Priority Nursing Diagnosis Goals/Outcomes
Risk for infection r/t The neonates’ vital signs
neonate’s immature will remain within normal
immune system, possible range, while remaining alert
GBS and active without signs or
symptoms of infection.
Supportive Data:
Mother has had history of
GBS (group B
streptococcus) and lab
results were positive for
infection. Goal/outcomes
attainment:
Outcomes attained:
Pt.’s VS remained within
normal limits, without signs
or symptoms of infection,
while remaining alert and
active in mothers’ arms.
(VS: Resp: 58, HR: 143,
B/P: 80/45, Temp: 97.8)
Nursing Interventions
1. Review maternal chart and
delivery record.
2. Washing hands before and
after providing care, following
aseptic technique before and
after handling neonate.
3. Assessing the neonates’
gestational age.
4. Assess respirations, pulse,
and blood pressure every 15
minutes for 1hour, then every
hour for 4 hours, then once per
shift or more frequently as
indicated.
5. Encourage mother to begin
breastfeeding early.
Rationale
1. This detects risk factors that
predispose neonate to infection
and determine adequate
treatment before delivery.
2. Hand washing is the single
best way to avoid spreading
pathogens.
3. Passive immunity of neonate
via placenta increases
significantly in the last
trimester, making premature
neonates much more
susceptible to infections.
4. Unstable vital signs,
persistent elevations in
temperature, or hypothermia
may indicate neonatal infection.
5. Colostrum and breast milk
contain high amounts of
immunoglobulin A, which
provides passive immunity to
neonate and helps reduce
infection.
Evaluations
1. Mother received antibiotics during the
latent phase of the first stage of labor in
order to prevent spreading of pathogen
to the neonate at the time of delivery.
2. Patient was able to state the risk
factors that can lead to infection;
“Washing my hands will help me
prevent spreading an infection to my
baby.”
3. Neonates’ gestational age was 38.6,
indicates term neonate which reduces
susceptibility to infections.
4. Neonates’ vital signs remained stable
with no elevation in temperature or
hypothermia.
(Resp: 58 HR: 143, BP:
80/45, TEMP: 97.8).
5. After mother received neonate in her
arms, she was able to draw the neonate
to her breast while helping the neonate
properly latch on, she was able to
verbalize the importance of colostrum
and breast milk, “Though my milk has
not come in and it might seem my baby
is not getting enough, this is full of the
nutrients the baby needs for now, and
this will also help my baby’s immune
system.”
Students Name: Iris Lopez Date: 2/2/11

Client Summary: Obstetrical History: EDC: 2/4/2011 Gestational age: 38.6

G: 3 P: 2 T: 2 P: 0 A: 0 L: 2

Significant history and pregnancy complications: History of positive GBS

Summary of labor and delivery process:

Stage 1 latent phase: FHR 143, BP 118/81, contractions 5 minutes, 50-80 seconds duration. Patient grimacing, fidgety, not
able to keep same position for more than 3-5 minutes, verbalizing the feeling of a large amount of pressure in the perineal area.

Active phase: FHR 135, B/P 118/80, contractions 2-3 minutes, 40-70 second duration, patients epidural was placed in her
back; she stated the feeling of numbness in her lower extremities and a decrease in pain but no decrease in the feeling of
pressure in the perineal area. Demeanor was more relaxed and patient was drowsy after epidural medication was started,
patient positive for GBS, antibiotics were administrated within limits before expulsion of the infant.

Transition phase: FHR 143, B/P 118/81, contractions 1-2 minutes, 10-20 seconds duration, patient in lithotomy position with
hands wrapping around thighs to help in the expulsion of the fetus----the primary nurse and doctor were instructing patient not
to bear down, since she was not able to feel the contractions she was unable to use the contraction to her advantage which was
making her feel more pressure and pain-----she was moaning and groaning with low screams due to pain.

Stage II: Patient was able to use contractions to her advantage, though at one, time instead of using her hands wrapped around
her thighs, she lifted herself off the lithotomy position with her hands---- both the primary nurse and doctor instructed her to
use her hands and thighs, my fellow student and I were instructed to help her understand why she needed to keep her sacral
area on the bed-----she was expressing pain through moaning and groaning with low screams, her eyes bulged when bearing
down, patient was verbalizing that she was not able to go through the expulsion of the infant, she was effaced 100% and
dilated 10cm, a few minutes later the infant was delivered, baby birth weight 8lbs, 20 inches long, VS within normal limits,
APGAR of 8, pink with slight bluish color to soles of feet and palms of hands, given to mother for bonding, the parents were
very happy and expressing gratitude for everyone’s help.