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.”

Question: (****answer in depth and with bullets****)

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

2. Explain that the nurse would check to see if the interventions were successful; they would monitor patient, make changes to plan if necessary, make sure she gave appropriate, helpful and successful care.

Answer 1

1. Nursing diagnosis - Risk for aspiration related to the backflow of stomach contents or gastroesophageal reflux.

Nursing interventions :-

- Feed the baby smaller amounts at a time.

- Before feeding ,hold the baby in upright position

- Make each feed calm and relaxed

- Feed the baby without delay . If the baby has cried for a long time before having the feed ,baby must have swallowed air . Spitting up is more likely if the baby has air in the stomach at the beginning of feeding.

- Ensure burping of your baby after feeding

- Keep the baby in upright position after feeding for atleast 30mins .

- Make sure baby's napkins are not too tight and do not put pressure on the stomach .

The rationale behind all these interventions is that it will prevent the backflow of feed.

2.Yes ,the nurse will check whether the interventions were successful or not and will modify if the existing interventions does not work . Proper monitoring of the baby before and after feeding will be done by the nurse and if the baby does not show any improvements then further examination will be done to find out the cause behind it which are in depth by certain investigations like X-ray ,Scans etc and appropriate actions according to the image results will be initiated .