Exhibit: the newborn record at six hours
Simulated electronic health record frame with five tabs, an Apgar scoring board in tab 1, and a five-zone cephalocaudal jaundice body map in tab 3.
EXHIBIT · NEWBORN RECORD
DELIVERY SUMMARY | VITALS | ASSESSMENT | LABS | INTAKE AND OUTPUT
TAB 1 · DELIVERY SUMMARY
Gestational age at birth 39 weeks 2 days. Birth weight 4,140 grams, plotted above the 90th percentile, classified large for gestational age. Length 53 centimeters. Vaginal birth, spontaneous, no instrumentation. Membranes ruptured spontaneously 9 hours 20 minutes before birth; fluid clear. Maternal group B streptococcus culture negative. Maternal history: gestational diabetes, diet controlled. Delayed cord clamping performed. Vitamin K and erythromycin eye ointment given at 55 minutes of life.
Apgar board
| 0 | 1 | 2 | 1 min | 5 min | |
|---|---|---|---|---|---|
| Heart rate | Absent | Below 100 | 100 or above | ■ 2 | ■ 2 |
| Respiratory effort | Absent | Slow, irregular, weak cry | Good, strong cry | ■ 2 | ■ 2 |
| Muscle tone | Flaccid | Some flexion | Active motion | ■ 1 | ■ 2 |
| Reflex irritability | No response | Grimace | Cry, cough, sneeze | ■ 2 | ■ 2 |
| Color | Blue or pale | Body pink, extremities blue | Completely pink | ■ 1 | ■ 1 |
| TOTAL | 8 | 9 |
TAB 2 · VITALS (axillary temperature)
| Time | 30 min | 1 hr | 2 hr | 6 hr |
|---|---|---|---|---|
| Temperature | 36.7 C (98.1 F) | 36.4 C (97.5 F) | 36.1 C (96.9 F) | 36.6 C (97.9 F) |
| Heart rate | 148 | 152 | 158 | 140 |
| Respiratory rate | 46 | 52 | 64 | 44 |
| Oxygen saturation | 96 percent | 96 percent | 95 percent | 97 percent |
TAB 3 · ASSESSMENT
Nursing note, 6 hours of life. Tone decreased at 2 hours with a weak, high-pitched cry; tone improved and cry strong at 6 hours. Moro and rooting reflexes present and symmetric at 6 hours; suck weak at 2 hours, coordinated at 6 hours. Cord clamped, three vessels, base dry, no drainage. Skin with acrocyanosis of hands and feet, mottling of the trunk noted at 2 hours, resolved at 6 hours. Faint yellow discoloration of the face and sclerae observed at 6 hours of life under natural light; jaundice zone map, zone 1 only, zones 2 through 5 clear. Gestational age assessment by New Ballard examination completed at 3 hours: neuromuscular criteria of posture, square window, arm recoil, popliteal angle, scarf sign, and heel to ear, plus physical criteria of skin, lanugo, plantar surface, breast bud, eye and ear, and genitalia. Total score corresponds to 39 weeks, consistent with obstetric dating. Zone assessment estimates only and is confirmed by measured bilirubin.
TAB 4 · LABS
| Test | Time | Result |
|---|---|---|
| Point-of-care glucose | 2 hr 10 min | 34 mg/dL |
| Point-of-care glucose | 3 hr 5 min, after feeding and rewarming | 52 mg/dL |
| Point-of-care glucose | 5 hr 50 min, before feeding | 61 mg/dL |
| Transcutaneous bilirubin | 6 hr 5 min | 4.2 mg/dL |
Bilirubin result is plotted on an hour-specific nomogram against gestational age and risk factors, not compared to a single fixed number.
TAB 5 · INTAKE AND OUTPUT
Feeding 1 at 45 minutes, breast, 12 minutes, latch effective. Feeding 2 at 2 hours 20 minutes, breast, 8 minutes, latch weak, infant sleepy. Feeding 3 at 3 hours 15 minutes after rewarming, breast, 15 minutes, latch effective. Voids: one, at 3 hours 10 minutes. Stools: one meconium, black and tarry, at 4 hours 5 minutes. Weight at 6 hours 4,090 grams, 1.2 percent below birth weight.
PROMPT STRIP
- Which finding on this record is the earliest sign of cold stress?
- Which finding requires a glucose recheck before the next feeding?
- Which single finding on this record requires immediate provider notification?
Margin noteread the tabs in the order the question asks, not the order they are printed. Every threshold implied here → BOOK 07 · P4. The case that resolves this record → BOOK 12 · P11
Takeawaya newborn record is read as a trend across tabs, and the temperature trend is usually the first thing to move.