A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which of the following equipment should the nurse prepare for use?
1. Equipment for intubation
2. Appropriate bag-valve-mask system
3. Sterile gauze and saline
4. Soft arm restraints
1
Rationale:
1. A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so that the newborn's respiratory status can be stabilized.
2. A bag-valve-mask or ambu bag could push air into the stomach and cause abdominal distension, increase pressure on the diaphragm, and impair breathing.
3. The defect is not external, so sterile gauze and saline are not needed.
4. Soft arm restraints might be necessary, but at are not an immediate concern.
Nursing Process: Implementation
Client Need: Physiological Integrity
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