Question

Danny is a full-term infant who was born via an emergency cesarean section for a placental abruption. Danny’s 15-year-old mother, Karla, admitted to having used “some cocaine” during her pregnancy. Karla has been discharged home but Danny is still in the hospital awaiting clearance from the Department of Social Services. Karla’s mother Anna arrives at the hospital to visit Danny. Anna is considering taking care of Danny. After trying to feed Danny for several minutes, Anna called the nurse and exclaimed, “ I believe that something is wrong with Danny. He is spitting up a lot, he gets all stiff and rigid, and he has not stopped crying since I have been here. I do not think I know how to care for him if this is how he is going to behave.”

Critical Thinking Questions

1. What are the priority nursing diagnoses at this time?

2. What are the expected outcomes associated with these diagnoses?

3. Describe the teaching/learning needs related to the scenario that correspond to the priority nursing diagnosis.

4. List nursing interventions with rationales that correspond to the priority nursing diagnosis.

Answer 1

1. Nursing diagnosis:

1. Risk for impaired fetal gas exchange related to placental insufficiency.  

2. Risk for pre eclampsia related to disease condition.

3. Risk for spontaneous abortion related to fetal growth restrictions.

4. Knowledge definition related to pregnancy management.

II. Expected outcome:

1. Improve gas exchange to the fetus.

III. Teaching needs:

1. Explain the adverse effects of cocaine.

2. Provide left lateral positions.

3. Give psychological support.

4. Prenatal cocaine exposure causes intra uterine growth retardation.

5. Importance of continuous fetal monitoring need to be educated.  

IV. Nursing intervention:

1. Assess the non reassuring fetal status.

2. Oxygen adminsterations.

3. Do not perform vaginal examination.

4. Continue to monitor maternal vitamins signs.

5. Provide intravenous fluid and blood products as perfect doctors order.