The APGAR total score of the child at 1 and 5 minutes after birth are 4 and 6 respectively. These scores suggest that the child is in moderate distress (Pilliteri, 2002). The priority nursing interventions in this infant should address the respiratory problems of the child. The nurse should ensure that the mucous blocking the airway of the infant is suctioned in order to promote a good and clear airway. The nurse should also ensure that the infant is positioned properly (prone) to promote good chest expansion.
Continuous monitoring of the infant’s respiration and appropriate referral for oxygen supplementation, if necessary. Thermoregulation is also important, hence the infant should be properly dried up and adequately clothed after bathing to cover the infant (Pilliteri, 2002). B. The nurse should provide adequate education to the mother regarding hyperbilirubinemia. First, the nurse should inform the client that the hyperbilirubinemia in the baby is not pathologic, rather it is only physiologic jaundice which is considered normal in majority of babies.
This is supported by the laboratory result of conjugated bilirubin of the baby, which is within normal levels (Fischbach, 2004). Hyperbilirubinemia or increased levels of bilirubin occurs in the child because there is a high production of bilirubin but low elimination. Bilirubin is a byproduct of the breakdown of red blood cells. In a newborn, they have larger red blood cells (RBCs), which is in excess of what is needed by the body, hence, an increased breakdown of RBCs occur during the first few days of life. However, the infant’s liver, which is responsible for processing bilirubin, is still immature.
Hence, bilirubin accummulates and bilirubin levels increase leading to jaundice, the physical manifestation of hyperbilirubinemia (Gomella, 2009). Phototherapy is initiated in infants with physiologic jaundice. Before starting the phototherapy, the nurse prepares the equipments (light, crib) to be used and performs handwashing. After the set-up is prepared, the nurse positions the child on his crib (or incubator) under the overhead lamp. The nurse ensures that the maximum surface area of the child’s body is exposed except for the eyes and genitals.
Hence, the child is undressed while keeping the diapers to cover the genitals and an eye patch to cover both eyes. The genitals are covered to protect the gonads from being damaged because of the radiation from the light exposure. When covering the child’s eyes, the nurse makes sure that the infant’s eyes are closed to prevent excoriation of the cornea. In addition, the eyes are also protected to prevent damage to the retina, which can cause blindness (Bowden ; Greenberg, 2008). References Bowden, V. R. ; Greenberg, C. S. (2008). Pediatric nursing procedures.
2nd ed. Available from http://books. google. com/books? id=JcRc-Lrf1zIC;printsec=frontcover;dq=bowden+and+greenberg;cd=1#v=onepage;q;f=false Brown, S. T. , Douglas, C. , ; Flood, L. P. (2001). ‘Women’s evaluation of intrapartum nonpharmacological pain relief methods used during labor. ‘ Journal of Perinatal Education, 10(3), 1-8. doi: 10. 1624/105812401X88273 Fischbach, F. T. (2004). A manual of laboratory and diagnostic tests. 7th ed. Philadelphia: Lippincott Williams & Wilkins Griese, M. E. & Prickett, S. A. (2006). ‘Nursing management of umbilical cord prolapse.
‘ Journal of Obstetric, Gynecologic, and Neonatal Nursing. doi: 10. 1111/j. 1552-6909. 1993. tb01811. x Gomella, T. L. (2009). Neonatology: Management, procedures, on-call problems, diseases, and drugs. Available from http://books. google. com/books? id=Q5EfiEAodmEC&printsec=frontcover&dq=gomella&cd=1#v=onepage&q&f=false Kark, J. (2000). ‘Sickle cell trait. ‘ Retrieved May 19, 2010 from http://sickle. bwh. harvard. edu/sickle_trait. html Klossner, N. J. (2006). Introductory Maternity Nursing. Available from http://books. google. com/books? id=B47OVg25g-QC&printsec=frontcover#v=onepage&q&f=false
Kozier, B. , Erb, G. , Berman, A. , & Snyder, S. (2004). Fundamentals of nursing practice. 7th ed. New Jersey: Pearson Education Inc. Murray, M. L. & Huelsmann, G. M. (2009). Labor and delivery nursing: guide to evidence-based practice. Available from http://books. google. com/books? id=q22jEEZo7rwC&pg=PA78&dq=intradermal+water+blocks+during+labor&cd=5#v=onepage&q&f=false O’Connor, M. (1998).
Anatomy and physiology: Hormones involved in breast development and breastfeeding. ‘ Retrieved May 19, 2010, from http://www. breastfeedingbasics. org/cgi-bin/deliver. cgi/content/Anatomy/physiology. html Pilliteri, A. (2002). Maternal and child health nursing. 4th ed. Philadelphia: Lippincott Williams & Wilkins Ricci, S. S. & Kyle, T. (2009). Maternity and pediatric nursing. Available from http://books. google. com/books? id=gaYtFuND7VIC&printsec=frontcover&dq=ricci+and+kyle&cd=1#v=onepage&q&f=false Simkin, P. & Bolding, A. (2004). ‘Update on Nonpharmacologic Approaches to Relieve Labor Pain and Prevent Suffering. ‘ Journal of Midwifery and Women’s Health, 49(6). Retrieved from http://www. medscape. com/viewarticle/494120
Simpson, K. R. ; Creehan, P. A. (2008). Perinatal nursing. 3rd ed. Available from http://books. google. com/books? id=oz_4cTmVFD4C;printsec=frontcover;dq=simpson+and+creehan;cd=1#v=onepage;q;f=false Wagner, C. L. (2009). ‘Counseling the breastfeeding mother. ‘ Retrieved May 19, 2010, from http://emedicine. medscape. com/article/979458-overview Weiss, R. E. (2010). ‘Positions for breastfeeding your baby-cradle hold, football hold, cross-cradle, side-lying. ‘ Retrieved May 19, 2010, from http://pregnancy. about. com/od/breastfeedinginfo/ss/breastpositions. htm