The 2-day-old full term child has been rooming in with the mother...

The 2-day-old full term child has been rooming in with the mother who reports successful breastfeeding. Which information is most important to report to the provider?

Birth History
Discharge Readiness
Intake and Output
Assessment

Birth weight: 3100 g
Daily weight 3055 g
37 3/7 estimated gestational age
23 y/o G1P1 mother who is married to father of baby. She had good prenatal care and an uncomplicated pregnancy. Membranes ruptured spontaneously 3 hours prior to delivery. Baby was initially limp with little respiratory effort but began breathing spontaneously with initial resuscitation steps. Apgars were 7 and 8 at 1 minute and 5 minutes of life. Went skin to skin with mom at 30 seconds of life and attempted breastfeeding for the first time at 6 minutes of life.
Critical Congenital Heart Disease (CCHD) screening: Right wrist 99%; Left foot 93%
State metabolic screen: Completed
Hearing screen: Passed
0000 Breastfed 6 minutes on the right, 8 minutes on the left breast with frequent swallows and good latch. 10 mL urine.
0300 Breastfed 4 minutes on the right breast, 4 minutes on the left breast. Good latch, frequent swallows. Diaper was dry.
0600 Breastfed 7 minutes on the right breast, 5 minutes on the left breast. Good latch, frequent swallows. 15 mL urine
Skin: Warm, dry, jaundice
HEENT: Mucous membranes moist and intact; No cleft lip or palate; No nasal flaring
Cardiovascular: Peripheral pulmonary stenosis murmur noted. All pulses palpable. Capillary refill 2 seconds
Respiratory: Occasional tachypnea. Mild subcostal and intercostal retractions. Abdominal muscle use. Breath sounds clear to auscultation.
Abdomen: Soft and nondistended. Abdominal cord clamp is off, cord is drying well. Bowel sounds present and active. Anus patent; has passed meconium.
Genitourinary: Bloody vaginal discharge noted.
Social: Mom and dad rooming in, providing all care for the child.

Urine output

CCHD results

Heart murmur

Vaginal discharge

Category: Management of Care
Difficulty: 10

Topics: Communication & Documentation Delegation, Prioritization and Leadership Disease Prevention Health Care Ethics, Law, and Policy Cardiovascular Growth & Development Health Care Quality Health Promotion Health Screening Labor and Delivery Neonatal Care Pediatrics Sexuality and Reproduction Postpartum Care

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