Normal Newborn UNFOLDING Reasoning (Baby Boy Jones, 1 hour old)

Primary Concept Reproduction Interrelated Concepts (In order of emphasis) Thermoregulation Nutrition Perfusion Pain Clinical Judgment Patient Education Communication Collaboration NCLEX Client Need Categories Percentage of Items from Each Covered in Category/Subcategory Case Study Safe and Effective Care Environment • Management of Care 17-23% ✓ • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity • Basic Care and Comfort 6-12% ✓ • Pharmacological and Parenteral Therapies 12-18% ✓ • Reduction of Risk Potential 9-15% ✓ Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. • Physiological Adaptation 11-17% ✓ History of Present Problem One hour after Delivery: Anne is a 17-year-old, gravida 1 para 1 who is 39 weeks gestation. She recently experienced a normal spontaneous vaginal delivery without the use of pain medications or an epidural. She delivered a baby boy who was placed skin to skin following delivery. You assign Apgars of 8 and 9. Baby voided right after delivery. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. After he had his first feeding, erythromycin ointment was applied to his eyes. Vitamin K and hepatitis B vaccine (after consent given) were administered in right and left thigh in the outer aspect of the left thigh. Ann is Group Beta Strep (GBS) positive and received antibiotics at 36 weeks and 3 doses before delivery, blood type is B-, and rubella positive. Cord blood was sent. Personal/Social History: Anne has her mother with her for support. She seems to be tired but is holding and interacting with the baby appropriately. The father of the baby is not involved. Anne plans on breastfeeding for “awhile.” Anne still lives at home, and her mother plans to help with the new baby and appears supportive. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Report: Clinical Significance: - Mom is 17 years of age - Teen mom so education should be provided as well as social - G1P1 - First baby so lots of info and teaching might be needed - Gave birth at 39 weeks gestation - Full term baby = should be a normal healthy baby - Apgars score of 8 and 9 - This score falls on the normal healthy side - Gave erythromycin on eyes - prevent bacterial infections or STI’s that can be passed from mom - Weighs 7lbs 20 inches - this is considered a normal size healthy baby - Mom is positive for rubella - mom has antibodies and is immune to rubella - Vit K and hep B vaccine given - this helps prevent blood clots and hep b is for protecting baby from - GBS positive hep b - baby temp should be monitored since mom is GBS pos RELEVANT Data from Social History: Clinical Significance: - has her mother for support