Infant Safety
–Verify baby’s wristband to mom’s wristband
Teach how to use the bulb syringe
o Mouth 1st then nose
LOC (sleeping, quiet alert, active alert, crying)
Pain Assessment
Vital Signs
o Auscultate Apical Pulse (1 full minute) ▪ Normal HR 110-160bpm
o Auscultate Respirations on flanks (1 full minute) ▪ Normal RR 30-60bpm
Auscultate Bowel Sounds
Assessment of head
o Fontanelles
o Sutures (Corneal, Sagittal)
Assessment of the face
Eye (symmetrical, space between, pupillary reflex) ▪ Never force the eyes open! Dim the lights
Ears (should be aligned, symmetrical)
Nose (nose may be flat after vaginal delivery, assess for patency)
▪ C- Section babies can have a stuffy nose
o Mouth (put finger in mouth to check palate, sucking reflex)
o Rooting reflex
Musculoskeletal
o Flexed position
o Xiphoid process
o 5 fingers on each hand
o Palmar grasp
o Count toes, 5 on each foot o Plantar grasp
o Babinskis
o Symmetry of legs
Female Genitals
o Clearly differentiated labia majora and labia minora o Pseudo menstruation
o Smegma (white stuff, normal)
Male Genitals
o Location of meatus (hypospadias, epispadias) o Testicles descended
Urinary assessment (concentrated urine, rusty color)
1st Bowel movement is meconium
Integumentary assessment
o Look for any birth marks, vernix and lanugo
Respiratory assessment (clear lung sounds)
Assessment of the umbilical cord
o Look for redness, swelling and discharge (there shouldn’t be any)
Look at baby’s back
o Curvature of the spine
o Sacral dimple
o Mongolian Spots
Pulses (Palpate brachial and femoral bilaterally)
Axillary temperature (always do last!)