A nurse is caring for a newborn immediately following birth. Exhibit 1 Medical History Vacuum-assisted
A nurse is caring for a newborn immediately following birth. Exhibit 1 Medical History Vacuum-assisted vaginal birth Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor Exhibit 2 Vital Signs Apgar: Heart rate 96/min Weak cry Muscle tone: some flexion Reflex: grimace Color: acrocyanosis Axillary temperature 36.9° C (98.5° F) Exhibit 3 Medications Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth Phytonadione 1 mg IM once 1 to 2 hr after birth Exhibit 4 Laboratory Findings WBC count 15,000mm (9,000 to 30,000/mm) Hgb 19 g/dl (15 to 24 g/dL) HCt 57% (44% to 70%) Blood glucose 44 mg/dl (40 to 60 mg/dL) The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client’s condition is improving, or indication that the client’s condition is worsening A. Muscle tone flaccid B. Colour: Conistent with genetic background C. Heart rate 140 bpm D. Axillary temperature 36.9 degree
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