Baby Faith is 18-hour old newborn born by spontaneous vaginal delivery to a 23-year-old gravida 2, para 1, blood type O-negative mother.
Uncomplicated pregnancy. Rupture of membranes 7 hours prior to delivery with clear fluid. APGARs 7 and 9.
Mom states that breastfeeding- is a struggle; baby has a poor latch and is easily frustrated. Mom has sore nipples.
General - Slightly lethargic, crying with exam, flexed posture, visible jaundice
Vital signs - T 37.3C/ 99.1F, HR 144, RR 48
HEENT - Fontanelle slightly depressed, eyes and ears normal set/shape, sclera yellow, palate intact, tongue with Epstein pearls, dry mucous membranes
Cardo/Respiratory - No murmur, pulses +2 bilaterally, breath sound clear
Gastrointestinal/Genitourinary - Soft, non-distended, liver palpable, umbilical stump intact/clamped; passed 1 meconium stool, voided 1 time since birth.
The client is most likely experiencing:
Breastfeeding jaundice
Pathological jaundice
Physiological jaundice
Due to:
Poor breastmilk intake
Hemolysis
Impaired excretion
Infection
Select the nursing action(s) from each of the categories the nurse should anticipate including in the plan of care. Each category may have one or more nursing action(s).
Therapy - Phototherapy
Apply Eye shield
Monitor temperature hourly
Start/Practice? Kangaroo care
Monitor phototherapy light level
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Therapy - Nursing
Contact Lactation consultant
Encourage breast feeding every hour
Supplement feedings with infant formula
Weigh diapers
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What is the most serious complication of neonatal jaundice?
A - Anemia
B - Kernicterus
C - Infection
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The first step in managing the neonate would have been to check
Total bilirubin levels
Direct coobs test
Hematocrit
Hemoglobin
The results from the above would determine the course of management in regards to phototherapy, exchange transfusion and intravenous immunoglobulin
Action with its rationale
Eye shield Phototherapy lights can cause retinal damage,
Monitor temperature hourly hyperthermia, and bronzed baby syndrome.
The nurse must plan interventions to decrease the risk of these adverse effects of therapy.
Weigh diapers to monitor hydration status Dehydration is potential complication of phototherapy. Phototherapy increases insensible water losses.
Lactation consultant*- A lactation consultant can help the breastfeeding parent maximize the efficiency of the time breastfeeding. Although this neonate is struggling to breastfeed,
supplementing feedings with formula are…
Baby is dehydrated, ivf admistration is necessary
Baby's blood group should be checked to rule out ABO incompatibility
The cause of jaundice is most likely due to ABO incompatibility or Pathological because the jaundice occurred at 18 hour of life
Serum bilirubin should be monitored closely
We have to know the blood group of the baby and the baby need to receive iV fluids because the baby is dehydrated.
Baby is clearly dehydrated
Blood group of the father is also essential for adequate nursing care.