Owen Harding
Owen Harding is a newborn male who was born about 15 minutes ago at 39 weeks via vacuum-assisted vaginal
delivery. Mother is Gravida 1, Para 1, and blood type O, Rh+. Newborn cord blood sample sent to the lab.
APGAR at 1 minute=8 (Acrocyanosis, Heart Rate 120/min, some flexion of extremities, strong cry, prompt
response to stimulation)
APGAR at 5 minutes=9 (Acrocyanosis, Heart Rate 122/min, well flexed extremities, strong cry, prompt response
to stimulation).
Oxygen saturation is 99% on room air.
Caput Succedaneum and cephalhematoma noted to the right side of the head.
Delayed cord clamping for 5 minutes. Skin to skin immediately after birth. Mother states that she plans to
breastfeed.
After receiving handoff report, the nurse should determine the newborn's priority needs. Indicate if the
newborn is a high priority or low priority using each of the priority frameworks below.
, Safety and Risk Reduction
Your response:
© High priority
You correctly selected 4 of the 5 responses.
Your response is correct.
Maslow’'s Hierarchy of Needs
Rationale:
Your response: The nurse should identify that this newborn is a high priority when using the Safety and Risk Reduction framework to organ
© High priority care. The newborn is at high risk for safety concerns due to his developmental age. The newborn is also at risk due to the
vacuum-assisted vaginal delivery and findings of cephalhematoma.
Your response is correct.
Rationale: Urgent vs nonurgent
The nurse should identify that this newborn is a high priority when using Maslow’s Hierarchy of Needs framework to organize client
Your response:
care. The newborn is in a critical time of transition to extrauterine life and is completely dependent on others for all physical needs. X Low priority
This newborn has some additional physiologic risk factors due to the vacuum-assisted vaginal birth and findings of
cephalhematoma. The major nursing focus during this stage is to assess and support the newborn’s airway and breathing efforts
while promoting warmth to prevent cold stress. Your response is incorrect.
Rationale:
The nurse should identify that this newborn is a high priority when using the Urgent versus Nonurgent framework to organi
Airway, Breathing, Circulation care. The newborns initial APGAR scores indicate that the newborn is having minimal difficulty with transition to extrauterin
however there are urgent needs including timed assessments, treatments, and procedures that need to occur over the cou
Your response: next hour.
© Low priority
Chronic vs Acute / Stable vs Unstable
Your response is correct.
Rationale: Your response:
© Low priority
The nurse should identify that this newborn is a low priority when using the Airway, Breathing, Circulation framework to organize
client care. The newborn is displaying acrocyanosis, which is a common finding in the initial newborn stage, however it is related to
circulation. Additionally, the newborn is at risk as he is in the immediate stage of transition from fetal to neonatal circulation and Your response is correct.
should be monitored closely for any alterations in airway, breathing, or circulation. Rationale:
The nurse should identify that this newborn is a low priority when using the Chronic vs Acute / Stable vs Unstable framewor
organize client care. The newborn is not displaying any clinical manifestations that they are unstable at this time; however,
have manifestations of an acute condition (cephalhematoma) that requires additional monitoring to assure that the finding
progresses as expected.
Owen Harding is a newborn male who was born about 15 minutes ago at 39 weeks via vacuum-assisted vaginal
delivery. Mother is Gravida 1, Para 1, and blood type O, Rh+. Newborn cord blood sample sent to the lab.
APGAR at 1 minute=8 (Acrocyanosis, Heart Rate 120/min, some flexion of extremities, strong cry, prompt
response to stimulation)
APGAR at 5 minutes=9 (Acrocyanosis, Heart Rate 122/min, well flexed extremities, strong cry, prompt response
to stimulation).
Oxygen saturation is 99% on room air.
Caput Succedaneum and cephalhematoma noted to the right side of the head.
Delayed cord clamping for 5 minutes. Skin to skin immediately after birth. Mother states that she plans to
breastfeed.
After receiving handoff report, the nurse should determine the newborn's priority needs. Indicate if the
newborn is a high priority or low priority using each of the priority frameworks below.
, Safety and Risk Reduction
Your response:
© High priority
You correctly selected 4 of the 5 responses.
Your response is correct.
Maslow’'s Hierarchy of Needs
Rationale:
Your response: The nurse should identify that this newborn is a high priority when using the Safety and Risk Reduction framework to organ
© High priority care. The newborn is at high risk for safety concerns due to his developmental age. The newborn is also at risk due to the
vacuum-assisted vaginal delivery and findings of cephalhematoma.
Your response is correct.
Rationale: Urgent vs nonurgent
The nurse should identify that this newborn is a high priority when using Maslow’s Hierarchy of Needs framework to organize client
Your response:
care. The newborn is in a critical time of transition to extrauterine life and is completely dependent on others for all physical needs. X Low priority
This newborn has some additional physiologic risk factors due to the vacuum-assisted vaginal birth and findings of
cephalhematoma. The major nursing focus during this stage is to assess and support the newborn’s airway and breathing efforts
while promoting warmth to prevent cold stress. Your response is incorrect.
Rationale:
The nurse should identify that this newborn is a high priority when using the Urgent versus Nonurgent framework to organi
Airway, Breathing, Circulation care. The newborns initial APGAR scores indicate that the newborn is having minimal difficulty with transition to extrauterin
however there are urgent needs including timed assessments, treatments, and procedures that need to occur over the cou
Your response: next hour.
© Low priority
Chronic vs Acute / Stable vs Unstable
Your response is correct.
Rationale: Your response:
© Low priority
The nurse should identify that this newborn is a low priority when using the Airway, Breathing, Circulation framework to organize
client care. The newborn is displaying acrocyanosis, which is a common finding in the initial newborn stage, however it is related to
circulation. Additionally, the newborn is at risk as he is in the immediate stage of transition from fetal to neonatal circulation and Your response is correct.
should be monitored closely for any alterations in airway, breathing, or circulation. Rationale:
The nurse should identify that this newborn is a low priority when using the Chronic vs Acute / Stable vs Unstable framewor
organize client care. The newborn is not displaying any clinical manifestations that they are unstable at this time; however,
have manifestations of an acute condition (cephalhematoma) that requires additional monitoring to assure that the finding
progresses as expected.
