TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and
Universities in the Philippines

CASE
STUDY ON A FULL-
TERM BABY
ALLYZA EUNICE R. GUILLERMO
BIETRIZE YSABELLE T. FONTANILLA
BRYAN E. GOPEZ
ERICA FERNANDEZ
FELIX MIGUEL R. OVIVIR
KATRINA JOYCE C. MALONGA
LAURISSE M. LAGERA
MA. BIENA LAPITAN
MARRON JANE A. GANOTICE
MICHAELLA DESIREE V. GONZALO
RALPH P. QUIAMBAO
TRINAH A. LUMNA
VIACEL G. GAMBOA
XYRENCE P. GONZALES

2022
I. INTRODUCTION

For early-term, full-term, late-term, and post-term pregnancies, new subcategories

with better categorization were developed to reflect increasing evidence showing that newborns
are healthiest when born during weeks 39 and 40. 

Of all reported pregnancies, about 57.5% are full-term. This is crucial because a full-term
pregnancy allows your baby the space and time to grow and develop, lowering the likelihood of
health issues. For instance, a baby born before the full term has a higher risk of ADHD, autism,
cerebral palsy, learning impairments, and many other conditions. Additionally, a baby born past
full term is more likely to be viewed problematically large, which might raise the risk of a
hemorrhage in the mother and metabolic issues in the child. (Strong & Sekhon, 2022)

Global Statistics

The United Nations estimates that approximately 385,000 babies are born every day, or
more than 140 million annually. Additionally, Our World in Data (2019) predicts that over the
next few decades, there will be a continuous 140 million births annually. About 60% of infants
referred for neonatal care are delivered at full term, which is when they are 37 weeks or older in
the womb.
National Statistics

According to the Philippine Statistics Authority (2022), a crude birth rate (CBR) of 14.1
or 14 births per 1,000 people was recorded in 2020, which amounted to 1,528,684 live births
overall.

An overall trend of decreasing live birth registrations was evident. In the last eight years,
there has been a -14.6 percent drop in the number of live births reported, from 1,790,367 in 2012
to 1,528,684 in 2020. In contrast to the 1,673,923 live births that were reported in total in 2019,
2020 had the biggest drop rate (-8.7%).

An average of 4,177 newborns were born each day, which equates to 174 births each
hour or around three (3) every minute. 

General Objectives

This case study aims to improve and broaden the knowledge of the nursing students on
pregnant clients by obtaining adequate and relevant information which will also be beneficial to
the patient. Acquiring the necessary information, skills, and acceptable attitudes to operate well
as a beginning professional nurse providing excellent care to clients undergoing full-term
pregnancy.

Specific Objectives

The following are presented in this case study, which will be helpful to:
 Accurately determine the client's signs and symptoms, which includes examining the
client physically and gathering family history.
 Identify the contributing elements in the formulation of the diagnosis.
 Recognize appropriate nursing diagnosis consistent with the client's state in order to
create an efficient nursing care plan. This requires knowledge of the physiology of
pregnancy.
 Assess each intervention's contribution to the achievement of the treatment objective.
Nurse-Centered
 Conduct a physical assessment to determine if there are any abnormalities.
 Develop nursing diagnoses which can serve as a baseline in prioritizing nursing care
plans for the infant.
 Formulate a thorough Nursing Care Plans and determine the expected outcome.
 Evaluate the effectiveness of all Nursing Care Plans rendered to the client, and to know
whether the expected outcomes are met.
 Document the nursing procedures are rendered to the client.

II. NURSING PROCESS

A. ASSESSMENT

1. PERSONAL DATA
a. Demographic Data

Name: Marcos Delos Santos

Age: 3-days old
Sex: Male
Civil Status: Newborn
Religion: Roman Catholic
Position in the Family: First born son
Address: Sn. Vicente Tarlac City
Date of Birth: August 18, 2022
Place of Birth: Central Luzon Doctor’s Hospital
Nationality: Filipino
Date of Admission: August 18, 2022, 8:00 am

b. Environmental Status

Baby Marcos lives with his mother and father, and their family is classified as a middle-
income class. They are currently residing in a subdivision at San. Vicente Tarlac City with a two-
storey house. Their house is made up of concrete and steel materials which have limited space
for five to six people with 3 bedrooms, 2 comfort rooms, a spacious living room, a very clean
kitchen, and a garden. Mrs. Delos Santos works as an office clerk and her husband Mr. Delos
Santos works as a city engineer. According to Mrs. Delos Santos, the place and the air is very
relaxing since their house is a bit far from vehicles and other environmental pollutants. The
house is ventilated with enough windows and ventilators. Their house is also free from floods
since the drainage in front of their house is well managed. Furthermore, their waste materials are
placed properly in a garbage bag, segregated and the garbage truck collector comes there every
week and collects their wastes.

c. Lifestyle

During Mrs. Delos Santos’ first trimester she began to exercise since she was already
experiencing morning sickness and hyperemesis gravidarum. She usually gets up around 7:00 in
the morning to have morning walks with her dog. After her morning walk, she will have her
breakfast ready since she is following a Mediterranean diet and eat healthy foods like fruits,
vegetables, whole grains and healthy fats to ensure that Baby Marcus will receive the best
possible nutrition. She always manages her food correctly since her father has hypertension to
prevent from having preeclampsia. Preeclampsia is a serious blood pressure condition that
develops during pregnancy. In her free time, she reads books or watches movies since her
husband is out for work as a city engineer. She is doing light work every hour for the whole day
to reduce backaches, boost mood, prevent excess weight gain, and help her sleep better. During
her pregnancy, she visited Dr. Pablo regularly for her prenatal checkup; she also had her Tetanus
toxoid immunization and took her prescribed vitamins such as Folic Acid, iron, calcium, vitamin
D, Docosahexaenoic acid, and iodine. After a long day, she usually sleeps around 9:30 in the
evening. 

2. FAMILY HISTORY OF HEALTH AND ILLNESS

3. HISTORY OF PAST ILLNESS

4. HISTORY OF PRESENT ILLNESS

There is no illness from the third generation of the family.

5. CEPHALOCAUDAL ASSESSMENT

I. Skin

Marcos has pink skin color, but his feet are bluish.

Norms: Skin is normally a warm temperature. Normally, the skin is mobile, with elasticity and
returns to original shape quickly. Skin rebounds and does not remain indented when pressure is
released.

Analysis: Marcos has acrocyanosis which is normal in newborns.

II. Hair and Nails

Marcos’ hair is black and is evenly distributed, and his nails are pink colored.
Norms: Natural hair color, as opposed to chemically colored hair, varies among clients from
pale blond to black to gray or white. The color is determined by the amount of melanin present.
Pink tones should be seen. Some longitudinal ridging is normal.

Analysis: Marcus’ hair and nails are normal.

III. Head

Marcos’ head circumference is 34.9 cm upon measuring.

Norms: Normal head circumference is often related to chest circumference. At birth, the average
infant’s head is 35 cm and generally varies only by 1 or 2 cm. (Kozier & Erb’s Fundamentals of
Nursing Australian Edition, 2015).

Analysis: Marcos’ head is normal.

IV. Eyes

Marcos’ eyes respond slowly but blinks properly.

Norms: The newborn can follow large moving objects and blinks in response to bright light and
sound. The pupils of the newborn respond slowly, and the eyes cannot focus on close objects.
(Kozier & Erb’s Fundamentals of Nursing Australian Edition, 2015).

Analysis: Marcos’ eyes are normal.

V. Ears

Marcos reacts to sounds properly.

Norms: Newborns with intact hearing will react with a startle to a loud noise, a reaction called
the Moro reflex.

Analysis: Marcos’ ears are normal.

VI. Nose

Marcos’ nose reacts properly and there’s no flaring of nostrils.

Norms: The senses of smell and taste are functional shortly after birth. There should be no
flaring of the nostrils, which could indicate respiratory distress. (Maternal Newborn Nursing
Demystified, a self- teaching guide).

Analysis: Marcos’ nose is normal.

VII. Mouth

Marcos’ palate is intact.

Norms: The oral area is checked for intact palate (note cleft in lip or palate). (Maternal Newborn
Nursing Demystified, a self- teaching guide).
 
Analysis: Marcos’ mouth is normal.

VIII. Reflexes

Marcos’ hands grips tightly upon holding his hands.

Norms: Reflexes normally present at birth are the sucking, rooting, Moro, palmar grasp, plantar,
tonic neck, stepping, and Babinski reflexes (Kozier & Erb’s Fundamentals of Nursing Australian
Edition, 2015).
 
Analysis: Marie’s reflexes are normal.

IX. Length

Marcos’ length is 48.2 cm upon assessment.

Norms: The average length of a European American newborn in the United States is about 50
cm (20 in.) (Kozier & Erb’s Fundamentals of Nursing Australian Edition, 2015).
 
Analysis: Marcos’ length is normal.

6. LABORATORY AND DIAGNOSTIC PROCEDURES

COMPLETE BLOOD COUNT

Date: August 19, 2022

Indication/Purpose: A CBC or Complete Blood Count with white blood cell differential is
commonly ordered to evaluate newborns at risk for sepsis. A complete blood count (CBC) test
tells what and how many red blood cells (RBCs), white blood cells (WBCs), hemoglobin,
hematocrit and platelets count in the blood. CBCs are done in a lab (laboratory) using an
automated machine. A CBC can help evaluate overall health, diagnose a medical condition, or
know if a treatment is working. The health care provider often orders a CBC with platelets and
differential. This means that the blood will be tested for the total number of all types of cells
and for the number of 5 kinds of white blood cells – neutrophils, eosinophils, basophils,
lymphocytes, and monocytes. If the CBC and platelet test is abnormal, a drop of blood may be
looked at under a microscope.

Procedure: In young infants, a nurse will typically sterilize the heel of the foot and use a
small needle called a lancet to prick the area. The nurse will then gently squeeze the heel and
collect a small amount of blood in a vial for testing.

Date: August 19, Result Reference Remarks

2022

Hemoglobin 14.2 13.4-19.9 mg/dL Normal

mg/dL

WBC 9.85 9 – 30 x 10 /mm

3 3
Normal

RBC 4.82 3.90-5.90 Normal

millions/mm3

Hematocrit 43.8 42.0 – 65.0 % Normal

Lymphocytes 5000 2000-11000 mm3 Normal

Monocytes 1100 540-1800 mm3  

Platelet count 330 150 × 103 to 450 × Normal

103/mcL

Neutrophils 67.3 40 – 74 % Normal

Eosinophils 4 0–7% Normal

Basophils 1 0–2% Normal

 RBS 135 140 mg/dL (7.8 Normal
mg/dL mmol/L)

Blood type A+    

HEARING SCREEN

Date: August 19, 2022

Indication/Purpose:  The newborn hearing screening test helps identify babies who have
permanent hearing loss as early as possible. This means parents can get the support and advice
they need right from the start.

Procedure: The newborn hearing test is called the automated otoacoustic emission (AOAE)
test. It takes just a few minutes. A small soft-tipped earpiece is placed in your baby's ear and
gentle clicking sounds are played. Can be done while your baby is asleep.

Nursing Responsibilities: Communicate newborn hearing screening information and parental

options to parents prior to screening. Test all infants for hearing loss prior to discharge unless
parents have signed the Parental Refusal of Newborn Screening form.

Document all hearing screening results and inform parents, primary care providers, and the
Newborn Screening Program of the hearing screening results within 7 days of screening. Plan
for alternative testing strategies when equipment is not working properly. Schedule outpatient
follow-up within 1-2 weeks for infants who do not pass.

Analysis: The result of baby Marcus hearing screen is within the normal limits.

HEEL STICK
Date: August 19, 2022

Indication/Purpose: Heel stick is the most common and minimally invasive method to draw
capillary blood from an infant for medical testing. Capillaries are tiny blood vessels which
carry blood to the tissues and connect arteries to the veins. A sharp device known as a lancet is
used to prick the baby’s heel to obtain blood samples. It is also a test for rare genetic, hormone
and metabolic disorders. Heel stick blood samples are used for tests such as:

·         Complete blood counts

·         Liver function tests

·         Toxicologic tests

·         Bedside glucose monitoring

·         Blood gas analysis

Procedure:  

·         Cleans the heel stick site with an antiseptic solution

·         Holds the heel between their thumb and forefinger

·         Applies light pressure on the heel

·         Places the lancet on the appropriate spot and activates it

·         Applies mild pressure to squeeze out a blood drop

·         Wipes away the first drop as it can contain some of the antiseptic solution and interfere
with the test results

·         Collects the blood in a collection tube

·         Blots blood drops in filter paper used for testing

·         Applies pressure to stop bleeding

·         Places a bandage over the heel stick site

Nursing Responsibilities: Warming reduces hemolysis/bruising and increases blood flow as

much as 7 times. Test on your own arm prior to applying to the infant's heel. includes: pacifier,
skin-to-skin holding, hand/or blanket swaddling with selected extremity exposed.
Breastfeeding with term and near-term infants also has an analgesic effect. Slow massage of
the outer aspect of the contralateral leg from toe to thigh for 2 minutes before the heel stick is
proven helpful.

Analysis: The results of baby Marcos heel stick test is within the normal limits.

PULSE OXIMETRY

Date: August 19, 2022

Indication/Purpose: Pulse oximetry screening is used to detect Critical Congenital Heart

Disease (CCHD) in infants. Sometimes called “pulse ox,” this painless, non-invasive test
measures the amount of oxygen in the blood. Infants with heart problems may have low blood
oxygen levels, and therefore, the pulse ox test can help identify babies that may have CCHD.
The pulse ox test takes a few minutes to complete and is performed after the baby is 24 hours
old and before he or she leaves the newborn nursery.

Procedure: A sensor is placed on your baby. Your baby's blood oxygen levels are measured
by placing an adhesive strip around your baby's thumb, wrist, hand, toe, or foot. The strip has a
red light on it that shines through the baby's skin. The strip is then attached to a monitor
(called a “pulse oximeter”) by a long wire or cord.

Nursing Responsibilities: Nursing care for a neonate with oximetry requires monitoring SaO2
trends, skin integrity, and perfusion. Technical problems may occur, and the battery must be
charged at appropriate intervals. SaO2 trends related to nursing procedures are important to
consider before and during weaning of supplemental oxygen. (Cunningham et al., 1986)

Analysis: The result of baby Marcos pulse oximetry is within the normal limits.

7. ANATOMY AND PHYSIOLOGY

Book Based Anatomy and Physiology

Each ejaculation contains 200-250 million sperm, but only around 2 million make it to
the cervix. Once there, only around 1 million of the 2 million sperm that penetrate the cervix
make it to the uterus. Only 10,000 of the 1 million eggs that enter the uterus are able to reach the
apex of this organ. Only half of the 10,000 that survive at this time proceed in the appropriate
direction, that is, toward the egg cell. Around 1,000 of the 5,000 sperm that penetrate the utero-
tubal junction make it into the Fallopian tube. Finally, it is believed that just 200 of the 1,000 that
enter the tube make it to the egg. However, only one of the 200 sperms that reach the egg is able
to enter and fertilize it.

After insemination through the vagina, the sperms normally proceed through the cervix,
the uterus, and eventually the ampullary isthmic junction, where fertilization occurs. A single
sperm will fertilize an egg cell, resulting in a single zygote that will grow into a single baby.
During unusual cases, one fertilized egg (ovum) separates and develops into two newborns with
identical genetic material to form identical or monozygotic twins. Two eggs (ova) are fertilized
by two sperm to produce two genetically distinct offspring known as fraternal or dizygotic twins.
These occurrences are extremely unusual, occurring once in 250 births. Scientists do not now
know what is causing this.
 The pregnancy is split into three stages known as trimesters. Nutrition and waste are
managed by the endometrial lining by diffusion throughout the first two to four weeks of
pregnancy. The outer layer of the embryo begins to integrate with the endometrium as the
trimester advances, and the placenta develops. During the first trimester, internal organs and
bodily structures begin to grow. By five weeks, limb buds, eyes, the heart, and liver are nearly
complete. The word fetus is used by eight weeks, and the body is essentially developed.  The
individual is around five centimeters (two inches) long, and several of the organs, including the
lungs and liver, are not yet functional. Toxin exposure is most harmful during the first trimester,
when all of the body's organs and tissues are developing. Anything that interferes with such
development can have a serious impact on the fetus' survival. 

The fetus grows to around 30 cm in the second trimester (12 inches). It gets active, and
frequently the mother feels the first movements. All organs and tissues are still developing.
During this trimester, the fetus will begin to develop face features. Many people find out whether
their baby will be male or female at birth during this time.

The fetus grows to 3 to 4 kg (6 12 -8 12 lbs.) and 50 cm (19-20 inches) long during the
third trimester and has already developed a coordinated reflex. This is the most rapid stage of
growth during the pregnancy. The internal systems are well developed, but from conception till
birth, organ development continues (and some systems, such as the nervous system and liver,
continue to develop after birth). It will also move less as the labor gets closer and the spaces
inside the mother get smaller.

Labor refers to the physical efforts of expelling the fetus and placenta from the uterus
during delivery (parturition), which is divided into three phases. The cervix thins and dilates
during stage one. This is required for the baby and placenta to be evacuated during the delivery
process. The cervix will eventually dilate to a diameter of roughly 10 cm. The baby is evacuated
from the uterus during stage two. To help with the birth, the uterus contracts and the mother
pushes while compressing her abdominal muscles. The final step is the placenta's transit after the
baby is born and the organ has entirely detached from the uterine wall. If labor stops before stage
two, synthetic oxytocin, known as Pitocin, can be given to restart and prolong labor.
Patient Based Anatomy and Physiology
 B. PLANNING

Prioritizing Problems

Nursing Diagnosis Rank Justification

1st
Insufficient parental knowledge regarding This is the 1st nursing priority because:
importance of breast feeding or breastfeeding  The mother does not have sufficient
techniques knowledge on breastfeeding. Thus, the
mother should be educated regarding
the proper ways on how to breastfeed
her infant, if the mother does not know
how to feed her baby correctly, how
can we make sure that the baby is
acquiring the sufficient nutrients it
naturally needs?
 The baby’s nutritional needs will be
compromised. Based on research, when
the infant does not receive enough
nutrients from the mother’s breastmilk,
the baby can have higher risks of
getting infectious morbidity, otitis
media, gastroenteritis, and pneumonia.
That’s why, it is our 1st nursing priority.

2nd
Risk for infection related to inadequate This is the 2nd nursing priority because:
primary defenses (broken skin specifically  If the mother does not have any idea on
referring to exposed umbilical cord) how to do cord care properly, the baby
can have an increased risk of infection
which can be detrimental if left
untreated. That’s why it is essential for
 the mother to know how to do
umbilical cord care properly. However,
this is less threatening compared to the
first one.

Knowledge deficit due to being a first-time 3rd

mother This is the least priority because:
 Educating the mother on how she will
take care of her infant correctly is less
threatening than the first two most
priorities, that’s why it is the least
priority.
 NCP #1: BREASTFEEDING
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Insufficient parental SHORT TERM:  Analyze the  To determine SHORT TERM:
“Hindi ko po alam knowledge regarding mother's views on whether more
breastfeeding, her instruction is After 2 hours of proper
kung paano ang tamang importance of breast After 1 hour of proper nursing nursing intervention, the
pagpapabreastfeed sa feeding or breastfeeding intervention, the patient will: knowledge of it, necessary and
and the extent of what the mother client was able to demonstrate
bata.” techniques to feed the baby.
 Have a deeper her education. currently
understanding on how understands.
do breastfeeding works
and the benefits of  Support the mother
Objective Data: breastfeeding to the emotionally and  to encourage the Remarks:
(+) nervousness baby. respect her choice woman to
on breastfeeding. continue GOAL WAS MET
(+) the mother doesn’t breastfeeding if
know how to hold the she chooses to.
baby while breastfeeding
 Show how to
operate a piston-
powered manual  When the mother
breast pump. is unable to
breastfeed the
baby, assistance
should be
 Pay attention to the provided.
procedures for
utilizing and
storing expressed  for the purpose of
breast milk. ensuring proper
nourishment and
promoting the
 See whether the maintenance of
mother may breastfeeding.
 receive an early
notification or a
regular visiting  A regular visiting
schedule. schedule might
encourage a baby
to consume
enough breast
 Make sure there is milk when she is
quiet and solitude hungry and eager
when the mother is to eat.
nursing.

 Successful infant
 Encourage the feeding is
mother to feed her facilitated by a
infant frequently. quiet, secluded
setting.

 Encourage the
mother to consume  reinforces that
a healthy diet, get eating is joyful
adequate rest, and while improving
nurse her baby digestion.
every three hours
while she is
awake..  to make sure that
breastfeeding
continues and that
enough milk is
produced.
 NCP #2: PROPER UMBILICAL CORD CARE
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Risk for infection related to SHORT TERM: Provide complete health For effective newborn After two hours of nursing
inadequate primary defenses teachings about: cord care: intervention, the mother was
“Nurse, ano pong (broken skin specifically After two hours of nursing able to learn and acquire the
gagawin ko, wala referring to exposed intervention, the mother will  Make sure to bathe  Bathing reduces information discussed to her
po akong ka ide- umbilical cord) be able to provide proper cord the baby first prior microorganisms regarding proper umbilical
ideya kung paano care by: to giving umbilical around the cord care along with the
ko aasikasuhin cord care. umbilical cord important considerations to
ang cord ng anak 1. Giving proper and which can prevent be remembered.
ko?” as stated by hygienic care to the contamination of
the mother. baby’s umbilical cord.  Make sure to microbes and
perform hand further infections.
washing before Remark:
doing umbilical  Hand washing
Objective Data: cord care. techniques can GOAL WAS MET.
prevent cross
(+) The cord is contamination of
still clean and  Make sure to microorganisms
neat. properly apply from the mother to
betadine solution the infant.
on the umbilical
cord and the  Betadine solution
surrounding area. is a disinfectant
and antiseptic,
which can kill
 Make sure the cord microbes and can
stump is clean, prevent further
neat, dry, and infections.
exposed to air.
 A clean and dry
  Make sure to leave cord stump will be
a space for the germ-free that can
stump when prevent spread of
putting a diaper on microbes.
the infant.
 To prevent
irritation on the
cord stump.

NCP #3: DEFICIENT KNOWLEDGE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Knowledge deficit due to After 2 hours of proper nursing
Subjective Data: being a first-time mother After 2 hours of proper Determine the  To avoid intervention, the parent:
nursing intervention, the knowledge, skill, and misunderstandings
“Hindi ko po alam patient will: want to learn of the and guarantee that
kung papaano ang parent or SO. Avoid the client completely • Verbalized comprehension of
mga gagawin sa bata using terms that the comprehends the the infant's condition, probable
at kung ano mga 1. Verbalize understanding patient wouldn't information and problems, personal risk factors,
bawal.” of condition, potential comprehend in medical instructions and treatment plan.
complications, terminology. provided
individual risk factors,  Utilizing multiple
Provide knowledge in a
and understanding of learning resources • displaying the initiative and
variety of learning
therapeutic regimen. improves the wisdom to follow the suggested
Objective Data: modalities, including
group activities, patient's engagement guidance.
(+) nervousness audiovisual recordings, and memory of the
programmed books, and knowledge.
Remarks:
(+) unfamiliarity with question and answer
 To inform the client
medical procedures and sessions.
medications. GOAL WAS MET
Describe the and stop damage
significance of child
care and how it may  to avoid potential
impact the health of the injury caused by an
child. improper diet and
exercise level.
Reiterate warnings about
 to assess the infant's
risk factors, dietary
status and avoid any
restrictions, and/or
potential damage.
exercise limitations.
consist of medicine
Inform the parent that if
their child exhibits any
symptoms, including
difficulty breathing or
not eating, they should
immediately call a
doctor.

To emphasize the value

of follow-up treatment,
include local resources
and support networks.
C. IMPLEMENTATION
1. Drug Study
Name of the Route of Mechanism Indication Contraindication Side Effects Nursing Rationale
Drug Administration, of Action and Adverse Responsibilities
Dosage and Effects
Frequency
Erythromycin Route: It works by For infants Contraindicated minor eye Get consent To respect
Eye Ointment Ophthalmic killing born to in patients with a irritations, from client. the client’s
Drug Name: route bacteria or mothers with history of redness, right to
preventing clinically hypersensitivity temporary choose and
Erythromycin
Stock Dose their apparent to erythromycin. blurred vision, be informed
Tablet: growth. It gonorrhea. and about the
Brand Name: 1/8 oz. (3.5 g) only kills hypersensitivity medication
Ilotycin tamper-resistant and prevent For the reactions. being given
tube bacteria. treatment of to them.
superficial Ask for any
Classification ocular allergies or look To prevent
: infections at the patient possible
Macrolide involving the allergic
Antibiotics chart.
conjunctiva reactions
and/or cornea caused by
Pregnancy caused by the
Category: organisms medication.
susceptible to
B
erythromycin. To be able
Assess every to have a
Image: now and then faster
for any possible intervention
side effects. in case of
side effects.

Vitamin K Route: Vitamin K Vitamin K is Contraindicated Pain, swelling, Get consent To respect
Drug Name: Intramuscular helps to needed for in patients with a or soreness at from parents. the right to
Phytonadione (IM) make blood to clot history of the injection refuse and
 proteins and prevents hypersensitivity site. Dizziness, be informed
Brand Name: Stock Dose needed for bleeding. to Vitamin K. rapid heartbeat, of the
Tablet: blood sweating, Observe for parents.
Mephyton possibility of
1 mg via IMj at clotting and shortness of
birth the building breath, or bluish jaundice To do
Classification of bones. lips/skin/nails interventions
: may also rarely in case of
Fat-soluble occur jaundice and
vitamin report to
Hypersensitivit Document that physician.
y medication is
Pregnancy Reaction given to baby. To prevent
Category: confusion
C Jaundice whether
medication
Image: is already
given and
for proof
that
intervention
is done.

2. Medical Management
Medical Date General Description Indication/ Client’s reaction to treatment
Management/ performed/ Purpose
Treatment discontinued
Radiant 08/18/2022- A body warming This device helps to The baby had an initial body temperature of
Warmer 08/18/2022 device to provide heat maintain the body 36.39oC. After 6 hours, it became stable within
(6 hours) to the body. temperature of the baby. normal range (37.2oC).
Vitamin K 08/18/2022 Vitamin K is needed to To prevent vitamin K There were no side effect upon administration.
form blood clots and to deficient bleeding
stop bleeding. (VKDB) which can cause
bruising or bleeding in
 nearly every organ of the
body. Almost half of
VKDB cases involve
bleeding in the brain and
brain damage.

3. Diet
TYPE OF DIET DATE INDICATION/S NURSING
RESPONSIBILITIES
Breastfeeding 08/18/2022- It protects against allergies, sickness, Encourage the mother to breastfeed the baby on
08/20/2022 and obesity. It protects against demand. Refrain from giving the baby other
diseases, like diabetes and cancer. It fluids.
protects against infections, like ear
infections.

4. Activity/Exercise
TYPE OF GENERAL INDICATION/ CLIENT’S
ACTIVITY/ DESCRIPTION PURPOSE RESPONSE
EXERCISE
Rooting Reflex When a baby’s cheek is This reflex helps the baby find The baby turned his head in response to the
stroked, the baby will turn and latch onto a bottle or a touch and opened his mouth.
toward the cheek that was breast to begin feeding.
stroked and will make a
gentle sucking motion.

Moro Reflex While in a seated stance, If the Moro reflex is lacking on The baby appeared “startled” when he was
(Startle Reflex) the baby will be gently one side of your baby's body, it leaned backwards, flinging his arms upwards and
leaned backwards slightly can be the result of a broken brought it back towards the body after being
and then the head is caught shoulder or a nerve injury. If the caught.
right before it hits a reflex is lacking on both sides, it
pillow. The baby should might suggest brain or spinal
appear startled, lifting his cord damage.
palms upwards and thumbs
 out. After being caught,
the baby will bring his
arms back to its body.

Sucking Reflex A nipple or a clean finger The sucking reflex allows him to The baby started to suck the nipple after being
is placed in the baby’s suck and swallow the milk. placed inside the mouth.
mouth. If fully developed,
the baby should place
around it and squeeze it
between their tongue and
palate.

Grasping Reflex Triggered by pressing a It prepares the infant for The baby responded by making a fist and
finger or other object into grasping actions. gripping strongly.
the palm of a newborn’s
hand.

Scarf Sign The tone of the shoulder A test done to assess tone of the The arms and legs are flexed close to the body.
girdle is assessed by taking flexors about the shoulder girdle.
the baby’s hand and The hand should not go past the
pulling the hand to the shoulder and the elbow should
opposite shoulder like a not cross the midline of the
scarf. chest.

Tonic Neck Reflex When a baby's head is Absence of the reflex suggests a The baby extended the same arm where the head
(Fencer’s Position) turned to one side, the arm flaccid disorder or hypotonicity. is facing while the other arm is flexed.
on that side stretches out
and the opposite arm
bends up at the elbow.
D. Evaluation
A. General Condition Discharge
The patient was wearing white baby clothes while being carried by her mother and
breastfeeding. He appears normal, and active, and no complications or problems were noticed
during diagnostic procedures, so upon discharge, he doesn’t need any medications and treatment
aside from giving vitamins.
B. Methods of Approach

MEDICATIONS Vitamin D

EXERCISE Advise the mother to follow the following exercises for her baby:

A.    Grip the Finger- this helps strengthen muscles in the baby’s arms,
core, and back.

B.     Strap on your baby carrier and go for a walk

C.     Tummy Time- it helps the development of muscles in the stomach,

shoulders, back, and neck.

D.    Cycle Away- it provides relief from gas troubles and strengthens the
abs, legs, hips, and knees.

TREATMENT As the patient is normal and in good condition, he doesn’t need any
treatment.
  Teach the mother about the proper breastfeeding techniques,
HEALTH cues, and positions.
TEACHINGS  Teach the mother on how to clean the umbilical cord.
 Advice to always keep the baby warm or keep the baby’s
temperature in normal range.
 Advise the mother to not give food or drink other than
breastmilk
 Do not give pacifiers to quiet them as this can reduce the
sucking initiative
 Advise the mother to change diapers frequently and, with each
diaper change, wash the area with clean water and dry well.

OPD- FOLLOW UP The mother should follow the scheduled check-up for the baby.

III. Conclusion

The purpose of the study was to enhance and widen the understanding of
nursing students regarding expectant moms and newborns who have reached their full
term of development. In this instance, the parents were responsible enough to give
birth to a healthy baby who was born at the full term.

The physiology of the full-term baby up to the time of birth is the primary topic
of discussion here. According to silvestre et al., the fact that child death is a common
occurrence in all regions of the world makes it a tragedy that occurs on a daily basis
that is vast in magnitude (2018) In the studies conducted by Ionio, Ciuffo, and
Landoni, researchers found that immediate skin-to-skin contact led to improvements
in cardiovascular stability, sleep, weight gain, and a reduction in crying behavior
(2021).

More complete and accurate physical assessments, nursing interventions, and

nursing diagnoses will reduce child and infant mortality rates. Therefore, based on the
analysis that was conveyed, the nursing students can come to the conclusion that there
are a lot of factors that can contribute to the delivery of the baby (full term baby).
These factors include the family, the lifestyle, the nursing care and procedures that
were rendered, and having the knowledge about what is going on in the body of the
mother as well as their newborns.

IV. Recommendation
To the health care providers
This case study can help advise healthcare professionals to continue to assist struggling parents,
especially those new parents in finding ways to overcome the problems to prevent complications
for their future babies. Additionally, they will have a further understanding of the case and find
better ways to manage patients who might have complications or the same condition.
To the parents
We proposed this study to help parents to have better management in taking good care of the
baby and identify if there are further complications that may put their health at risk. They should
also be assisted by giving health teachings about the risk, treatments, and effects of the problem
in future pregnancies. Through this, they will be able to determine what steps to follow and
factors to keep in mind when preparing for a future pregnancy.
V. REVIEW OF RELATED LITERATURE AND STUDIES
LOCAL
Teenage pregnancy refers to pregnancy that occurs in females under the age of 20, these
females also face the same pregnancy issues as other women. However, in the study of Tabei et
al. (2017), teenage pregnancy puts females more at risk of maternal mortality, delivery
complications, obstructed labor, systemic infections, stillbirth, premature birth, and severe
neonatal complications. Inadequate knowledge is the primary reason for all the negative effects
of teenage pregnancy. Without proper health education, it puts these adolescent females at a
more significant disadvantage of not being able to bear a full-term healthy child and protect
themselves before, during, and after childbirth.
Child mortality is a common phenomenon in all parts of the world, it is an everyday
tragedy of enormous scale. According to Silvestre et al. (2018), the Philippines has an estimated
82 000 out of 2.4 million children die annually before turning 5 and half of the cases occur
among newborns. With improved services of policy development, health financing packages,
health facility standards, capacity building, and health communication, health workers can
deliver quality newborn care practices. This includes delayed cord clamping, dry cord care,
uninterrupted skin-to-skin contact, timing and duration of initial breastfeed, and bathing that will
enormously contribute to a better starting life to infants.
INTERNATIONAL
A sepsis occurring within an infant’s week of life is called an early-onset neonatal
bacterial sepsis (EOS), caused by organisms that colonize in the birth canal during vertical
transmission. Jefferies et al. (2017), stated risk factors associated to sepsis occurring within one-
week infants and such are: maternal intrapartum GBS colonization during pregnancy, previous
infant with GBS disease, prolonged rupture of membranes for over 18 hours, and maternal fever
with a temperature of greater than 38-degree Celsius. In management of well term infants, a few
blood tests and proper screening for possible risk is recommended to do. In management of
unwell term infants, it requires prompt investigation, along with CBC, blood culture, and lumbar
puncture. 
Newborn babies with anemia might experience asymptomatic to an acute life-threatening
condition. However, Tiruneh. et., al. (2020) explained that in the research area, anemia among
full-term newborns constituted a moderate public health issue. The fetus is known to be very
dependent, it takes iron from maternal circulation. But in preterm newborns, the majority of their
mother’s iron is stored in the last trimester of their pregnancy during delivery, causing an
imbalanced iron. Moreover, unlike full-term infants, preterm babies’ kidneys are immature and
are unable to produce sufficient amounts of erythropoietin. Even though full term infants are
validated to have moderate public health issue regarding newborn anemia, early infant anemia
screening may prevent future difficulties, as suggested by the research.
The skin-to-skin contact is a practice done right away upon delivery. Improvement in
cardiovascular stability, sleep, weight gain, and decrease in crying behavior are concluded in the
study of Ionio, Ciuffo, and Landoni (2021). In the recent research of Rheinheimer. et., al. (2022),
it suggests that early daily SSC in full-term newborns promotes behavioral development that
benefits up until early childhood. Future replications are justified, along with behavioral
observations of child conduct to validate maternal reports.
Instantaneous weight loss in newborns after birth is confirmed, yet, this controversial
subject lacks data. In 2018, the demanded data was satisfied with the calculation of an average of
4.43% weight loss on the first day and an average of 2.51% on the second day, with a total
weight loss of 6.85% within 48 hours, determining that it was because of the type of delivery. 
Term infants delivered through cesarean section and those that are fed with artificial formula
were specifically confirmed to lose more weight. (López, Cadenasso E., & Cadenasso L., 2018).
The findings of this study confirm the risk of presenting substantial weight loss after delivery in
term infants, which require additional care and follow-ups.
Usually, the vast majority of newborn babies move from fetal to neonatal life unaided.
However, a 20% or more number of newborns are recognized to fail in commencing breathing at
birth, not only preterm babies who are more prone to complications, but this includes term
infants. With a research conducted by Viaroli and Schmölzer in 2018, a respiratory support was
provided by the clinical team that will serve as the cornerstone of neonatal resuscitation,
claiming that these practices are significant in this study as an effective medical management.
The respiratory support includes use of 21% oxygen; mask ventilation implemented with proper
mask technique; utilization of a T-piece device in delivering a sustained inflation; face mask and
nasal prongs for PPV; surfactant administration, only if infant has been admitted to the NICU
after delivery due to transient tachypnea, meconium aspiration syndrome, respiratory distress,
pulmonary hemorrhage, or presumed sepsis; application of 3:1 C:V (compression: ventilation)
ratio during neonatal CPR.
VI. Bibliography

Book Reference
Silbert-Flagg, JoAnne, and Adelle Pillitteri. (2017) Maternal and Child Health Nursing. 8th ed.,
LWW

Internet Reference

Registered Live Births in the Philippines, 2020. Philippine Statistics Authority. (2022, January
26). Retrieved September 11, 2022, from https://psa.gov.ph/content/registered-live-births-
philippines-2020

How many babies are born a day? The world counts. (n.d.). Retrieved September 11, 2022, from
https://www.theworldcounts.com/challenges/toxic-exposures/polluted-bodies/how-many-babies-
are-born-a-day

Ritchie, H. (2019, Sept 11). How many people die and how many are born each year? Our
World in Data. Retrieved September 11, 2022, from https://ourworldindata.org/births-and-deaths

Jaime R. Herndon, M. S. (2022, Aug 25). When is my pregnancy full-term? Very well Family.
Retrieved September 11, 2022, from https://www.verywellfamily.com/what-does-it-mean-to-
have-a-full-term-pregnancy-4174638

Khan, Aliya. (2018, April 5) “Easy Exercisies for Baby - 0 to 2 Years.” First Cry Parenting, 
Retrieved September 11, 2022 from https://parenting.firstcry.com/articles/easy-and-effective-
exercises-for-babies/?
fbclid=IwAR1HnLjXBLkKWynV7kcrJ7DMjBFpslnYko7FqTjvLru3jJS8bcP35QgybE8.

N.a. (n.d.). “Discharge Instructions: Keeping Your Newborn Warm.” Saint Luke’s Health
System., Retrieved September 11, 2022 from
https://www.saintlukeskc.org/health-library/discharge-instructions-keeping-your-newborn-warm

Silvestre, Maria Asuncion, et al. (2018, March 31)  “Improving Immediate Newborn Care
Practices in Philippine Hospitals: Impact of a National Quality of Care Initiative 2008–2015”
International Journal for Quality in Health Care, Oxford University Press, Retrieved September
11, 2022 from https://academic.oup.com/intqhc/article/30/7/537/4957982. 

N.a. (n.d.). “6 Ways To Fit In Exercise With A Newborn” The Healthy Mummy., Retrieved
September 11, 2022 from https://www.healthymummy.com/done-6-ways-to-fit-in-exercise-with-
a-newborn/

Tabei, Kozue, et al. (2021, Dec 13),  “Association between Teenage Pregnancy and Family
Factors: An Analysis of the Philippine National Demographic and Health Survey 2017 - PMC.”
PubMed Central (PMC), Retrieved September 11, 2022 from 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8701314/

Tiruneh, Tegenaw, et al. (2020, Jan 3,) “Prevalence and Associated Factors of Anemia among
Full-Term Newborn Babies at University of Gondar Comprehensive Specialized Hospital,
Northwest Ethiopia: A Cross-Sectional Study” BioMed Central, . Retrieved September 11, 2022
from  https://ijponline.biomedcentral.com/articles/10.1186/s13052-019-0764-1.
Rheinheimer, Nicole, et al. (2022 Aug 9), “Effects of Daily Full-Term Infant Skin-to-Skin
Contact on Behavior and Cognition at Age Three - Secondary Outcomes of a Randomized
Controlled Trial - PubMed.” PubMed, Retrieved September 11, 2022 from
https://pubmed.ncbi.nlm.nih.gov/35942886/

Jefferies, Ann. (2017, June 15) , “Management of Term Infants at Increased Risk for Early Onset
Bacterial Sepsis.” Canadian Paediatric Society, Retrieved September 11, 2022 from
https://cps.ca/en/documents/position/management-infant-sepsis.

López, Miguel, et al. (2018, June)  “Weight Decrease in Full-Term Newborns in the First 48
Hours Post Natal.” SciELO - Scientific Electronic Library Online, September 11, 2022 from

https://www.scielo.cl/scielo.php?
script=sci_arttext&pid=S037041062018000300325&lng=en&tlng=en.

Viaroli, Francesca, and Georg Schmölzer. (2018, Feb 7) “Resuscitation of Term Infants in the
Delivery Room.” Intechopen, , Retrieved September 11, 2022 from
https://www.intechopen.com/chapters/62569.