Problem: Risk for Ineffective Airway clearance r/t the excessive fluid and mucus in the newborns respiratory

passages. Goal: Newborn will maintain airway aeb having a respiratory rate within normal range of 30 to 60 breaths per minute, showing no signs of respiratory distress (McKinney & Murray, 2010). Assess: 1. Look for signs of respiratory distress, including tachypnea, retractions, flaring of the nares, pallor or cyanosis, grunting, seesaw respirations, and asymmetry of chest movements. a. This will aid in detecting an abnormalities that need further interventions. 2. Note the rate and character of the heart rate, pulses, respirations, and breath sounds. b. Early detection could be seen through these vital signs. 3. Check blood pressure if indicated. c. Shows the workload of the heart, which could reveal if the heart is getting oxygenated blood from the lungs. (McKinney & Murray, 2010) Do: 1. Make sure the mucus surrounding the face, mouth, and nose is whipped off of the newborn. a. Mucus surrounding the newborns airway passages could interfere with breathing. 2. Suction and clear any mucus in the airway. b. Clears any excess fluid causing difficulty breathing. 3. Place the infants head midline with flexion. c. This opens and can help maintain airway. (McKinney & Murray, 2010) Teach: 1. Teach and point out characteristics of the infants possible respiratory status change.

a. Early recognition of the onset of respiratory difficulties could mean saving that newborns life. Time is everything. 2. Explain to the mother that regurgitation, gagging, and brief episodes of cyanosis are common. b. Anxiety may be reduced of the knowledge of the mother is increased, providing her with a sense of comfort and reassurance. 3. Teach pt how to use the bulb syringe. c. If the mother is educated on tools used for newborn intervention, she feels better equipped. It also provides an extra hand for the nurse when not present. (McKinney & Murray, 2010)