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Nb Assessment

Table 21-2 SUMMARY OF NEWBORN ASSESSMENT *MCH pages 479-473| NORMAL| ABNORMAL (POSSIBLE CAUSES)| NURSING CONSIDERATIONS| Initial AssessmentAssess for obvious problems first. If infant is stable and has no problems that require immediate attention, continue with complete assessment. | Vital Signs| TemperatureAxillary: 36. 5– 37. 5°C (97. 7 – 99. 5°F). Axilla is preferred site. | Decreased (cold environment, hypoglycemia, infection, CNS problem). Increased (infection, environment to warm). | Decreased: Institute warming measures and check in 30 minutes. Check blood glucose. Increased: the excessive clothing.Check for dehydration. Decreased or increased: look for signs of infection. Check radiant warmer or incubator temperature setting. Check thermometer for accuracy if skin is warm or cool to touch. Report abnormal temperature to physician. | PulsesHeart rate 120 – 160 BPM. (100 sleeping, 180 crying). Rhythm regular. PMI at 3rd-4th intercostal space lateral to mid-clavicular line. Brachial, femoral, and pedal pulses present and equal bilaterally.