Time Vital Signs Nurses Notes Diagnostic Results Med…
Time Vital Signs Nurses Notes Diagnostic Results Medical History 0800: Ax temp 36.1° C (97.0° F) Heart rate 160/min Respiratory rate 82 /min O2 sat 95% Newborn placed on radiant warmer. Color consistent with newborn’s genetic background. Acrocyanosis present. Mild grunting, nasal flaring and intermittent retractions noted. 38-week gestation Emergency cesarean birth non-reassuring fetal heart rate. Apgar 6 at 1 min, 8 at 5 min Positive pressure ventilation given for 2 min followed by free-flow oxygen and tactile stimulation, bulb suction with scant amount of clear fluid noted. 0830: Axillary temperature 36° C (96.8° F) Heart rate 156/min Respiratory rate 88/min O2 sat 96% Grunting, nasal flaring, and sternal retractions noted. Color consistent with newborn’s genetic background. Acrocyanosis present. Hemoglobin: 14 g/dL (14 to 24 g/dL) Hematocrit: 40% (44% to 64%) Platelets: 290,000/mm3 (150,000 to 300,000/mm3) White Blood Cell count: 9,000/mm3 (9,000 to 30,000/mm3) Serum glucose: 35 mg/dL (above 40 mg/dL) 0900: Axillary temperature 36° C (96.8° F) Heart rate 156/min Respiratory rate 88/min O2 sat 96% A nurse is caring for a newborn 2 hours following birth. Which priority findings should the nurse report to the provider from the above assessment cues? Select all that apply.
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