Scenario Title
Patient Name
Medical Record #
Level (year 1, last
term)
Author , w/email
Keywords - Theory
Keywords - Skills
Patient
Case
History:
Medical
history:
Allergies:
Healthy Newborn assessment
Emma Berry (Mother – Hally Berry)
DOB:
NUR 112
Course:
Age:
Maureen Harter, RN, BSN (assist Marilyn McGuire-Sessions, RN, MSN)
Newborn - Respiratory, GI, Thermo regulation, Cardiovascular
New born assessment,
Emma is a healthy baby girl, weighing 7 lb, 2 oz, born to Halle Berry 30 minutes
ago. Apgar scores of 8 at 1 minute and 9 at 5 minutes.
Height:
NKA
50
cm
Weight:
7 lb 2 oz
Meds:
VS:
BP
Labs:
70/55
HR
140
RR
34
T
37.2
SpO2
95%
Pre Printed Orders – All listed Orders are in Effect Unless Crossed Out.
Exceptions: Orders Preceded by a ___ require an (X) to initiate
Physician Orders: ( Dr. Michael Hogan ) for Emma Berry
Allergies NKA
1. Admit as inpatient and notify provider of maternal or newborn risk factors or abnormal
findings.
2. Place infant in warmer crib as needed. To open crib when stable
3. Vitals: Note and record: B/P, T,P,R on initial exam. Check T,P,R every 30 minutes X 4,
every 1 hour X 4, then every 4 hours. If Axillary Temp > 99.5, then recheck Rectal Temp.
4. Provide thermoregulation method to maintain temperature 97.8 - 99.5 degree Fahrenheit
axillary
5. Nursing:
Head Circumference and Weight at Birth
Weigh daily
Bulb syringe suction prn
__Continuous pulse oximetry parameters< 92%
__Monitor in Nursery
__CR Monitor parameters: P>200 or < 80, RR>70 or<70, apnea > 20 s
__Strict I’s + O’s
6. Diet: Feedings on demand, every 2-4 hrs. If formula feeding, use house formula.
__NPO
__Other Formula instead of house formula
7. ___IVF If patient < 24 hours, start D 10 W at __________________________________
If patient > 24 hours, start D10W ¼ NS at _____________________________
__IV to heplock, flush per routine
8. Medications:
A. Treat cord with triple dye after first bath unless mother is Rh neg or O+. Then
treat cord after cord blood work up results are reported and coombs is negative,
or after 24 hours of age. Treat cord daily
B. Admission medications within one hour of birth
1) Phytonadione ( Vitamin K ) 1mg IM
2) Erythromycin ophthalmic ointment 0.5% 1.5-2.0cm ribbon O.U.
C. ____If maternal HbsAg status is positive, give concurrently in separate sites by
12 hrs of age:
1) Hepatitis B immune Globulin 0.5 ml IM
2) Hepatitis B virus vaccine 0.5 ml IM
D. ____If maternal HbsAg status is unknown, Give Hepatitis B virus vaccine 0.5 ml
IM by 12 hrs.
E. Newborn Pain:
___24% Sucrose 0.5 ml/ kg PO 2 mins prior to painful procedure
___Circumcision
___Blood draws ( except glucose monitoring)
___injections
(Maximum 6 doses in 24 hours without further written order from physician)
___Acetaminophen (Tylenol) Infant drops 10mg/kg P.O prior to circumcision
F. ___Ampicillin (<7 days of age and > 2kg) 50mg/kg IV Q8 hours or ___________
G. ___Cefotaxime (<7 days of age and > 2kg) 50mg/kg IV Q8 hours or __________
H. ___Acyclovir (preterm) 10mg/kg IV Q 8 hours or _________________________
I. ___Oxygen by Hood or NC to keep O2 sats > 92%
9. Call MD Orders: Temp> 100.5 rectal, Temp< 97.6 Rectal; HR. 200, HR < 80; RR > 70m
RR < 20, Weight > 10% down from Birth Weight pulse ox < 92%, or other concerns.
Notify physician if no voiding or stool in 24 hours of if bloody stool passed
Initial Computer Set Up EMMA BERRY
VS:
BP
Lungs:
Heart:
Ectopy:
Other:
Report to
68/56
Lt: clear
HR
142
RR
Rt: Clear
36
T
37.2
Bowel
sounds
SpO2
normal
Rhythm:
Waiting:
“
Emma’s apgar scores were 8 at 1 minute and 9 at 5 minutes. Emma was
start
scenario:
delivered about 30 minutes ago. The nurse that was with them during delivery
needs to assist the doctor in the episiotomy so you will be responsible for the care
of the infant. The nurse has given the Vitamin K, and has done the cord care, but
the ophthalmic ointment needs to be given within an hour of birth. No IV antibiotics
needed because membranes were beta strep negative.
“
Priorities (in order)
Assessment
SN Interventions
1-Assess for obvious
problems first.
-Talks to mother about what is
being done and teaches the
mother during the
assessment
Assessment continued
EMMA BERRY Assessment
con’t
Assessment continued
-Take Axillary temp (36.537.5C or 97.7-99.5 F); explain
the importance of keeping the
baby warm with blanket
wrapped around snugly, hat
on, baby not in drafty area,
room kept warm. Teach how
to take temperature and what
the normal temp is
-check heart rate, (120-160)
PMI, brachial, femoral, and
pedal pulses present
-respirations ( 30-60)
Yes the babies chest
movement symmetric, breath
sounds present and clear
bilaterally
- Head – fontanels, soft
Spots show mother can rub
head is OK, fontanels are
good indicator of infants
condition. Anterior fontanel
may swell when newborn
cries or passes a stool or may
pulsate with the heart beat
which is normal. A bulging
fontanels signifies increased
intracranial pressure, and
depressed indicates
dehydration.
Weight baby, SN explains the
importance of not letting baby
lose more than 10% of its
Patient Responses
The patient voice is the mother
asking questions about her
newborn
What are you doing? Is my
baby ok.
Is she breathing OK
Is the babies head OK, don’t
you have to be careful of the
soft spots.
Why are you doing all these
measurements?
body weight. Will talk about
breast feeding and have
infant breast feed after babies
assessment
Measure length
Measure head circumference
( approx ¼ of infants length
13-14 in)
Measure chest circumference
(12-13 in, approx 2-3 cm less
than head circumference)
Assessment continued
SN replies that breast feeding
is learned and she and the
other nurses will work with her
Assessment continued
-Skin, pink with good skin
turgor, vernix caseosa in
creases. Tells mother what
she is looking for.
Assessment continued
For EMMA BERRY
-Posture flexed extremities
that resist extension, and
return quickly to flexed state.
Hands are usually clenched.
Movements symmetric
-Face (symmetry, facial
features) Assess ears to be
well formed. Eyes clear, tears,
pupils, following of objects.
Mouth gums and tongue pink,
sucking rooting, swallowing
and gag reflexes present. SN
talks to mom about routing
and sucking in preparation for
breast feeding.
Assessment continued SN
shows mom how to properly
use bulb syringe
(turn
infants head to side,
compress bulb before
insertion, insert into the side
of the mouth, suction the nose
only if necessary) educate
mother on cleaning the bulb
This is my first baby, I have
never breast fed before, and I
hope the baby will be able to
get enough to eat.
Do you think Emma is hungry?
Looks
like
Emma
has
something in her mouth she
sounds a little stuffed up
syringe with water.
Assessment continued
-Neck and Clavicles (ability to
turn head from side to side)
-Cord ( 3 vessels)
-All extremities examined for
signs of fractures, redness,
lumps etc.
Assessment continued
Discussion of labia, that the
labia may be a little swollen,
may
have
some
white
discharge or may have a little
vaginal bleeding. That this is
all normal.
Teaches in girls
to always wipe from front to
back. Bowel movements will
start out dark and tarry
Assess and clean umbilical
cord. Cleans umbilical cord
with triple dye per MD order.
-Hands and feet
-Hips (Bend knees and hips at
90 degree angle, a hip click
may be felt or heard but is
usually normal) (Barlow test
adduct hips, apply gentle
pressure down and back in
hip dysplasia examiner can
feel femoral head move out of
acetabulum)
-Legs – (extend legs to
determine if equal in length)
Preparation to give ordered
medication
Applies
Erythromycin
ophthalmic ointment per MD
order
Faculty Notes (theory, medications, etc.) FOR EMMA BERRY
1. Vitamin K – Promotes the formation of factors II (prothrombin), VII, IX, and X by the liver for clotting.
Indicated for the prevention or treatment of hemorrhagic disease of the newborn. .5 to 1mg (0.25 to
.5ml) given once intramuscularly within 1 hour of birth for prophylaxis. ( The lower dose may be
used for small infants weighing less than 2500 g)
( Potential adverse reaction – pain and edema at the site of administration)
2. Erythromycin Ophthalmic ointment – Prophylaxis against gonorrhea and Chlamydia. (Prophylaxis
against gonorrhea is required by law for all infants, regardless of whether the mother is known to be
infected.
3. Hepatitis B vaccine given IM, Induration, erythema, and swelling at injection site most common
reaction
4.
Heel stick for PKU – Phenylketonuria – disorder caused by a missing or decreased enzyme call
phenylalanine hydroxylase. Phenylalanine is not properly processed by the body. When there is
too much phenylalanine in the diet the substances that build up in the blood can gradually cause
brain damage. Babies with PKU are normal at birth; if phenylalanine is not restricted the damage is
gradual with the IQ dropping 4 points per month. If untreated for a year the baby has lost almost 50
IQ points, resulting in severe mental retardation.
Debrief Priorities (facts, feelings, behaviors, priorities, noticing, interpreting, responding,
evaluating and reflecting-what went well, what would you do differently) FOR EMMA BERRY
1. Teaching of parent
 Temperature – importance of maintaining, whats normal
 dehydration as shown in sunken fontanel,
 use of cry for communication,
 skin conditions,
 reflexes
 nutritional needs ( every 2-3 hours)
 expectations of stool characteristics, and changes.
2. Breast feeding, how does mom know baby is getting enough milk
3. Injections, giving all at the same time ( including Hep B even though it is not due)
4. Heel stick for PKU
5. Hearing test
6. injections in infant – size of needle and max volume (needle size 25g, 5/8” needle, max
volume in vastus lateralus .5cc in preme or neonate, 1 ml in infant.
Possible Increased Complexities for this scenario:
1.
References:
1.
Suggestions for Future Advanced Scenarios:
1.