NCLEX: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: THE NEWBORN INFANT

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

General overview: Effective nursing care of the newborn infant is based on: (1) knowledge of the conditions present during fetal life; (2) requirements for independent extrauterine life; and (3) alterations needed for successful transition. The first 24 hours are the most hazardous.

I. BIOLOGICAL FOUNDATIONS OF NEONATAL ADAPTATIONGeneral aspects:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Fetal anatomy and physiology

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Fetal circulation—five intrauterine structures that differ from extrauterine structures (Fetal circulation):

a. Umbilical vein—carries oxygen and nutrient-enriched blood from placenta to ductus venosus and liver.

b. Ductus venosus—connects to inferior vena cava; allows most blood to bypass liver.

c. Foramen ovale—allows fetal blood to bypass fetal lungs by shunting it from right atrium into left atrium.

d. Ductus arteriosus—allows fetal blood to bypass fetal lungs by shunting it from pulmonary artery into aorta.

e. Umbilical arteries (two)—allow return of deoxygenated blood to the placenta.

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

2. Umbilical cord—extends from fetus to center of placenta: usually 50 cm (18–22 inches) long and 1 to 2 cm (½–1 inch) in diameter. Contains:

a. Wharton’s jelly—protects umbilical vessels from pressure, cord “kinking,” and interference with fetal-placental circulation.

b. Umbilical vein—carries oxygen and nutrients from placenta to fetus.

c. Two umbilical arteries—carry deoxygenated blood and fetal wastes from fetus to placenta. Note: Absence of one artery indicates need to rule out intra-abdominal anomalies.

3. Characteristics of fetal blood

a. Fetal hemoglobin (HbF)

  • Higher oxygen-carrying capacity than adult hemoglobin.
  • Releases oxygen easily to fetal tissues.
  • Ensures high fetal oxygenation.
  • Normal range at term: 12 to 22 g/dL; average: 15 to 20 g/dL.

b. Total blood volume at term: 85 mL/kg body weight; Hct: 38% to 62%, average 53%; RBCs: 3 to 7 million, average 4.9 million/unit.

B. Extrauterine adaptation: tasks

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family    

1. Establish and maintain ventilation, successful gas transfer—requires patent airway and adequate pulmonary surfactant.

2. Modify circulatory patterns—requires closure of fetal structures.

3. Absorb and utilize fluids and nutrients.

4. Excrete body wastes.

5. Establish and maintain thermal stability.

C. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Facilitate successful transition to independent life.

2. Protect infant from physiological stress and environmental hazards.

3. Encourage development of a strong family unit.

II. ADMISSION/ASSESSMENT: 1 TO 4 HOURS AFTER BIRTH

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Admission assessment of normal, term neonate

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Color and reactivity.

2. General appearance, symmetry.

3. Length and weight.

4. Head and chest circumferences.

5. Vital signs:

a. Axillary temperature.

b. Respirations (check rate, character, rhythm).

c. Apical pulse.

6. General physical assessment (Physical Assessment of the Term Neonate) and reflexes (Assessment: Normal Newborn Reflexes).

7. Estimate of gestational age (Estimation of Gestational Age: Common Clinical Parameters).

B. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Altered health maintenance related to separation from maternal support system.

2. Impaired skin integrity related to umbilical stump; incontinence of urine and meconium stool; skin penetration by scalp electrode, injections, heel stick, scalpel during cesarean birth; abrasion from obstetric forceps.

3. Ineffective airway clearance related to excessive mucus.

4. Pain related to environmental stimuli.

5. Ineffective thermoregulation related to immature temperature regulation mechanism.

Health Promotion and Maintenance; Nursing Care of the Childbearing FamilyCaptureHealth Promotion and Maintenance; Nursing Care of the Childbearing FamilyCaptureHealth Promotion and Maintenance; Nursing Care of the Childbearing Family

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing FamilyCapture

 

C. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Goal: promote effective gas transport.

a. Maintain patent airway—to promote effective gas exchange and respiratory function.

b. Position: right side-lying, head dependent (gravity drainage of fluid, mucus).

c. Suction prn with bulb syringe for mucus.

2. Goal: establish/maintain thermal stability.

a. Avoid chilling—to prevent metabolic acidosis.

b. Dry, wrap, and apply hat.

c. Place in heated crib.

d. Monitor vital signs hourly until stable.

3. Goal: reduce possibility of blood loss.

a. Check cord clamp for security.

b. Administer vitamin K injection, as ordered, in anterior or lateral thigh muscle—to stimulate blood coagulability.

4. Goal: prevent infection.

a. Administer antibiotic treatment to eyes (if not performed in birth room)—to prevent ophthalmia neonatorum.

b. Treat cord stump (alcohol), as ordered.

c. Use standard precautions.

5. Goal: promote comfort and cleanliness. Admission bath when temperature stable.

6. Goal: promote nutrition, hydration, elimination.

a. Encourage breastfeeding within 1 hour after birth.

b. Check blood sugar (Dextrostix or Chem-strip) at 30 minutes, 1, 2, and 4 hours for infants at risk for hypoglycemia (e.g., SGA, LGA, infant of diabetic mother).

c. First feeding at 1 to 4 hours of age with sterile water (or formula) if permissible and if not breastfeeding.

d. Note voiding or meconium stool; report if failure to void or defecate within 24 hours.

7. Goal: promote bonding.

a. Encourage parent-infant interaction (holding, touching, eye contact, talking to infant).

b. Encourage breastfeeding within 1 hour of birth, if applicable.

c. Encourage parent participation in infant care—to develop confidence and competence in caring for newborn.

  • Assist with initial efforts at feeding.
  • Discuss and demonstrate positioning and burping techniques.
  • Demonstrate/assist with basic care procedures, as necessary:

(a) Bath.
(b) Cord care.
(c) Diapering.
(d) Aid parents in distinguishing normal vs. abnormal newborn characteristics.

8. Goal: health teaching—to provide anticipatory guidance for discharge.

a. Facilitate sibling bonding.

b. Describe/discuss normal newborn behavior:

  • Sleeping—almost continual (wakes only to feed) or 12 to 16 hours daily.
  • Feeding—from every 2 to 3 hours to longer intervals; establish own pattern; babies who are breastfed feed more often.
  • Weight loss—5% to 10% in first few days; regained in 7 to 14 days.
  • Stools—(Infant Stool Characteristics).
  • Cord care—cord drops off in 7 to 10 days

(a) Keep clean and dry.
(b) Alcohol may be applied to stump, or it may be allowed to dry naturally.
(c) HIV precautions.

  • Circumcision care

(a) Keep clean and dry; heals rapidly.
(b) Watch for bleeding.
(c) Petroleum jelly, gauze prn, if ordered.
(d) Do not remove yellowish exudate.

  • Physiological jaundice—occurs 24 to 72 hours after birth.

(a) Nonpathologic.
(b) Need for hydration.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

  • Identify need for newborn screening test after ingestion of milk (done routinely at 24 hours of age and later). Includes screen for congenital hypothyroidism and galactosemia.
  • Describe suggested sensory stimulation modalities (mobiles, color, music).
  • Discuss safety precautions:

(a) Position on back for sleep.
(b) Infant seat for travel and home safety.

(c) Maintaining contact/control over infant to prevent falls, drowning in bath.
(d) Instruct parents in infant cardiopulmonary resuscitation (CPR).
(e) Hepatitis B vaccination—first dose can be given at 24 to 48 hours of life; second dose at 1 month; third dose at 6 months. If infant born to mother who is infected, hepatitis B vaccine and hepatitis B immune globulin should be administered within 12 hours of birth.

  • Describe signs of common health problems to be reported promptly:

(a) Diarrhea, constipation.
(b) Colic, vomiting.
(c) Rash, jaundice.
(d) Differentiation from normal patterns.

D. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Infant demonstrates successful transition to independent life:

a. Breastfeeds well.

b. Normal feeding, sleeping, elimination patterns.

c. No evidence of infection or abnormality.

2. Mother/family evidences bonding.

a. Eye contact.

b. Stroking, cuddling.

c. Crooning, calling baby by name, talking to infant.

3. Mother demonstrates comfort and skill in basic newborn care.

4. Mother verbalizes understanding of subjects discussed:

a. Safety precautions.

b. Health maintenance actions.

c. Signs of normal infant behavior and health.

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Health Promotion and Maintenance; Nursing Care of the Childbearing Family: Complications During the Neonatal Period: The High-Risk Newborn

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

I. GENERAL OVERVIEW—Successful newborn adaptation to the demands of independent extrauterine life may be complicated by environmental insults during the prenatal period or those arising in the period immediately surrounding birth. The nursing role focuses on minimizing the effect of present and emerging health problems and on facilitating and supporting a successful transition to extrauterine life.

II. GENERAL ASPECTS—common neonatal risk factors:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Gestational age profile (see Assessment: Normal Newborn Reflexes and Estimation of Gestational Age: Common Clinical Parameters):

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

  1. Prematurity.
  2. Dysmaturity.
  3. Postmaturity.

B. Congenital disorders.

C. Birth trauma.

D. Infections.

III. DISORDERS AFFECTING PROTECTIVE FUNCTIONS: NEONATAL INFECTIONS

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assess for intrauterine infections.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

B. Oral thrush (mycotic stomatitis).

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—local inflammation of oral mucosa due to fungal infection.

2. Etiology:

a. Organism—Candida albicans.

b. More common in newborn who is vulnerable (i.e., sick, debilitated; those receiving antibiotic therapy).

3. Mode of transmission—direct contact with:

a. Maternal birth canal, hands, and linens.

b. Contaminated feeding equipment, staff’s hands.

4. Assessment:

a. White patches on oral mucosa, gums, and tongue that bleed when touched.

b. Occasional difficulty swallowing.

5. Analysis/nursing diagnosis:

a. Pain related to irritation of oral mucous membrane secondary to oral moniliasis.

b. Altered nutrition, less than body requirements related to irritability and poor feeding.

6. Nursing care plan/implementation: Goal: prevent cross-contamination.

a. Aseptic technique; good hand washing.

b. Give medications as ordered:

  • Aqueous gentian violet, 1% to 2%: apply to infected area with swab.
  • Nystatin (Mycostatin)—instill into mouth with medicine dropper, or apply to lesions with swab, after feedings. Note: Before medicating, feed sterile water to rinse out milk.

7. Evaluation/outcome criteria:

a. Oral mucosa intact, lesions healed, no evidence of infection.

b. Feeds well; maintains weight or regains weight lost, if any.

C. Neonatal sepsis

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—generalized infection; may overwhelm infant’s immature immune system.

2. Etiology:

a. Prolonged rupture of membranes.

b. Long, difficult labor.

c. Resuscitation procedures.

d. Maternal infection (e.g., β-hemolytic streptococcus vaginosis).

e. Aspiration—amniotic fluid, formula, mucus.

f. Iatrogenic (nosocomial)—caused by infected health personnel or equipment.

3. Assessment:

a. Respirations—irregular, periods of apnea.

b. Irritability or lethargy.

4. Analysis/nursing diagnosis:

a. Fatigue related to increased oxygen needs.

b. High risk for infection related to septic condition.

5. Nursing care plan/implementation:

a. Cultures (spinal, urine, blood).

b. Check vitals.

c. Monitor respirations.

d. Give medications, as ordered.

6. Evaluation/outcome criteria:

a. Responds to medical/nursing regimen (all assessment findings within normal limits).

b. Parent(s) verbalize understanding of diagnosis, treatment; demonstrate appropriate techniques in participating in care (as possible).

c. Parent(s) demonstrate effective coping with situation; express satisfaction with care.

IV. DISORDERS AFFECTING NUTRITION: INFANT OF THE DIABETIC MOTHER (IDM)

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Pathophysiology—hyperplasia of pancreatic beta cells → increased insulin production → excessive deposition of glycogen in muscles, subcutaneous fat, and tissue growth. Results in fetal:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Macrosomia—LGA infant.

2. Enlarged internal organs—common.

a. Cardiomegaly.

b. Hepatomegaly.

c. Splenomegaly.

3. Neonatal—inadequate carbohydrate reserve to meet energy needs.

4. Associated with increased incidence of:

a. Congenital anomalies (five times average incidence with pregestational diabetes) includes cardiac, pelvic, and spinal anomalies.

b. Preterm birth: respiratory distress syndrome (RDS); increased insulin needs prenatally lead to decreased surfactant production.

c. Fetal dystocia—due to CPD.

d. Neonatal metabolic problems:

  • Hypoglycemia.
  • Hypocalcemic tetany.
  • Metabolic acidosis.
  • Hyperbilirubinemia.

B. Etiology—high circulating maternal glucose levels during fetal growth and development; loss of maternal glucose supply following birth; decreased hepatic gluconeogenesis.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

C. Assessment:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Characteristics of IDM.

2. Hypoglycemia—Dextrostix or Chem-strip to heel stick at:

a. 30 minutes × 2.

b. 1, 2, and 4 hours of age; before meals × 4 or until stable.

c. Chem-strip: if less than 20 mg/dL, must draw glucose STAT.

d. Hypoglycemia laboratory values for preterm and term infants: under 45 mg/dL.

e. Behavioral signs—tremors; twitching, hypotonia, seizures.

3. Gestational age, since macrosomia may mask prematurity.

4. Hypocalcemia—usually within first 24 hours

a. Irritability.

b. Coarse tremors, twitching, convulsions.

5. Birth injuries:

a. Fractures: clavicle, humerus, skull.

b. Brachial palsy.

c. Intracranial hemorrhage/signs of increased intracranial pressure.

d. Cephalohematoma.

6. Respiratory distress:

a. Nasal flaring.

b. Expiratory grunt.

c. Sternal retraction.

d. Intercostal retractions.

e. Cyanosis—central.

7. Jaundice.

D. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. High risk for injury related to CPD, dystocia.

2. Altered cardiopulmonary tissue perfusion related to placental insufficiency, RDS.

3. Impaired gas exchange related to RDS.

4. Altered nutrition, less than body requirements, related to hypoglycemia, hypocalcemia.

5. Risk for altered endocrine/metabolic processes related to hyperbilirubinemia and kernicterus.

E. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Hypoglycemia—administer formula or IV glucose, as ordered (may cause rebound effect).

2. Preterm/immature—institute preterm care prn.

3. Hypocalcemia—administer oral or IV calcium gluconate, as ordered.

4. Inform pediatrician immediately of signs of:

a. Jaundice.

b. Hyper-irritability.

c. Birth injury.

d. Increased intracranial pressure/hemorrhage

F. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Infant makes successful transition to extrauterine life.

2. Infant responds to medical/nursing regimen. Experiences minimal or no metabolic disturbances (hypoglycemia, hypocalcemia, hyperbilirubinemia).

3. Infant exhibits normal respiratory function and gas exchange.

V. HYPOGLYCEMIA

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Pathophysiology—low serum-glucose level → altered cellular metabolism → cerebral irritability, cardiopulmonary problems.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

B. Etiology:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Loss of maternal glucose supply.

2. Normal physiological activities of respiration, thermoregulation, muscular activity exceed carbohydrate reserve.

3. Decreased hepatic ability to convert amino acids into glucose.

4. More common in:

a. Infants of diabetic mothers.

b. Preterm, post-term infants.

c. SGA infants.

d. Smaller twin.

e. Infant of mother with preeclampsia.

f. Birth asphyxia.

C. Assessment:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Jitteriness, tremors, convulsions; lethargy and hypotonia.

2. Sweating; unstable temperature.

3. Tachypnea; apneic episodes; cyanosis.

4. High-pitched, shrill cry.

5. Difficulty feeding.

D. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Altered tissue perfusion (fetal) related to placental insufficiency associated with maternal diabetes, preeclampsia, renal or cardiac disorders; erythroblastosis.

2. Risk for altered endocrine metabolic processes related to high incidence of morbidity associated with birth asphyxia.

3. Impaired gas exchange related to coexisting RDS.

4. Altered nutrition, less than body requirements, related to hypoglycemia.

5. High risk for injury related to coexisting infection, metabolic acidosis.

VI. DISORDERS AFFECTING PSYCHOSOCIAL-CULTURAL FUNCTIONS: NEONATE WHO IS DRUG-DEPENDENT (HEROIN)

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. General aspects

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Maternal drug addiction has been associated with:

a. Prenatal malnutrition and vitamin deficiencies.

b. Increased risk of antepartal infections.

c. Higher incidence of antepartal and intrapartum complications.

2. Infant at risk for:

a. Intrauterine growth retardation (IUGR).

b. Prematurity.

c. Fetal distress.

d. Perinatal death.

e. Child abuse.

f. Sudden infant death syndrome (SIDS) (5–10 times higher than normal).

g. Learning and behavior disorders.

h. Poor social adjustment.

B. Pathophysiology—withdrawal of accustomed drug levels → physiological deprivation response.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

C. Etiology—repeated intrauterine absorption of heroin/cocaine/methadone from maternal bloodstream → fetal drug dependency.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

D. Assessment—degree of withdrawal depends on type and duration of addiction and maternal drug levels at birth.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Irritability, hyperactivity, hypertonicity, exaggerated reflexes, tremors, high-pitched cry, difficult to comfort:

a. “Step” reflex (dancing)—infant places both feet on surface; assumes rigid stance—does not “step” or dance.

b. “Head-righting” reflex—holds head rigid; fails to demonstrate head lag.

2. Nasal stuffiness and sneezing; respiratory distress, tachypnea, cyanosis, or apnea.

3. Exaggerated acrocyanosis or mottling in the infant who is warm.

4. Sweating.

5. Hunger—sucks on fists; feeding problems—regurgitation, vomiting, poor feeding, diarrhea, and increased mucus production.

6. Convulsions with abnormal eye-rolling and chewing motions.

7. Developmental lags/mental retardation.

E. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. High risk for injury related to convulsions secondary to physiological response to withdrawal, CNS hyperirritability.

2. Impaired gas exchange related to respiratory distress secondary to inhibition of reflex clearing of fluid by the lungs.

3. Altered nutrition, less than body requirements, related to feeding problems secondary to respiratory distress and GI hypermotility.

4. High risk for impaired skin integrity related to scratching secondary to withdrawal symptoms.

F. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Goal: prevent/minimize respiratory distress.

a. Position: side-lying, head dependent—to facilitate mucus drainage.

b. Suction prn with bulb syringe for excess mucus—to maintain patent airway.

c. Monitor respirations and apical pulse.

2. Goal: minimize possibility of convulsions.

a. Decrease environmental stimuli—quiet, touch only when necessary, offer pacifier.

b. Keep warm, swaddle for comfort.

3. Goal: maintain nutrition/hydration.

a. Food/fluids—oral or IV, as ordered.

b. I&O.

c. Daily weight.

4. Goal: assist in diagnosis of drug and drug level. Collect all urine and meconium during first 24 hours for toxicological studies.

5. Goal: maintain/promote skin integrity.

a. Mitts over hands—to minimize scratching.

b. Keep clean and dry.

c. Medicated ointment/powder, as ordered, q2–4h, to excoriated areas.

d. Expose excoriated areas to air.

6. Goal: minimize withdrawal symptoms. Administer medications, as ordered.

a. Paregoric elixir—to wean from drug.

b. Phenobarbital—to reduce CNS hyperirritability, hyperbilirubinemia.

c. Chlorpromazine (Thorazine), diazepam (Valium)—to tranquilize, reduce hyper-irritability. Note: Valium is contraindicated for the neonate who is jaundiced because it predisposes to hyperbilirubinemia.

d. Methadone.

7. Goal: emotional support to mother.

a. Encourage verbalization of feelings of guilt, anxiety, fear, concerns.

b. Refer to social service.

G. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Infant responds to medical/nursing regimen.

a. Maintains adequate respirations.

b. Feeds well, gains weight.

c. No evidence of CNS hyperirritability, convulsions; demonstrates normal newborn reflexes.

2. Infant evidences bonding with parent(s). Responsive to mother’s voice.

VII. DISORDERS AFFECTING PSYCHOSOCIAL-CULTURAL FUNCTION: FETAL ALCOHOL SYNDROME (FAS)

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. General aspects:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Maternal alcohol abuse has been associated with:

a. Malnutrition, vitamin deficiencies.

b. Bone marrow suppression.

c. Liver disease.

d. Child abuse.

2. Infant at risk for:

a. Congenital anomalies (FAS).

b. Mental deficiency; learning disabilities.

c. IUGR.

B. Pathophysiology—permanent damage to developing embryonic/fetal structures; cardiovascular anomalies (ventricular septal defects).

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

C. Etiology—high circulating alcohol levels are lethal to the embryo; lower levels cause permanent cell damage.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

D. Assessment:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Characteristic craniofacial abnormalities:

a. Short, palpebral fissure.

b. Epicanthal folds.

c. Maxillary hypoplasia.

d. Micrognathia.

e. Long, thin upper lip.

2. Short stature.

3. Irritable, hyperactive, poor feeding.

4. High-pitched cry, difficult to comfort.

E. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Goal: reduce irritability.

a. Reduce environmental stimuli.

b. Wrap, cuddle.

c. Administer sedatives, as ordered.

2. Goal: maintain nutrition/hydration.

3. Goal: emotional support to mother.

F. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. No respiratory distress.

2. Infant feeding properly.

3. Maternal bonding apparent.

4. Social services—home involvement.

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