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 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 100000831525611 from CourseHero.com on 02-02-2022 11:55:21 GMT -06:00
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: Clinical Significance:
-Patient’s mother is present as a support system— -It appears that the patient is doing well at this point in
patient still lives at home with her time. She is interacting with her baby and wants to
-Baby’s father will not be involved breast feed. She has a solid support system, which is
-Patient plans on breastfeeding (for undetermined important due to her young age.
amount of time)
-She is holding and interacting with baby
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)
RELEVANT VS Clinical Significance:
Data:
-Temperature of -Baby’s temp is lower than we’d like to see and he his respiratory rate is on the high end
97.0 of acceptable range so it’s something I’m going to want to keep an eye on. But all other
This study source was downloaded by 100000831525611 from CourseHero.com on 02-02-2022 11:55:21 GMT -06:00
https://www.coursehero.com/file/59116290/Normal-Newborn-Case-Study-Saturdaydocx/
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 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 100000831525611 from CourseHero.com on 02-02-2022 11:55:21 GMT -06:00
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: Clinical Significance:
-Patient’s mother is present as a support system— -It appears that the patient is doing well at this point in
patient still lives at home with her time. She is interacting with her baby and wants to
-Baby’s father will not be involved breast feed. She has a solid support system, which is
-Patient plans on breastfeeding (for undetermined important due to her young age.
amount of time)
-She is holding and interacting with baby
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)
RELEVANT VS Clinical Significance:
Data:
-Temperature of -Baby’s temp is lower than we’d like to see and he his respiratory rate is on the high end
97.0 of acceptable range so it’s something I’m going to want to keep an eye on. But all other
This study source was downloaded by 100000831525611 from CourseHero.com on 02-02-2022 11:55:21 GMT -06:00
https://www.coursehero.com/file/59116290/Normal-Newborn-Case-Study-Saturdaydocx/
