Normal Newborn UNFOLDING Reasoning Case study

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 Case Category/Subcategory 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% ✓ • Physiological Adaptation 11-17% ✓ This study source was downloaded by 100000780339733 from CourseHero.com on 05-14-2022 23:06:29 GMT -05:00 https://www.coursehero.com/file/59116290/Normal-Newborn-Case-Study-Saturdaydocx/ 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: -Normal spontaneous delivery reported -There really isn’t anything of clinical significance -No pain medications used here, perhaps because everything appears as either an -Apgar’s of 8 & 9 expected finding and/or appropriate intervention and -Baby voided procedure. -All vaccines given to baby RELEVANT Data from Social History: -Patient’s mother is present as a support system— patient still lives at home with her -Baby’s father will not be involved -Patient plans on breastfeeding (for undetermined amount of time) -She is holding and interacting with baby Clinical Significance: -It appears that the patient is doing well at this point in time. She is interacting with her baby and wants to breast feed. She has a solid support system, which is important due to her young age. Patient Care Begins: You complete your assessment: Current VS: P-Q-R-S-T Pain Assessment: T: 97.0 F/36.1 C (axillary) Provoking/Palliative: P: 130 (regular) Quality: R: 50 (irregular) Region/Radiation: BP: none taken Severity: NIPS score 0 O2 sat: pink in color/no Timing: central cyanosis noted What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)