Professional Documents
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Antepartal risk factors (This will be obtained from the mother's chart!):
Maternal Age 31 Gravida/Para(GTPAL) 4-3-0-1-3 Gestational Age 40 4/7
Onset of Prenatal Care10 weeks Maternal Blood type A negative
Planned/Unplanned pregnancy Planned Maternal Substance abuse N/A Gestational Diabetes N/A
Maternal Infections N/A Abnormal US findings N/A
Additional information _N/A____________________________________________________
No
= Not present
NA = Not applicable
Skin: Clear __+____ Pressure marks ______ Abrasions ______ Dry ______
Ecchymosis ______ Petechiae ______ Nevi ______ Milia ______
Rash ______ Lanugo ______ Vernix __+____ Mongolian spots ______
Overriding
Separated
Approximated
Coronal
________
________
_____+______
Sagittal
________
________
______+_____
Lambdoidal
________
________
_____+______
Ears: (describe exact location & how you determined if it was normal)
Position: Normal ___+___ Abnormal ______ Describe normal position Symmetric, centered
Skin tags ______
Nose: Symmetry ___+_____ Flaring ______ Patent: Left __+___ Right __+___
Eyes: (describe what you found)
Right
Left
Subconjunctival hemorrhage
_____
_____
Nevi on lids
_____
_____
Edema
__+___
__+___
Red reflex
__+___
___+__
Other
_____
_____
Y N
Stool:
Y N Type Meconium
Extremities:
Right
Left
Symmetry
__+____
___+___
Movement
__+____
___+___
Digits (number)
___5___
___5___
Flexion creases
___+___
__+____
Palmar creases
___+___
___+___
Sole creases
___+___
___+___
Intact
Dislocated/subluxation
Hips:
Right
___+___
______
Left
___+___
______
Neuro-muscular: Tone: Normal __+___ Lethargic _____ Rigid _____ Tremors _____
Reflexes:
Reflex: Describe what
you observed
Describe normal
responses
toward hand
Sucking: Baby sucked hand
sensation
Baby should suck what
stretched out
is startled
he were walking
Grasp/hand: Baby gripped
walking motions
Baby should grip fingers
finger
Grasp/foot: Baby curled toes
downward
downward
What is your overall assessment and prognosis for this infant (do not say good):
This infant has acclimated well to life on his own outside of the womb. His body is making the
proper adjustments for life, and he is progressing as he should be at this stage. This is a healthy
infant, with a stable prognosis if he continues to progress this way. There are no signs of any
ailments in this baby at this time.
On the basis of your assessment, list 2-3 nursing diagnoses for this baby and the teaching
interventions you would use for each nursing diagnosis. Please include the rationale for your
actions. You must have at least two references other than your textbooks for your rationales.
Be sure your assessment and interventions correspond to your nursing diagnosis.
Nursing Diagnosis
Risk for altered nutrition r/t
insufficient breastfeeding
Ineffective thermoregulation
r/t transition to extrauterine
environment
Necessary
Assessments/Interventions
Rationale
Baseline to ensure what the client already knows to begin the education
plan
The increased calories ensures that the mother will produce enough milk
to satisfy her infant
The chance of having a successful breastfeeding session is increased if
the baby is in the proper position to feed, and the mother and baby are
comfortable
A lactation consultant can ensure that the mother is aware of all of the
requirements with breastfeeding, and she can address any concerns that
she has with the process with her
Appointments will help the team to ensure proper infant growth and
nutrition status (Leifer, 2012)
Infants have a decreased ability to regulate temperature, and are more
susceptible to heat loss via evaporation, conduction, convection and
radiation than adults (Knobel, 2014)
Skin-to-skin is as effective as an incubator for rewarming the infant, and
for preventing hypothermia (Smith, 2014).
Infants that take immersion baths have a delayed incidence of
hypothermia compared to those with sponge baths because of the
decreased time of exposed wet skin to the air (Loring, et al. 2010)
References:
Knobel, R. (2014). Fetal and neonatal thermal physiology. Newborn and Infant Nursing Reviews,
14 (2), p. 45-49. doi: 10.1053/j.nainr.2014.03.003
Smith, J. (2014). Thermoregulation and temperature taking in the developing world: A brief
encounter. Journal of Neonatal Nursing, 20 (5), p. 218-229.
doi:10.1016/j.jnn.2014.03.002
Leifer, G. (2012). Maternity Nursing (11th ed.). St. Louis, MO: Elsevier
Loring, C. F., Reilly, J. E., Gregory, K., Gargan, B., LeBlanc, V., Lundgren, D., Walker, K., &
Zaya, C. (2010). Temperature control in the late preterm infant: A comparison of
thermoregulation following two bathing techniques. Journal of Obstetric, Gynecologic,
& Neonatal Nursing, 39 (s1), p. S92. doi: 10.1111/j.1552-6909.2010.01124.x
Needs Improvement
Meets Expectations
Exc
(15 points)
Assessment has > 8 blanks
spaces, has poor analysis
(0 points)
Does not complete the care plan
(20 points)
Assessment has 9-12 blank spaces
(30 p
Asse
and e
(15 p
Choo
diagn
C. Interventions
(0 points)
Does not have any interventions
(10 points)
Has chosen inappropriate nursing
interventions
D. Rationale for
interventions
(0 points)
Does not have any rationales for
interventions
(10 points)
Stated inappropriate rationales for
nursing interventions
(25 points)
Assessment has 1-5 blanks
spaces, analysis lacks depth
(10 points)
Chooses 2 appropriate nursing
diagnosis based on the
assessment
(15 points)
Has chosen 2-3 appropriate
nursing interventions for each
diagnosis
(15 points)
Stated appropriate rationales for
nursing interventions for each
diagnosis
(0 points)
>10 errors in grammar or
spelling; Ideas are not presented
clearly.
(1 points)
5-10 errors in grammar or
spelling; Ideas are almost always
presented clearly
(3 points)
<5 errors in grammar or spelling;
Ideas are presented clearly
F. References
(0 points)
Has no citations and references
(2 points)
Has citations and references from
current textbooks.
(4 points)
Has citations and references from
other nursing textbooks,
Spectrums care plans or medical
websites.
A. Assessment
B. Nursing diagnosis
(5 points)
Chooses inappropriate nursing
diagnoses based on the assessment
(20 p
Has c
nursi
nursi
(20 p
In-de
interv
with
supp
(5 po
APA
in gr
prese
(10 p
Has c
journ