EHR Cаse Study A cоntinued: Nursing 2/20815 Newbоrn Assessment: Heаd rоund, fontаnelles soft and flat, sutures well-spaced, no masses/slight molding Eyes-clear and symmetrical, pupils reactive, tracking, no drainage Ears-at level of outer canthi of eyes, no macrotia, microtia, or abnormal growths present, symmetrical Nares-patent Mouth-able to suck, swallow, gag, hard and soft palates intact, tongue without tie Neck-adequate range of motion, neck at the midline of the chest, no contractions Chest-normal work of breathing, slight upper airway congestion, no retractions or flaring, chest symmetrical and thorax well-formed, nipples even and slightly swollen, clavicles intact, breath sounds clear in lower lobes, some crackles in upper lobes, coughing and sneezing, S1 and S2 audible at apex, slight diastolic murmur noted (will continue to evaluate), peripheral pulses strong and regular bilaterally Skin-dry and warm, milia noted on nose and cheeks, some acrocyanosis persists, no lesions or bruises noted, slight peeling of hands and soles of feed noted, skin turgor minimal elasticity, no jaundice noted Abdomen-cord intact and clamped, 2 arteries and one vein, no herniation, cord site clean, minimal bloody crusting, bowel sound soft and without distension, abdomen symmetrical, bowel sounds audible in all 4 quadrants Genitals/anus-anus patent, meatus at the end of the penis, testes not descended in the scrotum, meconium passed-green/black and jelly-like paste, scant urine output with rust color Spine/extremities-Spine intact and straight, no lesions or hair tufts, extremities well-toned and mobile, some head control noted. No hip clicks were noted. Neonatal reflexes intact (sucking, Moro, rooting, grasp) 2/20815 Nursing Notes: Infant sleepy and brought to warmer for treatments and health assessment. The midwife continues to monitor maternal status. Vital Signs 2/2 0815 97.3°F(36.3°C) Ax. 138 44 80/P 88% RA PRESCRIPTIONS & NOTES 2/20830 Gestational Age Assessment Neuromuscular Maturity: Posture, Square Window (wrist), Arm Recoil, Popliteal Angle, Scarf sign, Heel-to-ear Scale Score= 19 Physical Maturity: Skin, Lanugo, Plantar surfaces, Breasts, Eyes/Ear cartilage, and testes Scale Score = 16 Total Score= 35 Correlates to 38 weeks gestation MEDICATION ADMINISTRATION RECORD Day/Time Medication Initials 2/2 0820 Phytonadione 0.5 mg IM via right vastus lateralis BJE 2/2 0825 Hepatitis B vaccine via left vastus lateralis BJE 2/2 0830 Erythromycin ointment to eyes bilaterally BJE Before answering this question, review the client’s health information in the EHR. During the morning, a nurse not assigned to the client enters the room and asks the parents to sign the consent for the circumcision, stating that the provider requested the consent. The parents become upset and call for the primary nurse. Identify the following responses that would be most appropriate. Select all that apply.
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Beоwulf’s lоyаlty tо his people is rewаrded by his nephew, Wiglаf, who not only helps Beowulf in his last battle and in his hour of need but also rightfully punishes the ten disloyal deserters who do not come to Beowulf’s aid