Pediatrics — Newborn Examination Template

Patient Information

Date of birth: [Date]
Time of birth: [Time]
Sex: Male / Female / [Other]
Current age: [X] hours / [X] days
Exam type: Initial / Day [X] / Pre-discharge / Follow-up

Birth History

Maternal Information

Mother's name: [Name]
Maternal age: [X] years
G[X]P[X] (Gravida/Para)
Blood type: [A/B/AB/O] [Rh+/-]
Rubella immune: Yes / No / Unknown
Hepatitis B status: Negative / Positive / Unknown
HIV status: Negative / Positive / Unknown
GBS status: Negative / Positive / Unknown

• If positive, adequate prophylaxis: Yes / No / Unknown

RPR/VDRL: Negative / Positive / Unknown
Chlamydia/gonorrhea: Negative / Positive / Unknown

Prenatal History

Prenatal care: Yes (began [trimester]) / No / Late/Limited
Number of prenatal visits: [X]
Prenatal ultrasounds: [Number, findings]
Prenatal labs: [Relevant results]
Maternal medical history: [Relevant conditions — diabetes, HTN, thyroid, etc.]
Medications during pregnancy: [List]
Substance use: None / Tobacco / Alcohol / Drugs [specify]
Complications:

• Gestational diabetes: No / Yes — [Diet/insulin controlled]
• Preeclampsia/HTN: No / Yes
• Preterm labor: No / Yes
• PPROM: No / Yes — Duration: [X] hours
• Oligohydramnios/polyhydramnios: No / Yes
• Placental abnormalities: No / Yes — [Specify]
• Infections: No / Yes — [Type, treatment]
• Other: [Specify]

Labor and Delivery

Gestational age: [X] weeks [X] days
Delivery hospital: [Name]
Attending: [OB/Midwife name]
Labor type: Spontaneous / Induced — Reason: [X]
Rupture of membranes: Spontaneous / Artificial — Duration before delivery: [X] hours
Amniotic fluid: Clear / Meconium-stained / Bloody / Foul-smelling
Delivery type: SVD / Vacuum / Forceps / C-section

• C-section indication: [Reason]

Anesthesia: None / Epidural / Spinal / General
Complications: None / [Cord prolapse, shoulder dystocia, hemorrhage, etc.]

Immediate Newborn Status

APGAR scores:

• 1 minute: [X]
• 5 minutes: [X]
• 10 minutes (if applicable): [X]

Resuscitation required: None / [Stimulation, O2, PPV, Intubation, Compressions, Medications]
Cord blood gases (if obtained): [Values]
Cord: [Number of vessels — should be 3]
Placenta: [Weight, appearance if noted]
Immediate concerns: None / [List]

Birth Measurements

Birth weight: [X] grams ([X] lbs [X] oz) — [X] percentile

• [AGA / SGA / LGA]

Birth length: [X] cm ([X] in) — [X] percentile
Birth head circumference: [X] cm — [X] percentile

Current Status

Current weight: [X] grams — [% change from birth]
Current age: [X] hours

Feeding Assessment

Feeding method: Breastfeeding / Formula / Both

Breastfeeding:

• Number of feeds in last 24 hours: [X]
• Duration per feed: [X] minutes
• Latch: Good / Fair / Poor — [Concerns]
• Maternal nipple concerns: None / [Pain, cracking, flat/inverted]
• Milk production: Colostrum / Transitional / [Concerns]
• Supplementation: None / Formula / [Reason]
• Lactation consulted: Yes / No

Formula:

• Type: [Formula name]
• Amount per feed: [X] mL
• Frequency: Every [X] hours
• Tolerance: Good / [Concerns]

Feeding Concerns:

• Poor feeding: Yes / No
• Excessive sleepiness: Yes / No
• Choking/gagging: Yes / No
• Vomiting: Yes / No

Elimination

Urine output:

• First void: [X] hours of life
• Number of wet diapers in 24 hours: [X]

Stool output:

• First meconium: [X] hours of life
• Number of stools in 24 hours: [X]
• Stool character: Meconium / Transitional / Yellow seedy

Vital Signs

Temperature: [X]°F / [X]°C — Method: [Axillary/Rectal]
Heart rate: [X]
Respiratory rate: [X]
SpO2: [X]% on RA (right hand: [X]%, foot: [X]%)
Blood pressure (if indicated): [X/X]

Physical Examination

General

Activity: Active / Quiet / Lethargic
Tone: Normal / Hypertonic / Hypotonic
Color: Pink / Acrocyanosis / Jaundiced / Pale / Plethoric
Cry: Strong / Weak / High-pitched
Gestational age assessment: [Consistent with dates / Small for dates / Large for dates]
Dysmorphic features: None / [Describe]

Skin

Color: Pink / Jaundice [Kramer zone] / Pale / Plethoric
Rashes/lesions:

• Erythema toxicum: Present / Absent
• Milia: Present / Absent
• Mongolian spots: Present [location] / Absent
• Nevus simplex (stork bite/angel kiss): Present [location] / Absent
• Other: [Describe]

Peeling: None / Mild / Significant
Vernix: Present / Absent
Lanugo: Present / Absent
Birthmarks: None / [Describe]
Turgor: Normal

Head

Shape: Normal / Molding / Caput succedaneum / Cephalohematoma [location]
Anterior fontanelle: Open, soft, flat — Size: [X] cm
Posterior fontanelle: Open / Closed — Size: [X] cm
Sutures: Normal / Overriding / Widened
Scalp: Intact / [Findings]

Eyes

Red reflex: Present bilaterally / Absent [side]
Pupils: Equal, reactive
Conjunctivae: Clear / [Discharge, hemorrhage]
Sclera: White / Icteric / Blue
Eyelids: Normal / Edematous
Coloboma: Absent / Present
Spacing: Normal / Wide-set / Close-set

Ears

Position: Normal / Low-set
Shape: Normal / [Abnormality]
Pits/tags: Absent / Present [location]
Canals: Patent
Response to sound: Present / [Concerns]

Nose

Nares: Patent bilaterally
Shape: Normal
Septum: Midline
Nasal flaring: Absent / Present

Mouth

Palate: Intact (palpated) / Cleft [type]
Lip: Intact / Cleft
Gums: Normal / [Findings — natal teeth, Epstein pearls]
Tongue: Normal / Large / Tongue-tie (ankyloglossia)
Suck: Strong / Weak
Rooting reflex: Present

Neck

Range of motion: Full
Masses: None / [Cystic hygroma, torticollis]
Clavicles: Intact / Fracture [side]
Webbing: Absent / Present

Chest

Shape: Normal / [Pectus, asymmetry]
Breath sounds: Clear bilaterally / [Findings]
Work of breathing: Normal / [Retractions, grunting, flaring]
Breast tissue: [Appropriate for gestational age]
Nipples: Normal position / [Wide-spaced]

Cardiovascular

Heart sounds: Regular rhythm, no murmur / Murmur [grade, location]
Pulses:

• Brachial: 2+ bilaterally
• Femoral: 2+ bilaterally / Weak / Absent

Capillary refill: <3 seconds
Pre-ductal SpO2: [X]%
Post-ductal SpO2: [X]%

Abdomen

Shape: Soft, non-distended
Bowel sounds: Present
Liver: [X] cm below RCM / Not palpable
Spleen: Not palpable / [Palpable]
Kidneys: Not palpable / [Palpable]
Masses: None / [Describe]
Umbilicus:

• Vessels: 3 (2 arteries, 1 vein) / 2 (single umbilical artery)
• Cord: Drying / Clamped / [Concerns — erythema, drainage]
• Hernia: Absent / Present

Genitourinary

Male:

• Penis: Normal / [Hypospadias — location, chordee]
• Urethral meatus: Normal position / [Abnormal]
• Testes: Descended bilaterally / Undescended [R/L]
• Scrotum: Normal / [Hydrocele, hernia]

Female:

• Labia: Normal
• Clitoris: Normal / [Enlarged]
• Vaginal discharge: None / White mucoid (normal) / Bloody (pseudomenses — normal)
• Hymenal tag: Absent / Present (normal)
• Urethral opening: Normal

Anus

Patent: Yes / [Imperforate]
Position: Normal / [Anterior displacement]
Meconium passed: Yes / No — [Age at first stool]

Spine

Straight / Curved
Sacral dimple: Absent / Present — [If present: shallow <5mm, within gluteal crease]
Pilonidal sinus: Absent / Present
Hair tuft: Absent / Present
Masses: None / [Describe]

Extremities

Arms: Symmetric, full ROM / [Findings]
Hands: Normal / [Polydactyly, syndactyly, simian crease]
Legs: Symmetric, full ROM / [Findings]
Feet: Normal / [Clubfoot, polydactyly, syndactyly]
Digits: 10 fingers, 10 toes / [Abnormality]

Hips (Barlow and Ortolani)

Right: Stable / Click / Clunk (positive)
Left: Stable / Click / Clunk (positive)
Leg length: Equal / Unequal
Thigh folds: Symmetric / Asymmetric

Neurological

Tone: Normal / Hypertonic / Hypotonic
Activity: Appropriate for state
Primitive reflexes:

• Moro: Present / Absent / Asymmetric
• Grasp (palmar): Present / Absent
• Grasp (plantar): Present / Absent
• Rooting: Present / Absent
• Suck: Present / Absent / Weak
• Stepping: Present / Absent
• Tonic neck (fencing): Present / Absent

Movement: Symmetric / Asymmetric [describe]
Tremor: None / Fine / Coarse / Jitteriness

Risk Assessments

Hyperbilirubinemia Risk

Risk factors:

• [ ] ABO/Rh incompatibility
• [ ] Prematurity (<38 weeks)
• [ ] Cephalohematoma/bruising
• [ ] Previous sibling with jaundice
• [ ] Exclusive breastfeeding with poor intake
• [ ] East Asian race

Bilirubin level (if obtained): [X] mg/dL at [X] hours of life
Bilirubin zone: Low risk / Low-intermediate / High-intermediate / High risk
Phototherapy: Not indicated / Indicated

Sepsis Risk

Risk factors:

• [ ] GBS positive
• [ ] Inadequate GBS prophylaxis
• [ ] Prolonged rupture of membranes (>18 hours)
• [ ] Maternal chorioamnionitis
• [ ] Maternal fever
• [ ] Prematurity

Sepsis workup: Not indicated / Indicated — [Results]
Antibiotics: Not indicated / Indicated — [Duration]

Hypoglycemia Risk

Risk factors:

• [ ] Infant of diabetic mother
• [ ] SGA/LGA
• [ ] Prematurity
• [ ] Perinatal stress

Glucose monitoring: Not indicated / Indicated
Glucose levels: [Results]

Newborn Screening

Metabolic Screen

State newborn screen: Collected / Pending / [Results]
Date collected: [Date] — Age at collection: [X] hours

Hearing Screen

Method: OAE / ABR
Result: Passed both ears / Refer [R/L/both] / Pending

Critical Congenital Heart Disease (CCHD) Screen

Right hand SpO2: [X]%
Foot SpO2: [X]%
Result: Passed / Failed / [Repeat needed]

Other Screening

Hepatitis B vaccine: Given — Date: [Date], Lot: [X]

• HBIG (if indicated): Given / Not indicated

Vitamin K: Given IM — Date: [Date]
Erythromycin eye ointment: Given — Date: [Date]

Assessment

1) [Term/Preterm] [AGA/SGA/LGA] newborn, DOL [X]

• Birth weight: [X] grams
• Current weight: [X] grams ([%] change)

2) Feeding: [Breastfeeding/Formula] — [Establishing/Adequate/Poor]
3) [Additional diagnoses if applicable]

• [ ] Hyperbilirubinemia
• [ ] Hypoglycemia
• [ ] Birth injury: [Specify]
• [ ] Congenital anomaly: [Specify]
• [ ] Other: [Specify]

Plan

Current Management

• Continue current feeding plan: [Details]
• [Phototherapy if indicated]
• [Glucose monitoring if indicated]
• [Antibiotics if indicated]
• Bilirubin check: [Timing if indicated]

Discharge Planning (if applicable)

Discharge criteria:

• [ ] Vital signs stable for 12+ hours
• [ ] Feeding adequately
• [ ] Voiding and stooling
• [ ] No respiratory distress
• [ ] Bilirubin in safe range
• [ ] Car seat available

Discharge weight: [X] grams ([%] loss from birth)
Acceptable weight loss: Yes (<7%) / Borderline (7-10%) / Excessive (>10%)

Follow-up Appointments

• Pediatrician: [Date] — [X] days of life
• Earlier if: Weight loss >10%, jaundice, feeding concerns
• Weight check: [If indicated]
• Bilirubin check: [If indicated]
• Specialty: [If indicated]

Discharge Medications

• [ ] None
• [ ] Vitamin D: 400 IU daily (if breastfeeding)
• [ ] [Other]

Anticipatory Guidance Provided

• [ ] Safe sleep (back to sleep, firm surface, no soft bedding)
• [ ] Feeding (frequency, signs of hunger, adequate intake signs)
• [ ] Cord care
• [ ] Circumcision care (if applicable)
• [ ] Jaundice monitoring
• [ ] Car seat safety
• [ ] Temperature taking
• [ ] When to call/return

Parent Teaching Completed

• [ ] Safe sleep
• [ ] Feeding
• [ ] Cord care
• [ ] Skin care
• [ ] Signs of illness
• [ ] CPR/choking (offered)
• [ ] Car seat (checked by nurse)

Discharge instructions reviewed with: Mother / Father / Both / Guardian
Questions answered: Yes