Hyperbilirubinemia
UNFOLDING Reasoning
Sarah Daniels, newborn infant
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
• Clinical Judgment
• Patient Education
• Communication
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% ✓
✓ Physiological Adaptation 11-17% ✓
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
, History of Present Problem:
Sarah Daniels was born six hours ago by vaginal delivery after 22 hours of labor at 36 weeks gestation because of
premature rupture of membranes. She weighed 9 lbs 0 ounces. (4090 g). Her Apgar was 8 at one minute and 9 at 5
minutes. Her newborn assessment revealed a cephalohematoma on the right-posterior aspect of her head. All other
assessment data is within normal limits. Sarah has breastfed once since birth for seven minutes. She is noted to be sleepy
when at the breast and not an aggressive feeder, consistent with her gestational age. She has voided once since birth, but
has not yet stooled.
Sarah’s mom Morgan was a diet-controlled gestational diabetic. Morgan’s prenatal labs are as follows: Blood type is
O +, GBS is negative, Hepatitis B is negative. Her prenatal course was unremarkable other than the premature rupture of
membranes.
Sarah’s blood type is A+. Blood sugars were obtained per protocol starting at two hours after birth and have been
consistently > 50 mg/dL. Her hematocrit was tested per protocol of a baby of a diabetic mother born before 37 weeks and
was 48% four hours after birth. Twelve hours after birth, her transcutaneous bilirubin level is 6.1 mg/dL.
Personal/Social History:
Morgan Daniels is a 22-year-old single mom who attends a local community college. The father of the baby is not
involved. Morgan lives with her parents, who are supportive and available.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
36 weeks gestation due to PROM
APGAR score was at 8 during 1minute and then 9 after 5mins The baby was born prematurely due to the mother history of
Cephalohematoma --> right-posterior of the infants head.
No stool or urine present after birth
diabetes
Mom has diabetes
RELEVANT Data from Social History: Clinical Significance:
Mother of the baby is a college Mother is a single parent in college. Father is not present.
student. She is dependent on her Mom will need a lot of support from parents and family
parents and the father is not involved. around her
Patient Care Begins:
Current VS: NIPS Pain Assessment:
T: 98.3 F/36.8 C (axillary) Facial Expression: Relaxed
P: 138 (regular) Cry: No cry
R: 54 (regular) Breathing Pattern: Relaxed
Legs: Relaxed
State of Arousal: Sleeping
NIPS Score: 0
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance:
None VS within the expected ranges
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
UNFOLDING Reasoning
Sarah Daniels, newborn infant
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
• Clinical Judgment
• Patient Education
• Communication
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% ✓
✓ Physiological Adaptation 11-17% ✓
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
, History of Present Problem:
Sarah Daniels was born six hours ago by vaginal delivery after 22 hours of labor at 36 weeks gestation because of
premature rupture of membranes. She weighed 9 lbs 0 ounces. (4090 g). Her Apgar was 8 at one minute and 9 at 5
minutes. Her newborn assessment revealed a cephalohematoma on the right-posterior aspect of her head. All other
assessment data is within normal limits. Sarah has breastfed once since birth for seven minutes. She is noted to be sleepy
when at the breast and not an aggressive feeder, consistent with her gestational age. She has voided once since birth, but
has not yet stooled.
Sarah’s mom Morgan was a diet-controlled gestational diabetic. Morgan’s prenatal labs are as follows: Blood type is
O +, GBS is negative, Hepatitis B is negative. Her prenatal course was unremarkable other than the premature rupture of
membranes.
Sarah’s blood type is A+. Blood sugars were obtained per protocol starting at two hours after birth and have been
consistently > 50 mg/dL. Her hematocrit was tested per protocol of a baby of a diabetic mother born before 37 weeks and
was 48% four hours after birth. Twelve hours after birth, her transcutaneous bilirubin level is 6.1 mg/dL.
Personal/Social History:
Morgan Daniels is a 22-year-old single mom who attends a local community college. The father of the baby is not
involved. Morgan lives with her parents, who are supportive and available.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
36 weeks gestation due to PROM
APGAR score was at 8 during 1minute and then 9 after 5mins The baby was born prematurely due to the mother history of
Cephalohematoma --> right-posterior of the infants head.
No stool or urine present after birth
diabetes
Mom has diabetes
RELEVANT Data from Social History: Clinical Significance:
Mother of the baby is a college Mother is a single parent in college. Father is not present.
student. She is dependent on her Mom will need a lot of support from parents and family
parents and the father is not involved. around her
Patient Care Begins:
Current VS: NIPS Pain Assessment:
T: 98.3 F/36.8 C (axillary) Facial Expression: Relaxed
P: 138 (regular) Cry: No cry
R: 54 (regular) Breathing Pattern: Relaxed
Legs: Relaxed
State of Arousal: Sleeping
NIPS Score: 0
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance:
None VS within the expected ranges
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
