[textarea columns=80 rows=25 fillable="true"]SUBJECTIVE: Day of life *** for this newborn. Born by ***vaginal/vacuum assisted vaginal/forceps assisted vaginal/C-section*** delivery at ***time and date*** at ***gestational age*** weeks to a ***mothers age*** year old G*** now P*** mother. Pregnancy was ***uncomplicated/complicated by ***
Mother is blood type ***, Hepatitis B ***negative/positive/unknown***
HIV ***negative/positive/unknown***, and was found to be GBS ***negative/positive/unknown***
Baby is feeding well by ***breast/bottle/bottle and breast***
No problems with urine or stooling pattern.
OBJECTIVE: Skin: ***normal turgor and without lesions/Jaundice of face/Jaundice to nipple line/Jaundice to abdomen/Jaundice to thighs/Erythema toxicum***
Head: Normocephalic with age-appropriate fontanelles.
ENT: Normal appearing external ears. Nose clear. Palate is complete.
CV: Regular rate and rhythm. Normal S1 and S2. No murmurs, gallops, or rubs. No peripheral cyanosis or edema
Lungs: Unlabored respirations. Symmetric chest expansion. Clear breath sounds.
Abdomen: Soft, without organomegaly. Bowel sounds normal. No masses palpable. No distention.
Genitalia: ***Normal male external genitalia. Testes descended bilaterally./Normal female external genitalia.***
Joints: Hips with full range of motion. Negative Barlow and Ortolani.
#1 Newborn ***male/female***
-Continue normal newborn nursery cares and feeds ad lib
-Hearing screen, state newborn screen, prior to discharge
-Hepatitis B vaccine per nursing protocol[/textarea]