NORMAL NEWBORN UNFOLDING REASONING CASE STUDY

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 -No pain medications used -Apgar’s of 8 & 9 -Baby voided -All vaccines given to baby -There really isn’t anything of clinical significance here, perhaps because everything appears as either an expected finding and/or appropriate intervention and procedure. RELEVANT Data from Social History: Clinical Significance: -Patient’s mother is present as a support system— patient still lives at home with her -Baby’s father will not be involved -Patient plans on breastfeeding (for undetermined amount of time) -She is holding and interacting with baby -It appears that the patient is doing well at this point in time. She is interacting with her baby and wants to breast feed. She has a solid support system, which is important due to her young age. 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 central cyanosis noted Timing: 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: -Temperature of 97.0 -Baby’s temp is lower than we’d like to see and he his respiratory rate is on the high end of acceptable range so it’s something I’m going to want to keep an eye on. But all other -RR of 50/irregular clinical findings are as expected, and he’s onl