Passage / Scenario

A nurse is caring for a newborn immediately following birth.
NurseÔÇÖs Notes (0700 hrs):
ÔÇó The newborn is a male, born at 38 weeks gestation via vacuum-assisted vaginal birth. The mother has a history of positive group B streptococcus B-hemolytic and received two doses of ampicillin IV bolus during labor.
ÔÇó The newborn is placed under a radiant warmer.
ÔÇó Initial assessment shows the newborn is crying weakly.
ÔÇó The newbornÔÇÖs skin color is consistent with genetic background but has acrocyanosis.
ÔÇó Muscle tone is flaccid.
ÔÇó Reflex irritability is present with a weak cry.
ÔÇó The newbornÔÇÖs temperature is 36.3┬░C (97.4┬░F).
Vital Signs (0700 hrs):
ÔÇó Heart rate: 140/min
ÔÇó Respiratory rate: 60/min
ÔÇó Axillary temperature: 36.3┬░C (97.4┬░F)
ÔÇó Oxygen saturation: 92%

Laboratory Findings (0700 hrs):
ÔÇó WBC count: 15,000/mm┬│ (9,000 to 30,000/mm┬│)
ÔÇó Hgb: 19 g/dL (15 to 24 g/dL)
ÔÇó Hct: 57% (44 to 70%)
ÔÇó Blood glucose: 44 mg/dL (40 to 60 mg/dL)

Medications (0700 hrs):
ÔÇó Erythromycin ophthalmic ointment once 1 to 2 hr after birth
ÔÇó Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth
ÔÇó Phytonadione 1 mg IM once 1 to 2 hr after birth