Mom’s labor was induced due to gestational diabetes mellitus, diet controlled. A healthy baby was delivered lady partslly without complications, Apgar score 9,9.
4234 grams, 9 pounds 5 ounces
24 Hours of Life
The nurse assesses the newborn and finds a cephalhematoma to the left occipital region. Current weight is 4185 grams, 9 pounds 4 ounces.
Dextrostik result is 52. T 37 (98.6) P 140 R 40.
Breast feeding; LATCH of L=1, A=0, T=2, C=2, H=1. (Total 6)
Baby has had 1 void and 1 stool.
Day 2,
Dextrostik result is 60, jaundice noted to nipple line, total bilirubin is 12.
T 98.2 (36.8), 150, RR 50.
Day 2, Weight and Feeding
Current weight is 3984 grams (8#12.5oz) LATCH score is 9, 1 off for audible sucking. There have been 2 wet diapers and 1 stool in the last 24 hours.
Question @ Day 2 of Life
The mother says the baby is being good, the baby sleeps most of the time. The mother asks the nurse, “Is it okay for the baby to be discharged this morning? I am eager to go home.”
Here are my nsg diagnosis:
#1 Risk for newborn injury (neurological), related to elevated serum bilirubin levels secondary to hemolysis of RBCs occurs in cephalohematoma as manifested by bilirubin level of 12 mg/dl.
#2 Risk for newborn injury related to hypoglycemia secondary to trauma from lady partsl delivery from large for gestational age infant.
#3 and i need one more.
My plan is to discharge mom, and reschedule her for a follow-up care.
please check to see if im doing correctly. thanks for the help.
well...there are a couple of things that concern me in this post and replies....first of all you mentioned the baby had 2 wet and 1 soiled diaper in 24 hours...usually 6-8 wet/soiled diapers in 24 hours is more normal. .
in the first day or two of life??? really???? maybe a kid who is having double his quota of formula, but 6-8 is not normal in the first few days. some may take 24 hours to do the first wee! 6-8 is very normal once past the first few days and the milk is in or the kid is graded up to having bigger bottle feeds.
if it's for the baby, think about what you know about the assessment findings of a normal newborn compared to an adult. what's different? for one thing newborns can't regulate their body temperature which is why we don't leave them exposed to the room atmosphere for very long with just a diaper covering them. that's ineffective thermoregulation r/t immature compensation for changes in environmental temperature. some newborns just have a few difficulties with excessive secretions in the respiratory track (the big hint here is that the nurses will keep a bulb syringe nearby the baby) so ineffective airway clearance can be used. they also have a stump from the umbilical cord hanging off their future belly button. do you? are they treating this cord stump? if it's inflamed or there are umbilical cord problems there is risk for infection, so you can use risk for infection r/t break in skin integrity at umbilical cord site ([color=#3366ff]risk for infection). if the baby has been circumscribed that is another reason for a risk of infection. is this baby breastfeeding? if so, use effective breastfeeding. and, some babies just don't start feeding well at first by breast or bottle--it happens. these kids are imbalanced nutrition: less than body requirements r/t poor infant feeding behaviors ([color=#3366ff]imbalanced nutrition: less than body requirements). the underlined blue type are a weblinks to nursing diagnosis pages with nanda information and some goals and nursing interventions.
if the baby is under the bililight for hyperbilirubinemia the nursing diagnosis to use is risk for injury r/t phototherapy ([color=#3366ff]risk for injury).
if it's for the baby, think about what you know about the assessment findings of a normal newborn compared to an adult. what's different? for one thing newborns can't regulate their body temperature which is why we don't leave them exposed to the room atmosphere for very long with just a diaper covering them. that's ineffective thermoregulation r/t immature compensation for changes in environmental temperature. some newborns just have a few difficulties with excessive secretions in the respiratory track (the big hint here is that the nurses will keep a bulb syringe nearby the baby) so ineffective airway clearance can be used. they also have a stump from the umbilical cord hanging off their future belly button. do you? are they treating this cord stump? if it's inflamed or there are umbilical cord problems there is risk for infection, so you can use risk for infection r/t break in skin integrity at umbilical cord site ([color=#3366ff]risk for infection). if the baby has been circumscribed that is another reason for a risk of infection. is this baby breastfeeding? if so, use effective breastfeeding. and, some babies just don't start feeding well at first by breast or bottle--it happens. these kids are imbalanced nutrition: less than body requirements r/t poor infant feeding behaviors ([color=#3366ff]imbalanced nutrition: less than body requirements). the underlined blue type are a weblinks to nursing diagnosis pages with nanda information and some goals and nursing interventions.
if the baby is under the bililight for hyperbilirubinemia the nursing diagnosis to use is risk for injury r/t phototherapy ([color=#3366ff]risk for injury).
wow, thanks a lot. all the information you gave me are super! i need to formulate nursing diagnosis and care plan base on my clinical scenario.:)
Specializes in Obstetrics/Case Management/MIS/Quality.
in the first day or two of life??? really???? maybe a kid who is having double his quota of formula, but 6-8 is not normal in the first few days. some may take 24 hours to do the first wee! 6-8 is very normal once past the first few days and the milk is in or the kid is graded up to having bigger bottle feeds.
yes there are those babies that take 24 hours to void for the first time too! thank you for clarifying the point about 6-8 dirty diapers once mom's milk comes in!!
This scenario gives me the heeebies ......YIKES....I would NOT discharge this baby with bili of 12 at 24 hours. That is in the mod-high( I am going by memory here) range and this baby should probably be on blanket or under lights. This kid also sounds dry to me, and should be stooling much more than it has been. What I see is the kid is not breastfeeding well, and with colostrum being a natural laxative, this baby would be stooling more if it were to the breast correctly and more often. The hematoma is most definitely contributing to the hyperbilirubinemia, and more frequent checks of the TBILI should be performed. This baby needs continued observation of the bili, and perhaps a consultation from a lactation specialist. One or two stools in a newborn is not the norm. Bili is excreted in the meconium, and the more the baby stools, the better. If this bili continued to increase, supplementing with formula or IV could be considered to hydrate.
This mom needs to be VERY aware that if the baby becomes lethargic, that this is NOT NORMAL and should seek medical attention. She also seems to have a deficit in knowledge in feeding her baby, and therefore should be seen by a lactation consultant. (I wonder WHY the baby sleeps so much...perhaps its bili of 12 or higher???)
I am sorry...I really dn't mean to be rude, but what does the peds think of this case????
Thank you for all the help. i got 8.25/10. i guess i shouldnt discharge the baby final is over, summer is coming, and ill be on my last semester. I got a B in OB, yay!
final is over, summer is coming, and ill be on my last semester. I got a B in OB, yay! 
OzMW
172 Posts
in the first day or two of life??? really???? maybe a kid who is having double his quota of formula, but 6-8 is not normal in the first few days. some may take 24 hours to do the first wee! 6-8 is very normal once past the first few days and the milk is in or the kid is graded up to having bigger bottle feeds.