QUESTIONS & DETAILED CORRECT
ANSWERS LATEST UPDATE
Door way entry info - Correct Answer ✔✔ Your patient today is Olivia Bailey, a four-day-
old female. Olivia is brought to her health care provider's office today for her well-baby
visit by her mother. According to her mom, Olivia has been nursing poorly and has been
very fussy.
Once you have reviewed the electronic health record, you will need to perform a full
comprehensive
Orders (Health Care Provider) - Correct Answer ✔✔ Physician/Unit: Dr. Arnold/Kaplan
Pediatric Clinic.
Diagnosis: Well-baby visit
Condition: Stable.
Code Status: Full.
Vitals: Once.
Allergies: No Known.
Medications: Dr. Arnold will be in shortly.
Admitting Notes (Health Care
Provider) - Correct Answer ✔✔ Reason for Encounter: Well-baby visit.
HPI: Olivia Bailey, a four-day-old female infant, is brought to her health care provider's
office today for her well-baby visit by her mother. According to her mom, Olivia has
been nursing poorly and has been very fussy.
Other Concerns: None.
Med surg: • Medical history: None.
Surgical history: None.
Hospitalizations: Birth only.
Medications: Vitamin D3 400 IU PO once daily.
Allergies: No known.
FH: • Grandparents: Paternal grandfather is 54 years old with a history of high
cholesterol and elevated blood pressure. Maternal grandparents are both 55-years-old
and paternal grandmother is 53 years old; no known medical problems with these three
individuals.
Mother: 28 years old and is healthy.
Father: 27 years old and is healthy.
Siblings: None.
SH: • Employment: Mom and dad both work full-time. Mother is on maternity leave for
ten weeks.
Home environment: Lives with her mother and father. No second-hand smoke
exposure. The family has a pet dog.
, Diet: Exclusively breastfed and takes a vitamin D3 supplement.
Preventive Health:
Universal newborn screening: No evidence of disorders.
Hearing screening: Within normal limits.
Eye prophylaxis: 1 cm of Erythromycin ophthalmic ointment 0.5% placed in
theconjunctival sac of each eye at 1.5 hours old.
Vitamin K prophylaxis: 1 mg IM given at three hours old.
Pulse oximetry to screen for congenital heart disease: Sp02 at 24-hours oldwas 97%
on room air on both upper and lower extremities.
Hep B. Vaccine: Given IM at ten hours old.
Progress Notes (Health Care
Provider) - Correct Answer ✔✔ Olivia Bailey was a 39-week and three-day full-term
female born via spontaneous vaginal delivery at Kaplan Hospital. Labor was without
complications. Her mother began having contractions at home for about five hours
before her membranes ruptured and then she went into the hospital. She delivered five
hours later. Olivia cried immediately, weighed 6 pounds 13 ounces, and Apgar Scores
were 9 at one minute and 10 at five minutes. There were no abnormalities noted at
birth. She and her mom are ready for discharge and an appointment was made with her
pediatrician for her four-day-old well-baby visit.
Mother's obstetric history:
Olivia's mother was 28 years old when she was delivered. She received prenatal care
throughout the pregnancy and had no antenatal complications. She gained 20 pounds
throughout her pregnancy. During the pregnancy, she took prenatal vitamins daily only.
She did not use alcohol, tobacco, or illicit drugs. She has had no other pregnancies.
Prenatal Labs:
Blood Type: 0.
Rh: Positive.
Antibody: Negative.
Hepatitis B: Negative.
Rubella status: Immune.
RPR: Nonreactive.
GC: Negative.
Chlamydia: Negative.
GBS Status: Negative.
Infant Medical History:
Allergies: No known.
Diet: She is exclusively breastfed and takes a Vitamin D3 supplement.
Universal newborn screening: No evidence of disorders.
Hearing screening: Within normal limits.
Eye prophylaxis: 1 cm of Erythromycin ophthalmic ointment 0.5% placed in the
Nurses notes - Correct Answer ✔✔ Age: Four days old.
Form completed by: Layla Bailey.
Relationship to patient: Mom.