Question

Nursing care plan.

As a postpartum nurse, your next client is an LGA baby boy who was born at 37 weeks' gestation. He had Apgar scores of 8 and 9. He was circumcised. The mother is breastfeeding. Your unit requires a full assessment, screenings, discharge instructions, and documentation.

1.Develop 3 NANDA Priority Nursing Diagnosis

2. State Patient Goals/Plan Nursing Diagnosis

3. Write Interventions for Your Plan

4. Scientific Rationale for Interventions

5. Write How You Would Evaluate Your Plan

6. List of Medications Typical for the Medical Dosage; side effects

Answer 1

Ans.1) The 3 NANDA Priority Nursing Diagnosis is given below -

The initial newborn assessment establishes if the newborn is steady enough to stay with the parents or if it needs resuscitation or immediate interventions. Given that Apgar scores are 7 and 9, the baby appears to have made the transition to extra uterine life effectively.

2.) Nursing Diagnosis Plan- It includes assessment of the following -

• Respiratory examination - (nasal flaring, chest retractions, grunting on exhalation, labored breathing, abnormal breath sound and rate of respiration
• Cardiac examination - General cyanosis, color, heart rate and heart sounds
• Tone examination - Limp or active
• Other examination includes weight, length, head and chest circumference.

3.) The nursing interventions include: maintenance of airway potency, making sure the proper identification (i.d. bands and foot prints), timely administration of prescribed medications (vitamin K and erythromycin ophthalmic ointment), and maintaining thermoregulation  (quickly dry, place on pre-warmed bed, cap on head, and double wrap).

6.) In the given situation the baby’s medication mainly includes vitamin K and erythromycin ophthalmic ointment. Erythromycin ophthalmic ointment stops bacterial growth and prevents any infection in eye.