ATI Maternal Newborn Exam

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ATI Maternal Newborn Chapter 1- contraception  Contraception refers to strategies or device used to reduce the risk of fertilization or implantation in an attempt to prevent pregnancy  Natur... al family planning: behavioral methods o Abstinence – no gentialia contact o Withdrawal (coitus interruptus)  Choice for monogamous couple  Least effective methods  Risk for pregnancy o Calendar methods  ovulation occurs about 14 days before the onset of her next menstrual cycle, and avoid intercourse during that period  count at least 6 cycles o basal body temperature  body temperature can drop slightly at the time of ovulation  measure oral temperature prior to getting out of bed each morning to monitor ovulation  inexpensive, convenient, and no adverse effects  Basal body temperature and the symptothermal method are fertility awareness methods. o Lactational amenorrhea method  Barrier o Condoms  Only water-soluble lubricants should be used with latex condoms to avoid condom breakage o Diaphragm  Dome-shaped cup with a flexible rim made of silicon that fits snugly over the cervix with spermicidal cream or gel placed into the dome and around the rim  Client should be properly fitted with a diaphragm by a provider  Replaced every 2 years and refitted for a 20% weight fluctuation, after abdominal or pelvic surgery and after every pregnancy  Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim  The diaphragm can be inserted up to 6 hours before intercourse and must stay in place 6 hour after intercourse but for no more than 24 hrs.  Spermicide must be reapplied with each act of coitus  Patient should empty bladder before insertion  Wash with soap and water after use o Cervical cap o Contraceptive sponge o Question  Which method would the nurse identify as a barrier method of contraception? a. Basal body temperature b. Transdermal patch c. Diaphragm d. Symptothermal method  Hormonal o Oral contraceptives  Adverse effect Chest pain, shortness of breath, leg pain from a possible clot, headache, eye problems form a stroke, and hypertensive, breast tenderness, nausea, breakthrough bleeding (common adverse effects of estrogen component and progestin component)  Can increase the risk of thromboembolism, stroke, heart attack, hypertension, gallbladder disease, liver tumor  Effectiveness decrease when taking medications that affect liver enzymes, such as anticonvulsants and some antibiotics o Injectable contraceptives  Medroxyprogesterone is an IM or SQ injection given to a female client every 11 to 13 weeks  First injection should be during the first 5 days of period  In postpartum, 5 days after delivery  Maintain adequate intake of calcium and vitamin D  Very effective and require only 4 injections per year  Adverse effects  Decrease in bone mineral density, weight gain, increase depression and irregular vaginal spotting or bleeding  Contraindicated for osteoporosis patient  Return to fertility can be a long as 18 months after discontinuation o Transdermal patches o Vaginal rings o Implantable progestin  Minor surgical procedure to subdermally implant and remove a single rod contain etonogestrel on the inner side of the upper arm  Disadvantage  Etonogestrel can cause irregular menstrual bleeding  Adverse effects  Irregular and unpredictable menstruation (most common)  Mood changes, headache, acne, depression, decreased bone density and weight gain o Intrauterine contraceptives (IUD)  A chemically active T-shaped device that is inserted through the cervix and placed in the uterus by the provider  Device must be monitored monthly by clients after menstruation to ensure the presence of small string that hangs form the device into the upper part of the vagina to rule out migration or expulsion of the device  IUD can maintain effectiveness for 1 to 10 years  Contraception can be reversed  Can increase the risk of pelvic inflammatory disease, uterine perforation, or ectopic pregnancy and can be expelled  A client should report to the provider later or abnormal spotting or bleeding, abdominal pain or pain with intercourse, abnormal of foul-smelling vaginal discharge, fever, chills, a change in string length or if IUD cannot be located  IUD can cause irregular menstrual bleeding  Must be removed in the event of pregnancy o Emergency contraception  Morning-after pill that prevents fertilization from taking place  Pill is taken within 72 hr after unprotected coitus  Surgical methods o Tubal ligation  Sterilization for women  A laprascope is inserted; fallopian tubes are grasped and sealed o Vasectomy  Sterilization for men  Usually performed under local anesthesia Involves cutting the vas deferens, which carries the sperm Chapter 3 – Expected physiological changes during pregnancy  Signs of pregnancy o Presumptive, probable, positive  Presumptive: those changes felt by the woman o e.g., breast changes (darkened areolae, enlarged Montgomery’s glands), uterine enlarged, quickening (slight fluttering movements of the fetus feld by a woman, usually between 16 to 20 seeks of gestation) o Skipping period is not reliable sign of pregnancy by itself but if it accompanied by nausea, fatigue, breast tenderness, and urinary frequency, pregnancy would see very likely  Probable: those changes observed by an examiner o Hegar’s sign – softening and compressibility of lower uterine segment or isthmus o Ballottement  examiner pushes against the women's cervix during a pelvic exam and feels a rebound from the floating fetus  rebound of unengaged fetus o abdominal enlargement o Chadwick’s sign – deepened violet-bluish color of cervix and vaginal mucosa o Broxton Hicks contractions – falls contractions that are painless, irregular, and usually relieved by walking o Positive pregnancy test  Human chorionic gonadotropin (HcG) is earliest biochemical marker for pregnancy  Production begins as early as day of implantation  Can be detected in maternal serum or urine as soon as 7 to 8 days before the expected menses  Urine sample should be first-voided morning specimens and follow the direction for accuracy o Fetal outline felt by examiner  Positive: those signs attributed only to the presence of the fetus o Confirm that fetus is growing in the uterus o Fetal heart sound - hearing fetal heart tones (via Doppler) o visualizing the fetus by ultrasound o palpating fetal movements (20 weeks) by examiner o Pulse sock on mom to get mom’s HR to ensure it’s not baby’s heart sound  Calculating delivery date and determine number of pregnancies for pregnant client o Nagele’s rule  Date of last menstrual period (LMP)  Calculation of estimated or expected date of birth (EDB) or delivery (EDD)  Nagele’s rule  Use first day of LNMP 11/21/07  Subtract 3 months 8/21/07  Add 7 days 8/28/07  Adjust year 8/28/08 = EDB  Ultrasound is the best method of dating a pregnancy o Kathy’s rule  Add 9 months and 7 days o Measurement of fundal height  In centimeters form the symphysis pubis to the top of the uterine fundus (between 18 and 32 weeks of gestation)  Approximates the gestational age o Gravidity – number of pregnancies  Nulligravid – never been pregnant Primigravida – first pregnant  Multigravida – two or more pregnant o Parity – number of pregnancies in which the fetus or fetuses reach 20 weeks of pregnancy  Nullipara – no pregnancy beyond the stage of viability  Primipara – has completed one pregnancy to stage of viability  Multi para o Viability – infant has capacity to survive outside of uterus (22 to 25 weeks) o GTPAL acronym  Gravidity  Term birth (38 weeks or more)  Preterm birth (from viability up to 37 weeks)  Abortions/miscarriages (prior to viability)  Living children  Blood pressure o Position of pregnant woman affect blood pressure o In Supine position, blood pressure might appear to be lower due to the weight and pressure of the gravid uterus on the vena cava, which pressures venous blood flow to the heart o Maternal hypotension and fetal hypoxia might occur, which is referred to as supine hypotensive syndrome or supine vena cava syndrome o Signs and symptoms include  Dizziness, lightheadness, and pale, clammy skin o Encourage client to engage in maternal positioning on the left-lateral side, semi-fowler’s position o if supine, with a wedge placed under one hip to alleviate pressure of the vena cava  fetal heart tone o 110 to 160/min with reassuring FHR accelerations noted, which indicates an intact fetal CNS  By 36 weeks gestation, the top of uterus and the fundus will reach the xiphoid process o This cause pregnant woman to experience shortness of breath as the uterus pushes against the diaphragm  Skin changes o Chloasma – increase of pigmentation on the face o Linea nigra – dark line of pigmentation from the umbilicus extending to the pubic area o Striae gravidarum – stretch marks most notably found on the abdomen and thighs  Client is encouraged to keep all follow-up appointments and to contact the provider immediately if there is any bleeding, leakage of fluid, or contractions at any time during the pregnancy Chapter 5  Recommended weight gain during pregnancy o Healthy weight BMI: 25 to 35 lb  First trimester: 3.5 to 5 lb  Second and third trimesters: 1 lb/wk o BMI <19.8: 28 to 40 lb  First trimester: 5 lb  Second and third trimesters: 1+ lb/wk o BMI >25: 15 to 25 lb  First trimester: 2 lb  Second and third trimesters: 2/3 lb/wk  Client education o Increase calories  Second trimester – increase 340 cal/day  Third trimester – increase to 450 cal/day  During breastfeeding women should well nourished should be added 450 to 500 cal/day to a balanced diet o Increasing protein intake High in folic acid is important for neurological development and prevent fetal neural tube defects  Foods – green leafy vegetables, dried peas and beans, seeds, orange juice  Women who wish to become pregnant of childbearing age take 400 mcg of folic acid  Women who become pregnant take 600 mcg of folic acid to prevent fetal neural tube defects o Iron supplements  Best absorbed between meals and when given with a source of vitamin C (orange juice)  Foods – beef liver, red meat, fish, poultry, dried peas and beans and fortified cereals  Stool softener might need to be added to decrease constipation with iron supplement o Calcium  Foods – milk, nuts, legumes and dark green leafy vegetables  Postpartum women who are breastfeeding should continue taking calcium supplement during lactation o Fluid  8 to 10 glasses (2.3 L) of fluids are recommended daily o Limit caffeine  Recommend daily intake of no more than 200 mg of caffeine  It is recommended that women abstain form alcohol consumption during pregnancy Chapter 6 – Assessment of fetal well-being  Ultrasound o client should have full bladder for the procedure o fetal and maternal structures can be pointed out to the client as the US procedure is performed  Biophysical profile o Uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli o Client presentation  Premature rupture of membranes  Maternal infection  Decreased fetal movement  Intrauterine growth restriction o Variables  FHR  Fetal breathing movements  Gross body movements  Fetal tone  Qualitative amniotic fluid volume o Total score findings  8 to 10 is normal – low risk of chronic fetal asphyxia  4 to 6 is abnormal – suspect chronic fetal asphyxia  Less than 4 is abnormal – strongly suspect chronic fetal asphyxia  Nonstress test o Most widely used technique for antepartum evaluation of fetal well-being performed during the 3rd trimester o Noninvasive procedure that monitors response of the FHR to fetal movement o Disadvantage of an NST include a high rate of false nonreactive results with the fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications and nicotine use disorder  The acoustic vibration device is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus  Contraction stress test o Nipple-stimulated contraction test Consists of a woman lightly brushing her palm across her nipple for 2 min, which cause the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins o Oxytocin-stimulated contraction test  IV administration of oxytocin to induce uterine contractions  Oxytocin is used to induce uterine contraction  Contraindicated for placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incisions for C-section, reduced cervical competence  Can be difficult to stop and may lead to preterm labor  Negative results are a normal finding  Positive result is an abnormal finding o Indication for contraction stress test (CST)  Decreased fetal movement  Intrauterine growth restriction (IUGR)  Postmaturity  Amniocentesis o Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client’s uterus and amniotic sac under ultrasound guidance locating the placenta and determining the position of the fetus o It may be performed after 14 weeks of gestation o Indications  Prenatal diagnosis of genetic disorder or congenital anomaly of the fetus  Alpha-fetoprotein (AFP) level for fetal abnormalities  High AFP – neural tube defect  Low AFP – down syndrome  Lung maturity assessment o Instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture o Post procedure  Administer Rho(D) immune globulin to the client if she is Rh-negative (standing practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization)  RhoGAM is giving to Rh- moms at 28 weeks gestation after amniocentesis and after delivery to protect mon against baby’s blood of bay is Rh+ o Complications  Amniotic fluid emboli  Maternal or fetal hemorrhage  Maternal or fetal infection  Miscarriage or preterm labor  Premature rupture of membrane  Leakage of amniotic fluid o A test of the L/S ratio is done as part of amniocentesis to determine fetal lung maturity  High-risk pregnancy; chorionic villus sampling o CVS is ideally performed at 10 to 23 weeks of gestation o Indications  Risk for giving birth to a neonate who has a genetic chromosomal abnormality  Monitoring for adverse effects of substance use disorders o Substance use is a risk factor that can leads to spontaneous abortion and abruptio placentae o Teach patient to watch for  Vaginal bleeding uterine craping, partial/complete expulsion of products of conception sharp abdominal pain, and tender rigid uterus Chapter 7 – Bleeding During Pregnancy  Ectopic pregnancyo Ectopic pregnancy is abnormal implantation of a fertilization ovum outside of the uterine cavity usually in the fallopian tube, which can result in a tubal rupture causing a fetal hemorrhage o Unilateral stabbing pain and tenderness in the lower-abdominal quadrant o Instruct client who is taking methotrexate to avoid alcohol consumption and vitamins containing folic acid to prevent a toxic response to the medication  Molar growth o Bleeding is often dark brown resembling prune juice o Bright red that is either scant or profuse and continues for few days or intermittently for a few weeks and can be accompanied by passage of vesicles  Placenta previa o Placenta a previa occurs when the placenta abnormally implants in the lower segment of the uterus near of over the cervical os instead of attaching to the fundus  Complete or total – cervical os is completely covered by the placental attachment  Incomplete or partial – cervical os is only partially covered by the placental attachment o Painless, bright red vaginal bleeding during the 2nd and 3rd trimester o Refrain from performing vaginal exams – can exacerbate bleeding o Administer IV fluids blood products, and medications as prescribed  Corticosteroids, such as betamethasone, promote fetal lung maturation if early delivery is anticipated (cesarean birth)  Abruptio placentae o Abruptio placentae is the premature separation of the placenta from the uterus o It has significant material and fetal morbidity and mortality and is a leading cause of maternal death o Sudden onset of intense localized uterine pain with dark red vaginal bleeding o Risk factors  Blunt external abdominal trauma (motor-vehicle crash, maternal battering)  Cocaine use resulting in vasoconstriction  Smoking cigarette  Maternal hypertension (chronic or gestational)  Previous incidence of abruptio placentae  Premature rupture of membrane  Multifetal pregnancy Chapter 9 – Medical conditions  Cervical insufficiency (premature cervical dilation) o The client can require cervical cerclage (indicated for women who have singleton pregnancy) o Often placed at 12 to 14 weeks gestation and removed at 37 weeks gestation o Provide education about clinical findings to report to the provider for preterm labor rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push  Hyperemesis gravidarum o hyperemesis gravidarum is excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks gestation and results in 5% weight loss from pre-pregnancy weight, electrolyte imbalance, acetonuria and ketosis o Risk factors  maternal age younger than 30, history or migraines, obesity, first pregnancy, diabetes, multigestation, GI disorders, or family history of hyperemesis monitor patient I&O, assess skin turgor, weight and vital signs o laboratory test  Urinalysis for ketones and acetones (breakdown of PR and fat) is the most important lab test - Elevated urine specific gravity, urine ketone present  Chemistry profile  Thyroid test – indicate hyperthyroidism  CBC (complete blood count) – elevated Hcto Nursing care  Monitor I&O  Assess skin turgor and mucous membranes  Monitor vital signs  Monitor weight  Have the client remain NPO for 24 to 48 hours  Clear liquid after 24 if no vomiting and increase diet if tolerated o Medications  Give the client IV lactated ringer’s for hydration  Give pyridoxine (vitamin B6) and another vitamin supplement s as tolerated  Use antiemetic medications (ondansetron, metoclopramide) cautiously for uncontrollable nausea and vomiting  Use corticosteroid to treat refractory hyperemesis gravidarum o Advance the client’s diet as tolerated, with frequent small meals – start with dry toast, crackers, or cereal; then move to a soft diet; and finally, to a normal diet as tolerated  Iron-deficiency anemia o Occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron o Foods – legumes, fruits, green leafy veggies, and meat o Medications  Ferrous sulfate iron supplements  Instruct the client to take the supplement on an empty stomach and take with orange juice to increase absorption  Encourage a diet rich in vitamin C- containing foods to increase absorption  Gestational diabetes mellitus o Gestational diabetes mellitus (GDM) is an impaired tolerance to glucose with the first onset or recognition during pregnancy  Normal glucose during pregnancy – 70 to 110 mg/dL  Women will develop type II diabetes mellitus within 5 years of delivery o Laboratory tests  Glucola screening test/1-hr glucose tolerance test  50 g oral glucose load, followed by plasma glucose analysis 1 hour later perforated 24 to 28 weeks of gestation  Fasting is not necessary  Positive blood glucose screening is 130 to 140 mg/dL or greater  Additional testing with a 3-hr oral glucose tolerance test (OGTT) is indicated  Oral glucose tolerance test (OGTT)  Following overnight fasting  Avoid caffeine and abstinence from smoking for 12 hr prior to testing  Fasting glucose is obtained, a 100g glucose load is given and serum glucose levels are determined at 1,2, and 3 hr following glucose ingestion o Diagnostic procedures  Biophysical profile to ascertain fetal well-being  Nonstress test to assess fetal well-being o Medication  Oral hypoglycemic therapy is an alternation to insulin in women who have GDM who require medication in addition to diet for blood glucose control  Most oral hypoglycemic agents are contraindicated for gestational diabetes mellitus, but there is limited use of glyburide.  Gestational hypertension o Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the manifestations of pregnancy hyper tensive disorders o Gestational hypertension (GH) After 20th weeks of pregnancy  Elevated BP at 140/90 mmHg or greater recorded on 2 different occasions at least 4 hr apart  Not proteinuria o Mild preeclampsia  GH with addition of  Proteinuria of greater than or equal to 1+ o Severe preeclampsia  Bp 160/110 mmHg or greater  Proteinuria greater than 3+  Elevated serum creatinine greater than 1.1 gm/dL  Cerebral visual disturbances (headache and blurred vision)  Hyperreflexia with possible ankle clonus  Pulmonary or cardiac involvement  Extensive peripheral edema  Hepatic dysfunction  Epigastric and right upper-quadrant pain and thrombocytopenia o Eclampsia  Severe preeclampsia manifestation with the onset of seizure activity or coma o Help syndrome  H: Hemolysis – resulting in anemia and jaundice  EL: Elevated liver enzyme – ALT, AST  LP: Low platelet (less than 100,000) o Laboratory  Liver enzyme – elevated AST, LDH  Serum creatinine, BUN, uric acid, magnesium increases as renal function decreases  CBC  Clotting studies – thrombocytopenia  Chemistry profile – decreased Hgb, hyperbilirubinemia o Medication  Anti-hypertensive medication  Methyldopa  Nifedipine  Hydralazine  Labetalol  Avoid ACE inhibitors and angiotensin II receptor blockers  Anticonvulsant  Magnesium sulfate  Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS  Monitor for signs of magnesium sulfate toxicity o Absence of patella deep tendon reflexes o Urine output less than 30 mg/hr o RR less than 12/min o Decrease level of consciousness o Cardiac dysrhythmias  Antidote – calcium gluconate or calcium chloride o Client education  Maintain bed rest and encourage side-lying position  Promote diversional activities (TV, visits form family or friends, gentle exercise)  Avoid foods that are high in sodium  Avoid tobacco and alcohol and limit caffeine intake  Drink 6 to 8 oz glasses of water a day  Maintain dark, quiet environment to avoid inducing a seizure Maintain a patent airway in the event of seizure  Administer antihypertensive medications as prescribed Chapter 10 – Early Onset of Labor  Preterm labor o Preterm labor is uterine contraction and cervical changes that occur between 20 and 37 weeks of gestation o Assessment of preterm labor  Previous preterm birth  Multifetal pregnancy  Substance use  History of multiple miscarriages or abortions  Diabetes mellitus  Chronic hypertension  Second trimester bleeding  History of UTI o o Expected findings – uterine contraction o Diagnostic procedures  Obtain swab of vaginal secretions for fetal fibronectin between 24 and 34 weeks of gestation  This protein can be found in vaginal secretions and can be related to inflammation of the placenta and that can lead to preterm birth  This test is used to determine preterm labor o Nursing care  Focusing on stopping uterine contraction  Activity restriction  Strict bed rest can have adverse effects  Encourage the client to rest in the left lateral position to increase blood flow to the uterus and decrease uterine activity  Ensuring hydration  Dehydration stimulate the pituitary gland to secret and antidiuretic hormone and oxytocin o Medication  Nifedipine  Calcium channel blocker  Used to suppress contractions by in habiting calcium form entering smooth muscles  Nursing consideration o Monitor for headache, flushing, dizziness and nausea o These usually are related to orthostatic hypotension that occurs with administration  Magnesium sulfate  Commonly used tocolytic that relaxes the smooth muscle of the uterus and thus inhibits uterine activity by suppressing contraction  Nursing consideration o Contraindications for tocolysis include active vaginal bleeding, dilation of the cervix greater than 6 cm, chorioamnionitis, greater then 34 weeks gestation and acute fetal distress o Monitor for client for magnesium toxicity and discontinue for any of the following adverse effects  Loss of deep tendon reflexes  Urinary output less than 30 ml/hr  Respiratory depression (less than 12/min)  Pulmonary edema and chest paino Administer gluconate of calcium chloride as and antidote for magnesium sulfate toxicity  Notify provider – blurred vision, headache, nausea, vomiting, or difficulty breathing  Indomethacin  Non-steroidal anti-inflammation drug (NSAID)  Suppress preterm labor by blocking the production of prostaglandins  This inhibition of the prostaglandins suppresses uterine contraction  Betamethasone  Enhance fetal lung maturity and surfactant production in fetuses between 24 to 34 weeks gestation  Premature rupture of membranes o Client reports a gush or leakage of clear fluids from the vagina  Temperature elevation  Increased maternal hear rate or FHR  Foul-smelling fluid or vaginal discharge  Abdominal tenderness o Positive nitrazine paper test (blue, pH 6.5 to 7.5) or positive forming test is conducted on amniotic fluid to verify rupture of membranes o Medications  Ampicillin is an antibiotic uses to treat infection  Betamethasone  Glucocorticoid administered IM in 2 injections  Enhance fetal lung maturity and surfactant production o Tell the client to record daily kick counts for fetal movement Chapter 11 – Labor and Delivery Process  Stages of labor o First stage (onset of labor to complete dilation)  Latent phase (0 to 3 cm)  Onset of labor – contractions irregular and mild to moderate  Woman is talkative and eager  Active phase (4 cm to 7 cm)  Contractions – regular moderate to strong  Woman feeling of helplessness  Anxiety and restlessness increase as contraction become stronger  Transition phase (8cm to 10 cm)  Complete dilation  Feeling out of control, client often states “cannot continue”  Urge to push increased rectal pressure and feelings of needing to have a bowel movement o Second stage  Full dilation to birth o Third stage  Delivery of the neonate to delivery of placenta o Fourth stage  Delivery of placenta to maternal stabilization of vital signs  Physiologic changes preceding labor (premonitoring sign) o Backache, weight loss o Lightening  fetal head descends into true pelvis about 14 days before labor  feeling that the fetus has “dropped”  easier breathing but more pressure on bladder resulting urinary frequency o contraction – begin with irregular uterine contractions (Braxton Hicks)o increased vaginal discharge or bloody show o energy burst o gastrointestinal changes – nausea, vomiting and indigestion o Cervical ripening- cervix become soft (opens) and partially effaced and can begin to dilate o Rupture of membrane  Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse o Assessment of amniotic fluid  Amniotic fluid is alkaline – Nitrazine paper is deep blue, indicting pH of 6.5 to 7.5  Laboratory analysis o Group B streptococcus  Screening at 35 to 37 weeks  If positive, IV prophylactic antibiotic is prescribed, exceptions are planned cesarean birth and membranes intact o Urinalysis  Proteinuria, UTI (common diabetic pregnancy)  Characteristics of False Labor o Contraction  -Painless, irregular frequency, and intermittent contractions -Contractions decrease in frequency, duration, and intensity with walking or position changes -Contractions are felt in lower back or abdomen above umbilicus -Contractions often stop with sleep or comfort measures such as oral hydration or emptying of the bladder o Cervix (assessed by vaginal exam)  -The cervix has no significant changes in dilation or effacement -The cervix often remains in posterior position -The cervix has no bloody show o Fetus -The presenting part of the fetus is not engaged in the pelvis.  Nursing Care During Stages of Labor: Identifying the Need for Reassessment o If there are late declarations o if baby is tachycardic or bradycardia Chapter 12 – pain management  nonpharmacological o Reduce anxiety, fear and tension which are major contributing factors to pain in labor o Hypnosis, biofeedback, music therapy o Cutaneous stimulation strategies  Effleurage – light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions o Sacral counterpressure  using the heel of the hand or fist against the client’s sacral area to counteract pain in the lower back o hydrotherapy (whirlpool or shower) increases maternal endorphin levels o frequent maternal position changes to promote relaxation and pain relief  supine position only with the placement of a wedge under one of the client’s hip to tilt the uterus and avoid supine hypotension syndrome  pharmacological o To avoid slowing the progress of labor, prior to administering analgesic medications, the nurse should verify that labor is well established by performing a vaginal exam and evaluating uterine contraction pattern o Analgesia  Sedatives (barbiturates)  Secobarbital pentobarbital and phenobarbital can be used during the early or latent phase of labor to relieve anxiety and induce sleep Side effect - Neonate respiratory depression secondary to the medication crossing the placenta and affecting the fetus. This medication should not be administered if birth is anticipated within 12 to 24 hours  Nursing action  Assist the mother to cope with labor  Assess the neonate for respiratory depression  Opioid analgesics  Meperidine hydrochloride, fentanyl, butorphanol, nalbuphine act in CNS to decrease the perception of pain without the loss of consciousness  Client can receive opioid analgesics IM or IV but the IV route is recommended during labor because the action is quicker  these given early part of active labor  Butorphanol and nalbuphine o Adverse effect  Opioid analgesics can cause respiratory depression in the neonate  Sedation  Hypotension  Decreased FHR variability o Nursing action  Performing a vaginal exam that reveals cervical dilation of at least 4 cm with a fetus that is engaged  Administer antiemetics as prescribed  Prepare administer antidotes  Naloxone, an opioid antagonist, should be readily available for reversal of opioid-induced respiratory depression  Epidural and spinal regional analgesia o Fentanyl and sufentanil o Adverse effect  Bradycardia or tachycardia  Hypotension  Respiratory depression o Nursing action  Putting side rails up on the client’s bed – client can experience dizziness and sedation, which increases maternal risk for injury  Administer Antiemetics as prescribed  Continue FHR pattern monitoring o Pharmacological anesthesia  Epidural block  Injected into the epidural space at the level of 4th or 5th vertebrae  This eliminates all sensation from the level of umbilicus to the thighs, relieving the discomfort of uterine contractions, fetal descent and pressure and stretching of the perineum  It is administered when the client is active labor and dilated to at least 4 cm  It is suitable for all stages of labor and types of birth and for repair of episiotomy and laceration  Adverse effect o Maternal hypotension o Fetal bradycardia o Loss of the bearing down reflex  Nursing action o Administer a bolus of IV fluids to help offset maternal hypotension as prescribed o Side-lying modified Sim’s positiono Encourage the client to remain in the side-lying position after insertion of the epidural catheter to avoid supine hypotension syndrome with compression of the vena cava o Monitor maternal blood pressure and pulse, and observe for hypotension, respiratory depression and decreased oxygen saturation o Assess for orthostatic hypotension. If present, be prepared to administer an IV vasopressor such as ephedrine, position client laterally, increase rate of IV fluid administration and initiate oxygen o Do not allow the client to ambulate unassisted  Spinal anesthesia (block)  Injected into the subarachnoid space into the spinal fluid at the 3rd 4th and 5th lumbar interspace  Spinal block eliminates all sensation form the level of the nipples to the feet  Spinal block is administered in the late second stage or before cesarean birth  Adverse effect o Maternal hypotension o Fetal bradycardia o Potential headache form leakage of cerebrospinal fluid at the puncture site o Higher incidence of maternal bladder and uterine atony following birth  Nursing action o Assess maternal vital signs every 10 min o Manage maternal hypotension by administering an IV fluid bolus as prescribed, position the mother laterally, increasing the rate of IV fluid administration and initiating oxygen o To relieve postpartum headache resulting from cerebrospinal fluid leak, placing the client in a supine position, promoting bed rest in a dark room, and administering oral analgesics, caffeine and fluids. An autologous blood patch is the most beneficial and reliable relief measure for cerebrospinal fluid leaks  General anesthesia  Delivery complication or emergency  General anesthesia produces unconsciousness  Nursing action o NPO o Apply antiembolic stockings or sequential compression devices o Administer histamine-receptor antagonist – ranitidine to decrease gastric acid production o Administer metoclopramide to increase gastric emptying as prescribed o Assess the client postpartum for decreased uterine tone, which can lead to hemorrhage and be produced by pharmacological agents used in general anesthesia Chapter 13 – Fetal Assessment during labor  Leopold maneuvers o Leopold maneuvers consist of performing external palpations external palpations of the maternal uterus through the abdominal wall to determine the following o Place a small, rolled towel under the client’s right or left hip to displace the uterus off the major blood vessels to prevent supine hypotensive syndrome  Continuous electronic fetal monitoring o A normal fetal heart rate breathing at term is 110 to 160/min excluding accelerations, decelerations and periods of marked variability within a 10 min window. o Fetal heart rate baseline variability is described as fluctuations in the FHR baseline that that irregular in frequency and amplitude FHR patterns o Accelerations o Fetal bradycardia  FHR less than 110/min or 10 min or more  Causes/complications  Uteroplacental insufficiency  Umbilical cord prolapses  Anesthetic medications  Nursing intervention  Discontinue oxytocin if being administered  Assists the client to a side-lying position  Administer oxygen by mask at 10 L/min via nonrebreather face mask  Notify the provider o Fetal tachycardia  FHR greater than 160 /min for 10 min or more  Causes/complication  Maternal infection, chorioamnionitis  Nursing interventions  Administer prescribed antipyretics for maternal fever  Administer oxygen by nonrebreather face mask o Early deceleration of FHR  Causes/complication  Compression of the fetal had resulting form uterine contraction o Later decelerations of FHR  Uteroplacental insufficiency causing inadequate fetal oxygenation  Nursing intervention  Place client in side-lying position  IV fluid administration  Discontinue oxytocin if being infused  Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask  Elevate the client’s leg  Notify the provider o Variable deceleration of FHR  Umbilical cord compression  Nursing interventions  Reposition client form side to side or into knee-chest  Discontinue oxytocin if being infused  Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask Chapter 14 – Nursing care during stages of labor  Identifying the needs for reassessment each different stage of labor calls for different assessments of the mom  stage one should focus on rupture of membranes, bladder distention, temperature, and FHR  stage two should focus on BP, HR, and RR every 5-30 minutes, uterine contractions, pushing efforts by client, increase in bloody show, shaking of extremities  stage three is focused on BP, HR, and RR every 15 min, clinical findings of separation of placenta, vaginal fullness exam  stage four should focus on assessing maternal vital signs to a steady state Chapter 15 – Therapeutic procedures to assist with labor and delivery  Chapter 16 – Complications related to the labor process Prolapsed umbilical cord o A prolapse umbilical cord occurs with the umbilical cord is displaced, preceding the presentation part of the fetus, or protruding through the cervix o Nursing care  Notify the provider  Use a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord  Reposition the client in a knee-chest, Trendelenburg or side-lying position with a rolled towel under the client’s right or left hip to relieve pressure on the cord  Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow  Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation Chapter 17 – Postpartum physiological adaptations  Fundus o Immediately after delivery, the fundus should be firm, midline with the umbilicus, and approximately at the level of the umbilicus o At 12 hr postpartum, the fundus may be palpated at 1 cm above the umbilicus o Every 24 hours, the fundus should descend approximately, 1 to 2 cm o It should be halfway between the symphysis pubis and the umbilicus by the 6th postpartum day o After 2 weeks, the uterus should lie within the true pelvis and should not be palpated  Lochia o Lochia is post-birth uterine discharge that contains blood, mucus and uterine tissue o 3 stage of lochia  Lochia rubra – bright red color, bloody consistency, fleshy odor, last 1 to 3 days after delivery  Lochia serosa – pinkish brown color and serosanguineous, consistency. Last from 4 to 10 days after delivery  Lochia alba – yellowish white creamy color, flesh odor. Last 11 days up to 4 to 8 weeks postpartum o Assessment of lochia  Excessive blood loss: one pad saturated in 15 min or less, or pooling of blood under buttocks o Manifestation of abnormal lochia  Excessive spurting of bright red blood form the vagina  Numerous large clots and excessive blood loss (saturation of one pad in 15 min or less) which can indicate hemorrhage  Persistent lochia rubra in the early postpartum period beyond day 3, which can indicate retained placental fragments  Breasts o Physical changes of the breasts include the secretion of colostrum – 2 to 3 days immediately after birth o Assessment  Colostrum (early milk) transitions to mature milk by about 72 to 96 hr after birth and is referred to as the milk coming in  Cardiovascular system and fluid and hematologic status o Blood loss during childbirth (average blood loss is 300 to 500 mL in an uncomplicated vaginal delivery and 500 to 1000 mL for cesarean birth  Urinary system and bladder function o Urinary retention secondary to loss of bladder elasticity and tone and/or loss of bladder sensation resulting from trauma, medications, or anesthesia o Distended bladder as a result of urinary retention can cause uterine atony and displacement to one side, usually to the right o The ability of the uterus to contract is also lessened o Assessment Assess the client’s ability to void every 2 to 3 hours  Assess bladder elimination pattern (client should be voiding every 2 to 3 hr). excessive urine diuresis (more than 3,000 mL/day) is normal within the first 2 ot 3 days after delivery  Assess for evidence of a distended bladder o Patient-centered care  Encourage the client to empty her bladder frequently (every 2 to 3 hr) to prevent possible displacement of the uterus and atony Chapter 18 – Baby-friendly care  Phase of maternal postpartum adjustment o Dependent – taking-in phase  First 24 to 48 hours  Rely on others for assistance  Focused on meeting personal needs rely on others for assistance  Excited, talkative  Need to review birth experience with others o Dependent-independent – taking-hold phase  Begins on day 2 to 3  Last 10 days to several weeks  Focus on baby care and improving caregiving competency o Interdependent – letting-go phase  Focus on family as a unit  Resumption on role (intimate partner, individual) Chapter 19 - Client education and discharge teaching  Breast care o Lactating client  Initiate breastfeeding within the first 1 to 2 hr after birth unless contraindicated  To relieve breast engorgement, have client completely empty her breast at each feeding  For breast engorgement, apply cool compresses after feedings and apply warm compresses, or take a warm shower prior to breastfeeding. These actions will increase milk flow and promote the letdown reflex o Nonlactating client  Wear a well-fitting, supportive bra continuously for the first 72 hr  Suppression of lactation is necessary for clients who are not breastfeeding. Avoid breast stimulation and running warm water over the breast stimulation and running warm water over the breast for prolonged period until no longer lactating  For breast engorgement, which can occur on the third or firth postpartum day, apply cold compresses 15 min on and 45 min off. Fresh, cold cabbage leaves can be placed inside the bra. Mild analgesics or anti-inflammatory medication can be taken for pain and discomfort of breast engorgement Chapter 20 – postpartum disorders  Deep-vein thrombosis o Greatest risk for a deep-vein thrombosis (DVT) that can lead to a pulmonary embolism o Expected findings  Unilateral area of swelling, warmth, and redness  Hardened vein over the thrombosis  Calf tenderness  Pulmonary emboluso A pulmonary embolism is a complication of DVT that occurs if the embolus moves into the pulmonary artery or one of its branches and lodges in a lung, occluding the vessel and obstructing blood flow to the lungs o Acute pulmonary embolus is an emergent situation o Expected findings  Pleuritic chest pain  Dyspnea  Postpartum hemorrhage o Postpartum hemorrhage is considered to occur if the client loses more than 500 mL blood after a vaginal birth or more than 1000 mL after cesarean birth o Risk factors  Uterine atony, inversion of uterus, subinvolution of the uterus, Retained placental fragments o Expected findings  Uterine atony (hypotonic or boggy)  Perineal pad saturation in 15 min or less  Constant oozing trickling, or frank flow of bright red blood from the vagina  Tachycardia and hypotension o Nursing care  Firmly massage the uterine fundus  Assess bladder for distention. Insert an indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output o Medication – uterine stimulant  Oxytocin – promote uterine contractions  Methylergonovine – controls postpartum hemorrhage  Assess uterine tone and vaginal bleeding. Do not administer to clients who have hypertension  Monitor for adverse reactions, including hypertension, nausea, vomiting and headache  Misoprostol - controls postpartum hemorrhage  Uterine atony o Uterine atony results form the inability of the uterine muscle ot contract adequately after birth o Perform fundal massage is indicated Chapter 21 – postpartum infections  Infections (endometritis, mastitis, and wound infections)  Mastitis o Mastitis is an infection of breast involving the interlobular connective tissue and is usually unilateral o Expected findings  Flu-like clinical findings, such as body aches, chills, fever and malaise  Painful or tender localized hard mass and reddens area, usually on one breast o Client education  Instruct the client to thoroughly wash hands proor to breastfeeding  Allow nipples to air-dry  Proper infant positioning and latching-on techniques, including both the nipple and the areola  Instruct the client about completely emptying her breasts with each feeding to prevent milk stasis, which provides a medium for bacterial growth Chapter 23 – postpartum depression  Postpartum blues o Generally, continues for up to 10 days o Tearfulness, insomnia, lack of appetite, and feeling of letdown o Postpartum blues typically resolves in 10 days without intervention o Feeing sadness o Crying easily for no apparent reason Postpartum depression o Occurs within 6 months of delivery and is characterized by persistent feelings of sadness and intense mood swings  Postpartum psychosis o History of bipolar disorder o Confusion, disorientation, hallucinations, delusions, obsessive behaviors, and paranoia o The client might attempt to harm herself or her infant Chapter 23 – Newborn assessment  Apgar scoring o HR: Absent (0), less than 100/min (1), greater than 100/min (2) RR: Absent (0), weak cry (1), good cry (2) Muscle tone: flaccid (0), some flexion of extremities (1), well-flexed (2) Reflex irritably: none (0), grimace (1), cry (2) Color: blue, pale (0), pink body, cyanotic hands and feet (1), completely pink (2)  New Ballard scale o New born maturity rating scale that assesses neuromuscular and physical maturity o Neuromuscular maturity - Fully flexed - Square window - Arm recoil, where the neonate’s arm is passively extended and spontaneously return sto flexion - Popliteal angle, degree of the angle to which the newborn’s knees can extend - Scarf sign, which is crossing the neonate’s arm over the chest - Heal to ear, which is how far the neonate’s heels reach to her ears o Physical maturity - Skin texture, ranging from sticky and transparent to leathery, cracked and wrinkled - Lanugo presence - Plantar surface creases, ranging form less than 40 mm to creases ove the entire sole - Breast tissue amount, full areola with a 5 to 10 mm bud - Genitalia development – ranging form flat smooth scrotum to pendulous testes with deep rugae for males and prominent clitoris with flat labia to the labia majora covering the labia minora  Normal deviations o Milia (small raised whit spots on the nose, chin and forehead) can be present. Theses pots disappear spontaneously without treatment (parents should not squeeze the spots) o Mongolian spots (bluish purple spots of pigmentation) are commonly noted on the the shoulder, back and buttocks. Be sure the parents are aware of Mongolian spots, and document location and presence  Head o Head should be 2 to 3 cm larger than chest circumference o Anterior fontanel should be palpated and approximately 5 cm on average and diamond shaped. o Fontanel should be soft and flat o Fontanel can bulge when the newborn cries, coughs or vomits and are flat when the newborn is quiet o Bulging fontanels can indicate increased intracranial pressure, infection, or hemorrhage o Depressed fontanels can indicate dehydration o Caput succedaneum - (localized swelling of the soft tissues of the scalp caused by pressure on the head during labor) an expected finding that can be palpated as a soft edematous mass and can cross over the suture line - Caput succedaneum usually resolves in 3 to 4 days and does not require treatment o Cephalohematoma - Collection of blood between the periosteum and the skull bone that is covers - It does not cross the suture line - It results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery - It appears in the first 1 to 2 days after birth and resolves in 2 to 3 weeks  Ears – that are low set can indicate a chromosome abnormality such as down syndrome, or a kidney disorder  Moutho Epstein’s pearls (small white cysts found on the gums and at the junction of the soft and hard palates) are expected findings. They result from the accumulation of epithelial cells and disappear a few weeks after birth o Gray-white patches on the tongue and gums can indicate thrush, a fungal infection caused by candida albicans, sometimes acquired form the mother’s vaginal secretions  Reflexes o Sucking and rooting reflex – elicit by stroking the cheek or edge of mouth (birth to 4 month) o Palmar grasp – newborn’s fingers curl around examiner’s fingers (birth to 4 month) o Plantar grasp – curling toes downward (birth to 8 months) o Moro reflex – semistting position to fall backward to an angle of at least 30 degree. The newborn will symmetrically extend and then abduct the arms at the elbows and fingers spread to form a “C” o Tonic neck reflex (fencer position) – birth to 4 months o Babinski reflex – elicit by stroking outer edge of sole of the foot, moving up toward toes. Toes will fan upward and out (birth to 1 year) o Stepping – birth to 4 weeks  Complications o Hypothermia – monitor axillary temperature. Healthy newborn temperature is 36.6 to 37 (97.7 to t9.6) Chapter 24 – Nursing care of newborns  Identification o Identification (using 2 identifiers) is applied to the newborn immediately after birth by the nurse. It is an important safety measure to prevent the newborn form being given to the wrong parents, switched or abducted  The newborn, mother, and mother's partner are identified by plastic identification wristbands with permanent locks that must be cut to be removed.  Identification bands include the newborn's name, sex, date, and time of birth, and mother's health record number.  The newborn has one band placed on the ankle and one on the wrist.  the newborn's footprints and the mother's thumb prints are taken.  The above information is also included with the footprint sheet.  Each time the newborn is given to the parents, the identification band should be verified against the mother's identification band.  Thermoregulation o Interventions to maintain thermoregulation (36.5 to 37, 97.7 to 98.6)  Conduction – cooler surface direct contact  Convection – cooler environmental air – fan or air conditioning vent (swaddle newborn in the blanket)  Evaporation – surface liquid is converted to vapor (gently rub the newborn dry with warm sterile blanket immediately after delivery)  Radiation – cooler solid surface that is close to but not direct contact (keep infant away from window and air-conditioner)  Bathing o When newborn’s temperature is stabilized to at least 36.5 (97.7) o A complete sponge bath should be given within the first 1 to 2 hr after birth under a radiant heat source to prevent heat loss o Gloves should be worn until the newborn’s first bath to avoid exposure to body secretions  Medications o Erythromycin  Antibiotic ointment – prophylactic eye care  Ophthalmia neonatorum is caused by Neisseria gonorrhoeae of Chlamydia o Vitamin K  Prevent hemorrhagic disorders  Vitamin K is not produced in the gastrointestinal tract of the newborn until around day 7 o Hepatitis B immunization  Provide protection against hepatitis B At birth, 1 month, and 6 months  Do not five vitamin K and hepatitis B injections in the same thigh. Site should be alternated  Complications o Hypoglycemia  Jitteriness; twitching; a weak, high-pitched cry; irregular respiratory effect; cyanosis; lethargy; eye rolling; seizures; and a blood glucose level less than 40 mg/dL by heel stick  Have mother breastfeed immediately or give donor breast milk or formula to elevate blood glucose levels Chapter 25 – Newborn Nutrition  Nutritional needs for the newborn o Loss of 5% to 10% after birth (regain 10 to 14 days after birth)  Breast feeding o Breastfeeding is the optimal source of nutrition o Contains immunoglobulin A (IgA) o Benefit of breastfeeding  Reduces the risk of infection by providing IgA antibodies  Promotes rapid brain growth due to large amounts of lactose  Convenient and inexpensive  Reduces incidence of sudden infant death syndrome (SIDS), allergies, and childhood obesity o Nursing interventions – successful breastfeeding  Explain the let-down reflex (stimulation of maternal nipple releases oxytocin that causes the let-down of milk)  Encourage the mother to breastfeed at least 15 to 20 min per breast to ensure that her newborn receives adequate fat and protein, which is richest in the breast mild as it empties the breast  Voiding 6 to 8 diapers per day o Successful storage of breast milk obtained by a breast pump  Breast milk can be stored at room temperature under very clean conditions for up to 8hrs  It can be refrigerated in sterile bottles for use within 8 days or can be frozen in sterile containers in the freezer compartment of fridge for up to 6 months. Can be stored in a deep freezer for 12 months.  Thawing the milk in the fridge for 24hrs in the best way to preserve the immunoglobulins present in it. It can also be thawed by running lukewarm water over it.  Do not thaw in microwave  Do not refreeze thawed milk  Used portions of breast milk must be discarded  Formula (bottle) feeding o Instruct parents that prepared formula can be refrigerated for upto 48 hr Chapter 26 – Nursing care and discharge teaching  Cord care o Prevent cord infection by keeping the cord dry, an keep the top of the diaper folded underneath it o Sponge baths are given until the cord falls off, which occurs around 10 to 14 days after birth. Tub bathing and submersion can follow o If cord is not kept clean and dry  Monitor for manifestations of a cord that is moist and red, has a foul odor, or has purulent drainage  Circumcision care o Equipment for performing circumcision  The provider applies the Gomco (Yellen) or Mogen glamp to the penis, loosen the foreskin, and insert the cone under the foreskin to provide a cutting surface for removal of the foreskin and to protect the penis This applies pressure as the excess foreskin is removed form the penis o Parent teaching  With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper form adhering the penis  A tub bath should not be given until the circumcision is healed  Tell the parents that a film of yellowish mucus can form over the glans by day two, and it is important not to wash it off  Car seat safety o Use an approved rear-facing car seat in the back seat, preferably in the middle (away from air bags and side impact), to transport the newborn until 2 years old Chapter 27 – Assessment and management of newborn complication  Hypoglycemia o A healthy term newborn’s blood glucose level can drop to 30 mg/dL the first 1 to 2 hr following birth o Obtain blood by heel stick for glucose monitoring. Glucose should be over 40 mg/dL. o Expected findings  Poor feeding, jitteriness, tremors, lethargy o Should be offered oral feeding to increase levels to greater than 45 mg/dL  Respiratory distress syndrome, asphyxia, and meconium aspiration o RDS occurs as a result of surfactant deficiency in the lungs and is characterized by poor gas exchange and ventilatory failure o Complications form RDS are related to oxygen therapy a mechanical ventilation o Risk factors  Preterm gestation  Cesarean birth without labor o Expected findings  Tachypnea (respiratory rate greater than 60/min)  Cyanosis o Nursing care  Suction the newborn’s mouth, trachea and nose  Monitor pulse oximetry  Preterm newborn o Complications  Respiratory distress syndrome  Bronchopulmonary dysplasia  Necrotizing enterocolitis o Expected findings  Respiratory distress syndrome – nasal flaring or retractions of the chest wall during inspirations, expiratory grunting and tachypnea  Minimal subcutaneous fat deposit  Abundance of lanugo  Weak grasp reflex  Hypotonic muscle and weak cry  Large for gestational age (macrosomic) newborn o 4,000 g (8 lb, 13 oz) o At risk for birth injuries  Shoulder dystocia, clavicle fracture or a cesarean birth, asphyxia, hypoglycemia, polycythemia and Erb-Duchenne paralysis de to birth trauma o Uncontrolled hyperglycemia during pregnancy leading risk factor for LGA o Risk factors  Newborns who are postmature  Maternal diabetes mellitus during pregnancy o Expected finding Plump and full-faced  Manifestation of hypoxia including Tachycardia, retractions, cyanosis, nasal flaring and grunting  Birth trauma  Tremors form hypocalcemia  Hypoglycemia  Weight above 90th percentile  Large head  Sluggishness, hypotonic muscles, hyperactivity  Respiratory distress from immature lungs or meconium aspiration o Prior to delivery LGA  Prepare to apply suprapubic pressure to aid in the delivery of the anterior shoulder  Postmature infant o Competition of 42 weeks of gestation o Expected findings  Peeling, cracked, and dry skin; lethargy from decreased protection of vernix and amniotic fluid  Meconium staining of fingernails and umbilical cord  Hyperbilirubinemia o Hyperbilirubinemia is an elevation of serum bilirubin levels resulting in jaundice. o Jaundice normally appears on the head (especially the sclera and mucus membranes)  Physiologic jaundice  Considered benign resulting from normal newborn physiology of increased bilirubin production due to the shortened lifespan and breakdown of fetal RBC’s’ and liver immaturity  Pathologic jaundice  Persistent after day 14  Caused by a blood group incompatibility or an infection, but can be the result of RBC disorders o Acute bilirubin encephalopathy is when the bilirubin is deposited in the brain, resulting in necrosis of neurons – bilirubin level higher than 25 mg/dL that place the newborn at risk o Nursing care  Set up phototherapy if prescribed  Maintain an eye mask over the newborn’s eyes for protection of corneas and retinas  Keep the newborn undressed  Be sure to remove the metal strip from the mask to prevent burning  Avoid applying lotions or ointments to the skin because they absorb heat and can cause burns  Remove the newborn for phototherapy every 4 hr, and unmask the newborn’s eyes checking for inflammation of injury  Reposition the baby every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores  Dehydration – poor skin turgor, dry mucous membranes, decreased urinary output  Feed the newborn early and frequently every 3 to 4 hr this will promote bilirubin excretion in the stool [Show More]

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