Question

TA, an older adolescent, was admitted to the hospital for labor induction/augmentation with signs and symptoms of gestational hypertension at 42 weeks’ gestation (gravida 4, para 1). TA’s mother arrived at the hospital when TA was dilated 8 cm and in time for the late stages of TA’s labor. Her mother remained as TA’s support person throughout the delivery, which occurred at 6:00 AM by vacuum extraction. TA had a continuous epidural for her labor and delivery. An episiotomy was performed at the time of delivery, and a fourth-degree laceration occurred. A cluster of hemorrhoids was evident. Baby JA, weighing 8 lb 7 oz, had Apgar scores of 7 and 9. The infant is alert and active.

TA lives with her parents and has been going to high school while working part time in an automotive parts store. She wants to keep her infant and to breastfeed “for at least 3 months.” She plans to finish school and return to work in 6 weeks.

Immediately after the delivery, the nurse conducts an assessment of TA, analyzes the data, and determines and prioritizes TA’s nursing care needs. The same is done for the newborn.

1. Within the standard, how should bonding be promoted—including eye contact between mother and infant—while eye prophylaxis is being administered?

2. Including safety for the nurse administering the ointment, what steps should the nurse follow to instill ointment into the infant’s eyes?

3. What should TA be taught about the side effects of eye prophylaxis?
4. How should the nurse explain the reason for the vitamin K injection for the infant in terms TA can understand?
5. Which newborns are eligible to receive the hepatitis B vaccine?
6. How many doses constitute the total series, and what is the duration for these? 7. Why is this vaccine given to newborns? Why is it important?

Answer 1

1. Mother and new born bonding is vey important soon after the delivery both in terms of psychological and physiological. Eye to eye contact should be promoted soon after the eye prohylaxis is given to the new born, another technique which could be uses is skin-to-skin contact where the baby is placed on mothers chest, it is also known as kangaroo mother care, it has many benefits for instance it helps the baby to adjust the outside environment or the temperature and prevents hypothermia in new borns. Lastly, breastfeeding should be initiated as early as possible since it is also a way for the mother and child to bond.

2. Applying eye prophylaxis which is Ilotycin ointment usually applied to prevent nenatal conjunctivitis and other conditions such as Chlamydia and Gonorrhea could be very challenging as the new born may be constantly moving, hence it is not a job for a one person, the child should be placed in a supine position with his/her head tilt back slightly, following which a nurse cleans the surrouding of the eye and gently pulls the lower eyelid and applying almost an inch of the ointment and slowly releasing the lid and cleans the surroundings in case of any excess is left.

3. The nurse should educate TA about the eye prophylaxis and also its side effects. TA should report to the nurse immediately if she sees any of these nearby the eyes:

• Redness
• stinging
• fever
• Irritation

4. The nurse should provide comfortable position to the position and should make sure no interruption is there when she is explaining. She should inform TA that new borns are born with decrease level of vitamin K which is very important when it comes to stop the bleeding and it is sometimes known as vitamin K deficiancy bleeding.