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Walden University: i-Human Case Study – Week 4, Comprehensive Assessment of a 3-Day-Old Infant During a Well Visit at an Outpatient ClinicRoutine Evaluation of a Healthy 3-Day-Old Infant: Clinical Case Review

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Chief Complaint Mother brings her 3-day-old infant for a routine newborn well visit. History of Present Illness (HPI) Mother states the baby is feeding every 2–3 hours, primarily breastfeeding, w ... ith occasional expressed breast milk given by bottle. Baby latches well and swallows audibly. Infant has 4 wet diapers and 3 stools in the last 24 hours. She denies fever, vomiting, lethargy, or poor feeding. Perinatal/Birth History - Gestational age: 39 weeks, term - Delivery: Vaginal, spontaneous, uncomplicated - Apgar scores: 8 and 9 - Birth weight: 3.2 kg - No maternal complications during pregnancy. Negative for GBS, HIV, Hep B, or substance use. Family/Social History - Lives with both parents, strong family support. - No smokers in household. - Infant sleeps in a crib, on her back. - Rear-facing car seat used. Review of Systems - General: Active, alert, normal cry. - Nutrition: Breastfeeding well, no issues. - GU: Normal voiding and stooling. - Skin: Mild yellowing of face noted by mother. - Respiratory: No cough, apnea, or cyanosis. - Neuro: Normal tone, reflexes intact. Objective Findings Vitals: HR 130 bpm, RR 42, Temp 98.2°F (axillary), weight 3.0 kg (6% below birth weight). General: Vigorous, strong cry, active. Skin: Warm, mild jaundice to face, no rash. Head/Neck: Anterior fontanelle soft/flat; sutures normal. Eyes: Bilateral red reflex present. ENT: Palate intact; nares patent; good suck. Chest/Lungs: Clear bilaterally, no retractions. Cardiac: Regular rhythm, no murmurs, pulses equal. Abdomen: Soft, nondistended, bowel sounds present; umbilical stump clean. GU: Normal female genitalia; anus patent. MSK: Full ROM, negative Ortolani/Barlow. Neuro: Primitive reflexes (Moro, grasp, rooting, Babinski) intact. Assessment - Healthy 3-day-old term newborn - Normal physiologic weight loss (<10%) - Adequate feeding and elimination - Mild physiologic jaundice - No acute concerns Plan / Evaluation 1. Continue breastfeeding on demand q2–3 hrs. 2. Vitamin D supplementation if exclusively breastfed. 3. Anticipatory guidance: safe sleep (back to sleep), car seat, infection precautions, jaundice monitoring, when to call provider. 4. Confirm results of newborn screen, hearing test, CCHD screen. 5. Immunizations: Hepatitis B #1 received in hospital (verify). 6. Follow-up: Recheck weight and feeding at 2 weeks. Case Questions (i-Human Style) Q1. What percentage of weight loss from birth weight is considered normal in a newborn at day 3 of life?  A. <5%  B. <7%  C. <10%  D. <15% Answer: C Rationale: Up to 10% weight loss in the first week is considered normal. Q2. Which finding would be most concerning in this 3-day-old infant? [Show More]

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