Mrs.

Anita is 40 years of age and gave birth to her third baby at Blessed Family Doctors Hospital 5
days ago. Her labor, and birth were uncomplicated but she experienced gestational diabetes and
hypertension during pregnancy. Mrs. Anita noticed yesterday that her baby’s cord stump had an
offensive smell. She has brought Baby John to the health center for the first time today because she
is concerned that the cord may be infected.  Also concerned if she still has diabetes and
hypertension.

PRE-ASSESSMENT
1. Before beginning your assessment, what should you do for and ask Mrs. Anita and
Baby John?

First and foremost, greet the patient and collect demographic information such as the baby's name
and date of birth. By correctly identifying the patient, the nurse will be able to learn about the
newborn's full medical condition and history, which will aid in providing the necessary treatment.
This can also help to reduce the negative consequences of avoidable patient identification errors.
Then, ask her what is her problem, is her pregnancy, labor, and birth uncomplicated? Is her baby
feeling well? Finally, inform her that you will conduct a physical examination on his baby to
determine the cause of the problem.

2. What history will you include in your assessment of the mother and Baby John and
why?

The history that will be included in my assessment of the mother and Baby John is the birth weight,
which is an important indicator of the newborn's health; vital signs include the mother's blood
pressure and the baby's temperature, pulse rate, and respiratory rate; the physical examination is an
important part of newborn care to carefully check each body system for health and normal function,
which includes general appearance, skin color, the abdomen, and the cord stump. Aside from the
above history, I should include the following in the assessment: is there any bleeding in the umbilical
cord, has the baby vomited, and is the baby crying all the time? Because if we assess the above
assessment, we can find out the baby’s present condition and can evaluate the baby's problem.

3. What physical examination will you include in your assessment of the mother and baby
John and why?

The physical examination I will include in my assessment is the cephalocaudal, which is from head to
toe and includes general appearance, if awake, crying, or irritated (notice the newborn's facial
expressions), skin, neck, face, mouth, lungs, heart sounds, and pulses in the groin (femoral),
abdomen, genitals, and anus, arms, and legs. Examine the newborn's vital signs, including heart rate,
respiratory rate, and temperature, as well as those of the mother and her blood pressure. Before
using a stethoscope to check for the newborn's VS, make sure the instrument is warm. Examine the
skin around the cord stump for signs of redness and swelling. The appearance and odor of the cord
stump – examine the cord for redness and swelling, as well as any foul odors or odors coming from
it. The appearance and smell of the discharge from the cord stump - note the color of the discharge
coming out and the smell of it. This physical examination allows me to determine the mother's and
baby's physical conditions.

4. What laboratory tests will you think the doctor will include in the assessment of the
mother and baby John and why?

I think the laboratory test that the doctor will include in the assessment of the mother and baby john
is the blood test: cord blood testing to find out the blood level and is usually done if there is a
suspected infection in the umbilical cord, blood culture for aerobic and anaerobic organisms to
detect the infection, and bilirubin to detect the bilirubin level in the blood. The fasting blood sugar
test is for mother to find out if her blood sugar levels are in a healthy range.
History:
o  Baby weighed 3 kg at birth
o  Mrs. Anita reports that she had no infection during pregnancy, labor, or birth.
o  Mrs. Anita had FBS 140mg/dl and BP of 150/90 during pregnancy
o  The birth was attended by a doctor in a private hospital
o  Baby John is reportedly not breastfeeding well.
o  Mrs. Anita denies covering cord or putting any substance on the cord.

Physical Examination:
o  Baby E weighs 3 kg.
o  Vital signs are as follows: Respirations are 40 per minute, Temperature is 37.9°C. Baby John has a
moist cord stump that has an offensive smell and redness on surrounding area.
o  None of the following are observed: draining pus, skin lesions, or distended abdomen.
o  You observe that Baby John is having difficulty in breastfeeding
o  Mrs. Anita’s BP is 110/70mmhg

 5. Based on your assessment and diagnosis what would be your nursing care plan for the mother
and the baby.  One NCP for the mother and one for the baby. Baby John diagnosed with Umbilical
cord infection because baby has moist cord stump with offensive smell.