You are assigned to the mother-baby couplet unit. Your assignment for the day includes the
Sanchez family. Margarite is 28-year-old G3P2 Hispanic woman who gave birth to a healthy boy,
Manuel, at 0839. Margarite experienced an uncomplicated labor of 12 hours. Membranes
ruptured 7 hours before delivery. She received 2 doses of nalbuphine (Nubain) during labor.
The last dose was given at 0440.
Manuel weighs 4800 grams and is 50 cm in length. His 1 and 5-minute Apgar scores were 8 and
9. Manuel is 2 hours old. The Ballard score indicates that Manuel is 39 weeks. Margarite
attempted to breastfeed her son for 5 minutes on each breast immediately after the
birth.
Your initial postpartum shift assessment findings are:
• Vital signs: oral temperature 98.9, apical pulse 80, respirations 22, BP 110/62
• Alert oriented x 4
• Lungs clear in all lung fields
• S1S2 present, regular rate
• B=lactating: soft non-tender
• U= Fundus firm at Umbilicus midline
• B= voided 150 ml clear yellow urine
• B=Abd soft/nontender, bowel sounds active x 4, passing flatus, no BM since delivery
• L=Small rubra lochia, no clots
• E= Perineum intact
• E= No edema to extremities and pedal pulses 2+
• E= Mom holding newborn lovingly
Your initial newborn shift assessment findings are:
• Manuel is in a sleepy state and unresponsive to external stimuli
• Vital signs: axillary temperature 97.1, apical pulse 160, respirations 30
• Skin is warm and pink with acrocyanosis
• Fontanels are soft and flat, Molding is present
• Lung sounds are clear in all lung fields, mild nasal flaring
• S1S2 present, no murmurs, regular rate
• Abd soft/nontender, bowel sounds active x 4, no BM since delivery
• No void since delivery, testes descending
• Femoral pulses bilateral strong 2+
• Spine straight, intact, no openings
Newborn Questions
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