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A nurse is assisting in the care of a newborn. A nurse is assisting in the care of a newborn. Nurses’ Notes 8hr following birth: Newborn is awake, alert, and active. Oral mucosa pink. Respirations easy and unlabored. Extremities flexed. Good muscle tone. Breastfed vigorously two times for 30 to 40 min. Fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Voided. Passed meconium stool. 36hr following birth: Infant lethargic with hypotonia. Yellow discoloration noted of sclera and oral mucosa. Respirations rapid with intercostal retractions. Extremities extended. Decreased muscle tone. Difficult to arouse for feedings. Breastfed once in the past 6hr for 10 min. Fontanel level and soft. Large ecchymotic caput succedaneum noted. Has voided and stooled only once since birth. For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis. Each finding may support more than one disease process.
SCIENCE
HEALTH SCIENCE
NURSING

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