DATE TIME FOCUS DATA, ACTION.

RESPONSE
11/25/202 1:20 PM Immediate D> Baby E, 3,200 g was born exactly at 1:20 PM.
0 Newborn care Spontaneously started breathing and her
respiratory rate was 50 per minute. APGAR
SCORE = 2. mother tried to breastfeed, but Baby
E had difficulty sucking. The baby was pink with
acrocyanosis, Respiratory rate was 56 breathings
per minute, Axillary temperature was 35,4°C, No
grunting, no chest indrawing, No grunting, no
chest indrawing, The baby had a
cephalohematoma on the left side of the
head.--------------------------------
A> Dried the baby thoroughly from face/head to
trunk then extremities; rubbed back gently and
smoothly; removed soiled and wet linen; set the
baby in skin to ski contact with the mother for 1.5
hours; placed ID bands on both feet; covered head
with bonnet; clamped and the cut the cord
aseptically after the pulsation is no longer felt;
encouraged and initiated breastfeeding on 1:30
PM and ended on 1:50 PM; applied erythromycin
ointment, 1 squirt on both eyes; injected vitamin K
0.1mL at 1 squirt on both eyes; injected vit K 0.1
mL IM @ left thigh, noted and recorded
anthropometric data and vital signs taken;
monitored for change of color and breathing.-------
R> With good sucking reflex, endorsed to NICU
NOD/ROD for Ballard scoring and physical exam.