Student Name: MaricopaNursing NUR 252 OB Care Study Date:

CRITICAL THINKING EXERCISE

Issue: (Assigned by Instructor daily) positive Coombs test on newborn

1) What are you on alert for today with this patient?

Monitor for jaundice or signs of anemia.

2) What are the important assessments to make?

Lab work, CBC, Biliruben, assess for jaundice either by blanching the baby’s skin and seeing if it turns yellow or using the transcutaneous
meter to read the levels.

3) What complications may occur? What could go wrong? CITATION REQUIRED.

Erythoblastosis fetalis – in extreme cases of anemia, the infants body will produce erythrocytes to replace the RBC that were lysed by the
mothers antibodies in her blood.

The need for an exchange transfusion- (rare) The newborns blood would be transfused with Rh- blood to stop the lysing of the RBC, then the
newborns blood would slowly be returned back.

Wong, D. L. (2006). Maternal child nursing care. St. Louis, MO: Mosby Elsevier.
pg. 852-853

Durham, R. F., Chapman, L., & Chapman, L. (2014). Maternal-newborn nursing: the critical components of nursing care. Philadelphia: F.A. Davis
Company.
Chapter 17 High Risk Neonatal nursing care

Silvestri, L. A. (2014). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
Chapter 34 Care of the Newborn

4) What interventions will prevent complications?

Monitor labs
Do frequent bilirubin assessment to test for yellowing of the skin.
Place eye protection on newborn and place under a bili-light if needed.
Maintain hydration for newborn
. Assess for edema, pallor or hepatosplenomegaly
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Student Name: MaricopaNursing NUR 252 OB Care Study Date:

5) Create a Nursing Diagnosis using the PES statement (problem etiology symptoms)

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Student Name: MaricopaNursing NUR 252 OB Care Study Date:

DIAGNOSIS NURSING INTERVENTIONS EBP RATIONALE EVALUATION

PLAN/GOAL
 Specific
What is your priority nursing diagnosis for  Realistic
this patient?  Measurable
Nursing Diagnosis: The patient will___ by ___.
Risk for hemolytic disease (anemia or Remain free of disorders from
increased bilirueben) Rh incompatibility during
hospital stay.
How will you assist the patient in
achieving the goal?
Your intervention should start with an
action verb: Assist, Instruct, Provide…
Start with early feedings for the
newborn. Also maintain hydration
by feeding every 2-3 hours.
EBP citation needed
How does this intervention help Did the patient achieve the goal?
your patient reach the stated goal? Why or why not?
If the goal was not achieved, how
would you modify it?
Did the patient meet the overall
The will stimulate stool to goal? Circle One:
help the infant remove Yes
buildup of bilirubin if it is No
Partially
present from hemolysis of the
RBC.

Related to (r/t):
Mother is Rh- and baby is Rh+
blood, determined by a positive
direct Coombs test on the infant.
Mom O+ baby B+
AEB: (as evidenced by)
No signs of hemolytic disease.
Assess the degree of jaundice
every shift with the transcutaneous
meter or use fingers to blanch the
infants’ skin.
If jaundice is present
blanching the skin will cause
it to appear as a yellow color
before returning to normal.

Notify HCP if jaundice is present. Treatment is needed under

the floureescent bili lights.
The sooner that is donne, the
less chance there is for the
excess bilirueben to bild up
Defining Characteristics : as in the blood
manifested by (AMB):
Assess infant for pallor, edema or Erythroblastosis Fetalis is
Subjective: hepatosplenomegaly. caused by the destruction of
RBC that can occur with Rh
incompatibility.
.

Monitor labwork – CBC, Biliruben Early detection can help

levels facilitate getting the
Objective: intervention started earlier.
Severe anemia can lead to
hypoxia.
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Student Name: MaricopaNursing NUR 252 OB Care Study Date:

6) Complete the Nursing Care Plan (next page) based on Issue assigned from nursing diagnosis in #5

CARE PLAN

JOURNAL
7) Provide an Example of how you met at least 2 Objectives (use the formative Summative Clinical Evaluation Objectives) for this Course.
Describe your example with the QSEN KSA applied to the objective (you will find the KSA on the Formative Summative). How did you meet the
objective: (choose 2 different objectives each week)

1) Objective: _________________________________________________________________________________
KSA example:

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Student Name: MaricopaNursing NUR 252 OB Care Study Date:

2) Objective:__________________________________________________________________________________
3) KSA example:

8) Discuss and list the skills and items you learned from this clinical experience:

9) Reflect on your thoughts, actions, learning experiences and feelings during your clinical day. What did you learn and what do you need to
improve upon?

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Student Name: MaricopaNursing NUR 252 OB Care Study Date:

Wong, D. L. (2006). Maternal child nursing care. St. Louis, MO: Mosby Elsevier.
pg. 852-853

Durham, R. F., Chapman, L., & Chapman, L. (2014). Maternal-newborn nursing: the critical components of nursing care. Philadelphia: F.A. Davis
Company.
Chapter 17 High Risk Neonatal nursing care

Silvestri, L. A. (2014). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
Chapter 34 Care of the Newborn

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