NURSES PROGRESS NOTES

Patient’s Name: Mrs. HO___________________ Ward and Bed No. Labor Bed no.1
Hospital Number: 2021-89432RPR ____________

Date Time Focus Data Action

Response
Septembe 11:00a Immediate Newborn D: delivered spontaneously, a live baby boy @
r 27, m Care 10:30 am; cried vigorously, with Apgar score
2021 of 9, 10 at 1 and 5 minutes after birth
respectively; apical pulse of 115
bpm___________________//

A:Newborn placed on his back on bassinet;

undressed except his diaper; draped with
blanket to keep warm. V/S taken and recorded:
heart rate = 130bpm (regular and without
murmur), RR = 38 cpm (clear, regular,
unlabored respirations), T: 36.50C.
Anthropometric measurements taken and
recorded: HC=33cm, AG=32cm, CC=32cm,
body length=50cm, weight=2800g. Physical
assessment was performed and recorded:
Extremities move well, tucked close to the
body. Exerts resistance with movement and
begins to cry. Skin was pink and has small
white papules on nose. Birthmark on right
elbow, 2mmx2mm tan macule with smooth
borders. Vernix caseosa observed. A smooth
and flat diamond fontanelle (4cm) and
triangular shaped fontanelle (0.5cm) were
noted. Eyes were symmetrical, brown in color.
Some edema on the lids but no subconjunctival
hemorrhage. Face was symmetrical. Ears
symmetrical with pinnae placed at eye-occipital
line. Mouth and gums were pink. Rooting and
sucking reflex were strong. Anterior and
posterior palate were intact. White spots
observed on the hard palate. Tongue was
normal for size and movement; frenulum was
not short. Nose was clear with patent nares.
Neck was short, straight, and moves freely; free
from palpable masses. Clavicles were intact and
no crepitus was felt. Arms were symmetrical.
Five fingers on each hand. Chest expands
equally. All pulses palpable bilaterally. Nipple
line symmetrical with no palpable mass. Breasts
 secrete small amounts of whitish fluid.
Abdomen round and protrudes slightly. Bowel
sounds were positive, occurring every 10-15
seconds. Liver edge, spleen, and kidneys was
not palpable. Umbilical cord was clamped and
drying. Legs were straight and equal in length.
Ortolani maneuver does not produce hip click
and feet were straight. Gluteal folds were
symmetrical. Five toes on each foot. Penis was
normal size for age and no lesions were
observed. The foreskin was retractable. Urinary
meatus is at tip of glans penis and has no
discharge or redness. Scrotum was free of
lesions. Testes were palpable in scrotum. Testes
were equal in size, smooth, mobile, and free of
masses. In a prone position, his spine was
closed and straight. Anus was pink and mother
states that she has had several stools since
delivery. Spine was closed, with normal
curvature of the spine. Positive newborn
12:00p reflexes. Hepatitis B 0.5 mL IM given at right
m anterolateral thigh. Oxytetracycline Polymyxin
B sulfate 1 squirt OU applied on both eyes.
Phytomenadione 10mg/1mL, give 1 mg IM at
left anterolateral
thigh.______________________//

R: Skin warm to touch, completely pink,

clothed with diaper and wrapped snugly;
endorsed to mother, asleep soundly on mother’s
abdomen with good
suck.________________________________//