NAME: Adebola Amoo Ross

As a postpartum nurse your next client is an LGA baby boy who was born at 37 weeks’ gestation. He had Apgar scores of 8 and 9. He was circumcised. The mother is breast-feeding. Your unit requires a full assessment, screenings, discharge instructions, and documentation. (Learning Objectives 4, 7, 8, and 10)

1. Describe what a normal head-to-toe assessment would be for an infant born at 37 weeks’ gestation. What test is used to determine this gestational age? What is the scale used to determine the Apgar score, and are this baby’s scores normal?

2. As the discharging nurse, you are responsible for what screenings in an infant in the first 24 to 48 hours? What immunizations would be required?

3. What discharge instructions would be pertinent to this mother? How would you educate her or the family?

4. How would you document your discharge teaching? Write a sample narrative of your teaching.

Definition of the Diagnosis

A new born baby usually undergoes several tests in order to detect any disorders that might need immediate medical attention (Susan, Terri & Susan, 2009). The test begins with physical examination which includes measurement of weight, length and head circumference. The heart rate, muscle tone, skin color, reflexes and breathing effort is also examined and scores of between 0 and 10 are given using the Apgar scale depending on the observed conditions. A baby with good health has an Apgar score above 7 whereas an Apgar score below 5 indicates that the baby may need immediate medical care. The gestation age is determined using the Ballard scale. It could either be small for gestation age (SGA), appropriate for gestation age (AGA) or large for gestation age (LGA). LGA’s refers to babies or infants whose age or gender is larger than expected or their birth weight greater than the 90th percentile. Some of the common risks in LGA infants include birth trauma, diabetes mellitus, metatarsus, adductus and hip subluxation (Angelica , Flaminia , Mania, Simona, Sara , & Cristina, 2014). Gestation diabetes is the common cause of LGA babies, other causes include, excessive maternal weight gain, fetal sex, increased gestation age and use of amoxicillin and pivambicillin antibiotics during pregnancy (Lawrence, 2017).

Common Signs and Symptoms

The common signs and symptoms for LGA babies are those that are related to the complications that may occur.

Potential Complications

Some of the potential complications associated with LGA newborns are birth injuries, perinatal asphyxia, difficult delivery, meconium aspiration, low Apgar score, lung problems, hypoglycemia, birth defects, and polycythemia (Cervellin, Comelli , Bonfanti, Numeroso , & Lippi, 2019).

Head to Toe Assessment

Vital Signs: Temperature, 98.6°F; blood pressure, 45/80 mm Hg; heartbeat, 160 beats/min; respiratory rate, 60 breaths/min, oxygen saturation 100% on room air


Head: the average head circumference of 33 to 35cm, overriding sutures, caput succedaneum

Eye: visual acuity 20/400, normal red reflex, no discharge, white sclera.

Ear: normal configuration that is a third angle of the eye and response to sound

Nose: symmetrical

Mouth: normal configuration; Epstein’s pearl, no cleft palate.

Neck: normal rotation.

Chest: average circumference of 30 to 33 cm, clear heart and lung sounds.

Abdomen: slight protrusion, cord drying, 3 umbilical vessels, liver 2 cm below costal margin, presence of bowel sounds.

Skin: pink skin, erythema toxicum, Mongolian spots, acrocynosis, milia

Genitalia: an open and properly placed urethra; presence of testes in the scrotum.

Limbs: presence of limbs, pink nails and no deformities.

NANDA Nursing Diagnosis

1. Birth injuries

2. Hypoglycemia

3. Lung problems

4. Heart diseases

5. Obesity

Infant screening

1. Otoacoustic emissions (OAE) test and auditory brain stem response (ABR)

The OAE tests is used to determine the response of some parts of the ear to sound while the ABR test is used to evaluate the auditory brain stem and brains response to sound (Angelica et al., 2014).

Desired outcome

Normal hearing

Interventions and rationale

1. Place a miniature earphone and a microphone on the baby’s ear and play a sound.

Rationale: Back reflection of an echo into the ear canal shows normal hearing

Place Band-Aid-electrodes on the baby’s head

Rationale: sound response indicates normal hearing

2. Pulse oximetry test

The pulse ox is a non-invasive test that measures the amount of oxygen in the blood.

Desired outcome

Normal oxygen levels.

Interventions and rationale

Place a pulse CO oximeter on the baby’s skin. The CO oximeter measures the fractional oxyhemoglobin.

Rationale: an oxygen saturation level of more than eighty-nine percent is an indication of healthy individual.

3. Bilirubin test

A jaundiced look on the baby would indicate bilirubin test is required.

Immunization Vaccines

· BCG vaccine

· Hepatitis B


Discharge Instructions

· Keep the circumcision wound dry and clean and apply ointment daily.

· Breast feeding of the baby every two or three hours’ time

· Avoid any other food apart from the breast milk

· Wrap the baby to maintain normal temperatures

· Bathing the baby daily and take good care of the umbilical cord

· Contact the doctor in case of any abnormal signs and symptoms.

Documentation of the Discharge Teaching

The discharging teaching is done using the Focus, data, action, Response way. Mother of a circumcised LGA baby boy born at 37 weeks educated on wound care, baby care, breast feeding and follow up.






Documentation sample

Date Time focus Notes
15/02/2020 12:57pm Health education The mother is able to follow the guidelines given and can handle the baby well.














Angelica D., Flaminia C., Mania G., Simona C., Sara C, & Cristina O. (2014). Investigation of the 1H-NMR based urine metabolomics profiles of IUGR, LGA and AGA newborns on the first day of life. The Journal of Maternal-Fetal & Neonatal Medicine: 27(2)

Cervellin G., Comelli I., Bonfanti L., Numeroso F., & Lippi G. (2019). Emergency diagnostic testing in pregnancy. Journal of laboratory and precision medicine: 5(2). doi: 10.21037/jlpm.2019.10.04

Lawrence E. (2017). A matter of size: Part 2. Evaluating the large-for-gestational-age neonate. PubMed journals

Susan S., Terri K., & Susan C. (2009). Maternity and Pediatric Nursing, 2nd ed. ISBN: 978-1-60913-747