46. Users can log “Meds Brought In” from the Quick
Sarah works in the labor and delivery unit as a transition nurse. Her department has instituted a new bedside transition period where newborns make the transition to extrauterine life in their mother’s recovery room about an hour after birth. Sarah’s next assignment is a new baby boy with Apgar scores of 8 and 9, born by cesarean about 1 hour ago to Lindsay, a 28-year-old G1. Sarah’s assessment findings of the new baby boy are: Vital signs: axillary temperature 37.0°C, heart rate 145 per minute, respiratory rate 75 per minute Observations: color pink, respirations rapid and unlabored, good muscle tone, good arm and leg movement Auscultation: breath sounds clear and equal bilaterally, strong heart sounds with a soft murmur, active bowel sounds in all four quadrants Physical assessment: fontanels soft and flat, eyes clear with red reflex in both, ears normal shape and placement, soft and hard palate intact, strong suck, both nares patent, capillary refill less than 2 seconds, both testes descended Measurements: weight 8 lb 6 oz, length 20 in, head circumference 36.2 cm, chest circumference 36.0 cm As Sarah is charting her findings, Lindsay asks Sarah if everything is OK with her baby. Which assessment findings for this newborn are abnormal? What is the most likely cause of these abnormal findings? How would Sarah explain these abnormal findings to Lindsay? Describe the nursing interventions that Sarah would implement based on these findings.
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