Passage / Scenario

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Nurses' Notes
Term newborn birthed via spontaneous vaginal delivery at 39 weeks of gestation. Apgar 9/9 at 5-minute score. Breastfeeding 3 to 4 times per day. Newborn has voided once since birth and has not passed meconium stool since birth.
Physical Examination
ÔÇó Fontanels soft and flat
ÔÇó Head molded with caput succedaneum
ÔÇó Eyes symmetric, no discharge, sclera yellow
ÔÇó Mucous membranes dry
ÔÇó Abdomen soft and rounded, bowel sounds present x 4 quadrants
Vital Signs
ÔÇó Heart rate 154/min
ÔÇó Respiratory rate 44/min
ÔÇó Temperature 36.9┬░ C (98.4┬░ F)
Diagnostic Results
ÔÇó Coombs positive (negative)
ÔÇó Glucose 50 mg/dL (40 to 60 mg/dL)