On the basis of your assessment, list 2-3 nursing diagnoses for this baby and all the teaching

interventions you would use for each nursing diagnosis. Please include the rationale for your
actions. You must have at least two references besides your textbooks for your rationales. Be sure
your assessment and interventions correspond to your Nursing Diagnosis.

Nursing Diagnosis
Ineffective Airway
Clearance related to
excessive secretions
in the respiratory
passage

Necessary
Assessments/Interventions
A: Listen to HR, lungs. Check
pulses and respirations.
Distress may be shown by
grunting, nasal flaring,
external retractions, seesaw
respirations
I: Position infant in supine
position with head to tilted to
side. Using bulb syringe,
suction secretions from upper
respiratory system starting in
the oral cavity then the nasal
passage. Keep bulb syringe in
crib with infant.

Risk for ineffective

A: Check infants temperature

Rationale
Diminished lung sounds may indicate respiratory compromise.
Increase respirations, grunting, nasal flaring, retractions indicate
respiratory distress.
Positioning infant in supine position allows for secretions to
work their way up and out as well as nasal and oral secretions to
not effect airway.
Starting in oral passage first is needed as infant may gasp if the
nasal passage is first suctions causing aspiration of mucous.
Murray, S. S., & McKinney, E. S. (2014). Foundations of
maternal-newborn and women's health nursing (6th ed.,
p. 417). St. Louis, MO: Elsevier Saunders.
Galanes, S. (n.d.). Airway Clearance, Ineffective. In Elsevier.
Retrieved from
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/ar
chive/Constructor/gulanick03.html
Davis, F.A. (2004). Nurses Pocket Guide: Diagnoses, Interventions, and
Rationales. (9th ed.). Philadelphia: F.A. Davis Company.
Regular temperature monitoring is needed to adequately
determine if there is any heat loss. Axillary is a good

thermoregulation
related to immature
compensation for
changes in
environmental
temperature

shortly after birth and then

every half hour until stable for
two hours. Do this using the
axillary temperature method.
I: Warm up radiant heater
before birth of baby. Have
warm blankets ready for
cleaning the baby and
swaddling the infant. Educate
the parents on the importance
of keeping the baby wrapped
up. Make sure infants head is
covered as this is the largest
source of heat loss. Promote
skin to skin immediately after
birth to use mothers body temp
to warm the infant.

indicator of infants temperature. Wrapping the baby will

diminish loss of heat via convection, conduction, or
evaporation, or radiation. Most of an infants surface area is
located in the head and neck. By putting a hat on the infant,
loss of heat can be realty diminished.
Murray, S. S., & McKinney, E. S. (2014). Foundations of
maternal-newborn and women's health nursing (6th ed., p.
418). St. Louis, MO: Elsevier Saunders.
Davis, F.A. (2004). Nurses Pocket Guide: Diagnoses, Interventions, and
Rationales. (9th ed.). Philadelphia: F.A. Davis Company.
Glass, S. M. (1999). Assessment and Care of the Well Newborn.
Philadelphia: W.B. Saunders Company