeks to months Cord care: keep dry and clean When to call provider: fever, poor feeding, excessive crying
Case Study
(A) Assessment: Focused Observations
a. Subjective Data:
Mother reports "good" bonding with baby States baby latching well for breastfeeding Mother complaining of headache since delivery
Objective Data:
Baby girl, 39 weeks, AGA, 6 lb 5 oz APGAR 7/8 Vital signs stable Cephalhematoma right side of head Labial edema present Mother's BP normal (rules out pre-eclampsia) Baby alert, good cry, reflexes intact
b. Recognizing Deviations from Expected Patterns:
Cephalhematoma on right side (needs monitoring) Mother's headache post-delivery
c. Patterns to be Recognized as Potential Problems:
Risk for hyperbilirubinemia due to cephalhematoma Mother at risk for post-dural puncture headache GBS negative status noted - routine monitoring needed
d. Additional Information Needed:
Exact size of cephalhematoma for baseline Mother's headache characteristics (positional occurence?) Previous epidural notes
(D/O) Nursing Diagnosis and Outcome
e. Prioritized Problems with Supporting Data:
Risk for hyperbilirubinemia r/t cephalhematoma breakdown Risk for ineffective breastfeeding r/t first-time mother and latch concerns Knowledge deficit r/t newborn care and breastfeeding Maternal comfort impaired r/t post-epidural headache
(P/I) Plan and Interventions
f. Specific Interventions for Each Problem:
Monitor for jaundice, document cephalhematoma size, educate parents on signs of jaundice Monitor temp q4h, watch for feeding issues, lethargy Provide breastfeeding support, demonstrate diaper change, cord care Encourage maternal hydration, caffeine if appropriate, position changes
g. Delegation Opportunities:
Delegate vital signs to nursing assistant Lactation consultant for feeding support
h. SBAR Report
SBAR Intended for:
1. Situation:
Baby Girl Smith, 18 hours old, born vaginal delivery yesterday at 1700, stable newborn with cephalhematoma
2. Background:
39 weeks gestation, birth weight 6 lb 5 oz, APGARs 7/8, GBS negative mom, breastfeeding well
3. Assessment:
Vital signs stable, cephalhematoma right side unchanged, normal newborn exam otherwise, good latch, voiding and stooling appropriately. Mom with headache likely post-dural puncture
4. Recommendation:
Continue monitoring cephalhematoma, watch for jaundice, support breastfeeding, monitor mom's headache and encourage hydration
i. Psychomotor Nursing Skills Needed:
Newborn assessment skills Vital signs measurement Swaddling Assisting with breastfeeding positioning
(E) Evaluation and Reflection
j. Were you satisfied with all your decisions?
Yes, I feel good about the care I provided. I was able to identify and rule out a serious complication (pre-eclampsia) by checking vitals and recognizing the headache was likely from the epidural.
k. What did you do well?
I identified the mother's headache as a potential concern and took appropriate steps to rule out pre-eclampsia by checking blood pressure. I provided good support to the new mom and completed thorough newborn assessments.
l. Did you miss any data or assessment?
I could have been more specific about measuring the exact size of the cephalhematoma for better documentation and comparison later.
m. What could you have done differently?
I wish I had done more patient education and been more proactive in my care, but this early clinical helped me learn to advocate for myself better in later clinicals.
n. Overlooked interventions or decisions to include now:
Should have encouraged more specific positions for mom's headache relief and documented the exact characteristics of her headache better.
o. How will this assignment help with your future nursing career?
This taught me to think critically about complications and not assume symptoms are normal without proper assessment. It reinforced the importance of thorough documentation.
p. How did your ability to work through the nursing process improve?
I learned to connect assessment findings to potential problems and create specific interventions rather than general ones.
q. How did this help develop your critical thinking skills?
By working through the differential diagnosis of the mother's headache, I learned to consider multiple causes and use assessment data to rule out serious complications before assuming a benign cause.
Generate PDF Report