Normal Newborn RAPID Reasoning, Baby Boy Jones, 1 hour old

Normal Newborn
RAPID 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
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% 

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, 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:

 Apgar score of 8 and 9  - The Apgar score shows a healthy newborn

 - Newborn was delivered at 39  - 39 weeks is the average gestational age
weeks
 - The newborn bowel is sterile and will require a
 - Newborn received vitamin K dose of vitamin K to initially synthesize it, as well as
and hepatitis B vaccine. Hepatitis B vaccine to prevent newborn from
contracting Hep B.
 - Mother has B- blood type
 - Mother should be given RhoGam 72 hours after
 - Mother is rubella positive birth if baby is Rh positive.

 - Ointment was given to  - Rubella vaccine should not administered.
newborn’s eyes
 - Ointment is administered to prevent eye infection
from G/C.

RELEVANT Data from Social History: Clinical Significance:

 - Anne’s social support is her  - Anne’s mother is a significant character in Anne’s
mother. life. She played a role in her pregnancy and plans on
being supportive in raising her grandchild.
 - Anne is experiencing her first
childbirth.  - Anne may be feeling anxious and overwhelmed.
Patient feelings will be assessed. She will be provided
 - Father figure is not present in education regarding anxiety and calming
mother’s life. mechanisms will be used.

 - Patient is 17 years old  - No father figure for support.

 - Mother may have trouble in school.