Question

You are assigned to the mother-baby couplet unit. Your assignment for the day includes the Sanchez family. Margarite is a 28-year-old G3 P2 Hispanic woman who gave birth to a healthy boy, Manuel, at 0839. Margarite experienced an uncomplicated labor of 12 hours. Membranes ruptured 7 hours before delivery. She received 2 doses of Nubain during labor. The last dose was given at 0440. Manuel weighs 3,800 grams and is 50 cm in length. His 1- and 5-minute Apgar scores were 8 and 9. Manuel is 2 hours old. The Ballard score indicates that Manuel is 39 weeks. Margarite breastfed her son for 15 minutes on each breast immediately after the birth.

Your initial shift assessment findings are:

Vital signs: Axillary temperature, 36.2°C; apical pulse, 100 beats per minute; respirations, 30 breaths per minute. Skin is warm and pink with acrocyanosis. Fontanels are soft and flat.
Molding is present. Lung sounds are clear. There is mild nasal flaring. Manuel is in a sleep state and unresponsive to external stimuli.

1. Based on the above information, discuss the primary nursing diagnoses for baby Manuel.
2. Discuss the immediate nursing actions for baby Manuel. Provide rationales for your nursing actions.

Thirty minutes later you note that Manuel is jittery and exhibits signs of hypoglycemia.

3. List the signs and symptoms of hypoglycemia and related nursing actions.

Several hours later, Manuel’s father is present and holding Manuel.

4. List signs of parent-infant bonding.
5. Discuss nursing actions that will support parent-infant attachment.

Answer all questions and cite your sources!

Answer 1

1. Based on the above information , the child is having respiratory distress .

2. Immediate action is oxygen supplementation .

3. Nursing interventions :-

Continuous monitoring & close observation

Obtain necessary specimens for lab

Continuously monitor pulse oximetry

Suction as indicated, not ET suctioning

Maintain thermoregulation

Provide nutrition (parenteral, avoid oral)

Cluster nursing activities

Educate parents & provide emotional support

Silverman-Anderson Index

4. Signs and Symptoms of Hypoglycemia

Jittery (tremor, can look like seizure)

Irritability

High-pitched or weak cry

Poor feeding, poor suck or coordination (automatic lactation nurse)

Lethargy, hypotonia (floppy rag doll)

Hypothermia, tachypnea, cyanosis, apnea, seizures

May be asymptomatic (need to check)

#. Nursing Interventions :-

assess blood glucose before feedings, IV supplementation if can't orally eat, neutral thermal environment.