Question

Newborn Assessment

As a postpartum nurse your patient is an LGA baby boy who was born at 37 weeks' gestation. He had Apgar scores of 8 and 9. He was circumcised. The mother is breast-feeding.

1. Describe what a normal head-to-toe assessment would be for an infant born at 37 weeks' gestation. What test is used to determine this gestational age? What is the scale used to determine the Apgar score, and are this baby’s scores normal?
2. As the discharging nurse, you are responsible for what screenings in an infant in the first 24 to 48 hours? What immunizations would be required?
3. What discharge instructions would be pertinent to this mother? How would you educate her or the family?
4. How would you document your discharge teaching? Write a sample narrative of your teaching.

Answer 1

A.The head to toe assessment of an infant are

• Anthropometric measurement :Height(45 _50 cm), weight(2.5 _3.5kg),head circumference (33_35cm), chest circumference (30_33cm)
• Appearance :Birth marks (moles,Mongolian spots),muscl tone,posture ,lanugo ,alert
• Vital signs with temperature, pulse ,respiration, BP and SPO2
• Head
  • Larger compared to chest, soft,flat fontanelle (anterior and posterior, assessment of suture),microcephaly ,macrocephaly
  • Eyes:no discharge ,PERLLA,white sclera,distance between two eyes,red reflex test
  • Ears:hearing test by otoacuostic emission test,ears should be at 1/3 angle of eye (should not be low),microtia
  • Nose:symmetric
  • Mouth:reflex present,no cleft lip or palate
• Neck:able to rotate completely
• Assess clavicle for any fracture
• Chest:nipple at same line,any gynecomastia ,movement,discharge,clear lung sounds,and heart sounds with no murmur and regular heart beat
• Abdomen :soft,non tender,presence of bowel sounds,peristalsis,cord is dry and clamped which has no bleeding,discharge or odour
• Limbs:no deformities ,clubbing, nails pink,unrestricted movement
• CNS:All reflexes present

The gestational age is determined by Ballard score or Ballard scale

The APGAR scale is used to assess the score of the child 0_10.A score of 8,9,10 is normal.This baby's reading is normal

B.The hearing screening of the baby should be dine in first 24 to 48 hours of life.In case if the baby looks jaundiced a bilirubin test is indicated ,usually it settles in a week with adewyre breast feeding and sunlight

BCG,OPV and Hepatitis B vaccone to be given at birth are before discharge

C.The discharge instruction should be as following

• Insisting about the benefits of breastfeeding for baby as well as mother.Every 2 hourly or strictly every 3 hourly
• Observe for urine and stool passage,diaper care
• Care of circumcision wound (apply ointment as per order,keep it dry and clean)
• The care of the umbilical cord (falls in 5 to 7 days)
• Baby bathing
• Sleeping position
• Abnormal signs and symptoms
• Teach about wrapping the baby to maintain temperature
• No external feeds like sugar water,honey ,etc.,

D.The documentation of the discharge teaching are

Mother of 37weeks LGA baby healed educated on breastfeeding, wound care,follow up,baby care

(Use of FDAR (Focus,Data,Action,Response ) is a best way to write a discharge teaching

Date and time	focus	Progress notes
5/06/19 :10:30am	Health education	The mother is capable of handling the baby and is able to demonstrate the basic procedure (diaper change, wrapping,positioning, breastfeeding techniques)