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You are assigned to the mother-baby couplet unit, where your patients for the day include the...

You are assigned to the mother-baby couplet unit, where your patients for the day include the Sanchez family. Margarite is a 28 y.o. G3P2 Hispanic woman who gave birth to a healthy male, Manuel at 0839. Margarite experienced an uncomplicate labor of 12 hours. Membranes ruptured 7 hours before delivery. She received 2 doses of Nubain during labor. The last dose was administered at 0440.    Manuel weighs 3,800 grams and is 50cm in length. His 1 and 5 mins Apgar scores were 8 and 9, respectively. Manuel is now 2 hours old. The Ballard Score indicates that Manuel is 39 weeks gestation. Margarite breastfed her son for 15 minutes on each breast immediately after birth.    Your initial shift findings are: VS- Axillary temp-36.2 degrees C (97.2 F) Apical pulse 100bpm Respirations - 30pm 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 stimuli Based on the above information, discuss the primary nursing diagnoses for baby Manuel.    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. List the signs and symptoms of hypoglycemia and related nursing actions. Several hours later, Manuel'[s father is present and holding Manuel. List signs of parent-infant bonding. Discuss nursing actions that will support parent-infant attachment.

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Nursing diagnosis

Impaired thermoregulation/Metabolic alteration related to exposure to external environment as evidenced by acrocynosis

Intervention and rationale

  • Assess the vital signs, baseline to provide information and plan for care
  • Warm the baby's palm and sole by simple pressure rubing to improve circulation and oxygenation to the tissues
  • Swaddle the baby to keep warm
  • Encourage the mother to hold the baby for good thermoregulation

The signs and symptoms of hypoglycemia are

  • Jitters
  • Low body temperature (97°F)
  • Cyanosis
  • Difficulty in breastfeeding
  • Drowsy or sleeping
  • Others:perspiration, weakness ,high pitched crying

Nursing action for hypoglycemia

  • Monitor the blood glucose level to get the baseline data
  • Administer dextrose as per order
  • Ensure adequate breastfeeding
  • Keep the baby warm because cold stress can decrease blood glucose

The signs of parents infant bonding are

  • The baby be comfortable in their arm or on their touch
  • Able to sleep when they caress

The nursing actions necessary are

  • Teaching the parents especially the father about the technology to hold a child
  • Educate about the feeding and elimination pattern of the baby and encourage to change the diapers to establish the baby's comfort
  • Communicate or talk with the baby as they can hear without understanding and able to recognize the parents voice
  • Will be able to establish eye contact with parents
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