Normal Newborn
UNFOLDING Reasoning
Baby Boy Jones, 1 hour old
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.
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Report: Clinical Significance:
Normal Spontaneous vag delivery Important for follow up care and creating plan for care
No pain meds/epidural Need to know for recovery and continued meds
Skin to Skin after delivery Shows bonding started right after birth
Apgar 8 and 9 WNL Apgar scores speak to heath of baby and gives baseline
Baby voided after delivery for comparison for future assessments
7lbs 20 in Shows baby urinary system working
Had first feeding Size of baby WNL
Eye ointment, vaccine given Feeding shows that baby is rooting and hungry WNL
GBS + mom: antibiotics given Appropriate meds/vx for after birth for baby
Mom B-, rubella + Antibiotic status for GBS is important to prevent infection in
Cord blood sent baby
Rh – could be interaction with baby, mom should have been
given injection
Important documentation for chart
RELEVANT Data from Social History: Clinical Significance:
Mother for support Shows mother’s support system
Baby daddy not involved Shows involvement and identifies decision making as mother
Mom tired but interacting w/ baby only
Planning to breastfeed ‘awhile’ Interacting with baby is appropriate response and shows
Lives at home w/mom bonding and attachment
Identification of feeding for baby, also ‘awhile’ can be identified
as educational opportunity and connection with support group
for mom
Mom does not live alone and has her mother as live in help
and support
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?
RELEVANT VS Data: Clinical Significance:
T 97.0 Low Temp low identifies intervention focus. Temp is major transition point for newborn
P 130, R 50 in that they have to self-regulate temp. Early intervention is important
WNL Pulse and RR WNL
Pink color, Acrocyanosis in hands and feet is a normal finding after birth but important to
acrocyanosis monitor for prompt resolution to identify possible circulatory issues early
noted No pain noted for baby
NIPS 0 Baseline assessment helps for comparison for future assessments
Current Assessment:
GENERAL Calm, quiet, and in a crib next to the bed.
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
UNFOLDING Reasoning
Baby Boy Jones, 1 hour old
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.
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Report: Clinical Significance:
Normal Spontaneous vag delivery Important for follow up care and creating plan for care
No pain meds/epidural Need to know for recovery and continued meds
Skin to Skin after delivery Shows bonding started right after birth
Apgar 8 and 9 WNL Apgar scores speak to heath of baby and gives baseline
Baby voided after delivery for comparison for future assessments
7lbs 20 in Shows baby urinary system working
Had first feeding Size of baby WNL
Eye ointment, vaccine given Feeding shows that baby is rooting and hungry WNL
GBS + mom: antibiotics given Appropriate meds/vx for after birth for baby
Mom B-, rubella + Antibiotic status for GBS is important to prevent infection in
Cord blood sent baby
Rh – could be interaction with baby, mom should have been
given injection
Important documentation for chart
RELEVANT Data from Social History: Clinical Significance:
Mother for support Shows mother’s support system
Baby daddy not involved Shows involvement and identifies decision making as mother
Mom tired but interacting w/ baby only
Planning to breastfeed ‘awhile’ Interacting with baby is appropriate response and shows
Lives at home w/mom bonding and attachment
Identification of feeding for baby, also ‘awhile’ can be identified
as educational opportunity and connection with support group
for mom
Mom does not live alone and has her mother as live in help
and support
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?
RELEVANT VS Data: Clinical Significance:
T 97.0 Low Temp low identifies intervention focus. Temp is major transition point for newborn
P 130, R 50 in that they have to self-regulate temp. Early intervention is important
WNL Pulse and RR WNL
Pink color, Acrocyanosis in hands and feet is a normal finding after birth but important to
acrocyanosis monitor for prompt resolution to identify possible circulatory issues early
noted No pain noted for baby
NIPS 0 Baseline assessment helps for comparison for future assessments
Current Assessment:
GENERAL Calm, quiet, and in a crib next to the bed.
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
