NRSG 3302 maternity study guide - LONG/DETAILED, Updated 2021.

maternity study guide - LONG. Maternal History • Obtain and interpret information relevant to newborn health including: • Maternal medical, nutritional, prenatal, obstetric, and intrapartal history • Social/Family h ...

maternity study guide - LONG. Maternal History • Obtain and interpret information relevant to newborn health including: • Maternal medical, nutritional, prenatal, obstetric, and intrapartal history • Social/Family history • Results of maternal screening tests (e.g, Rh), rubella, hepatitis B and C, serology for syphilis, HIV, tuberculosis, illicit drugs, blood type, group B streptococcus, herpes simplex virus, gonorrhea, and chlamydia • Maternal medication use or substance use/abuse • Results of prenatal ultrasound testing Keep in mind: The babies review of systems (really mom’s medical history; prenatal care? Weight gain? Nutritional issues? Hx of frequent n/v? Did she keep her prenatal appointments? Obstetric history? Previous pregnancy/losses? Intrapartal history. Did the baby have repetitive variable decelerations? This can lead to hypoglycemia. Was there fetal tachycardia? May indicate sepsis How long was she in labor?What was the baby’s Apgar? Is it a traditional family? Is the mom going to be going back to work or staying home w/ baby?Mother’s GBS status. If positive, how many treatments of antibiotics did she receive prior to labor? Did baby grow at normal rate of speed? Babies are Smart • The healthy newborn is equipped to adjust to extrauterine life • The newborn is equipped at birth to survive, thrive and engage in social interaction. This is why babies will grab your hand and try to mimic you as the get older. The establishment of respirations is the most critical time of transition (from intra to extrauterine life). The change is initiated by the compression of the thorax, the lung expansion, increased alveoli oxygen concentration, and vasodilatation of the pulmonary vessels. Was it a vaginal birth or C-section? Mechanically the resp. system is stimulated to take it’s first breath. The biggest breath you ever take in your life is your first breath. Air will enter alveoli replacing the expelled amniotic fluid. Any fluids not initially expelled will be disbursed via the lymphatic system. The neonate starts to cry, changing the intrathoracic pressure, and it helps alveoli stay open. To avoid delays during an emergency situation: • vital to ensure that equipment is in good condition before resuscitation is needed: There needs to be infant dedicated oxygen and suction • Have the appropriate size masks available according to the expected size of the baby (size 1 for a normal weight newborn and size 0 for a small newborn). • Block the mask by making a tight seal with the palm of your hand and squeeze the bag: Resuscitation must be anticipated at every birth. Every birth attendant should be prepared and able to resuscitate since, if it is necessary, resuscitation should be initiated without delay. Always check room for emergency equipment. Do you have a laryngoscope? Is it working? Is the ambu bag working? If baby had meconium, will want to set up everything needed for intubation. • Maintenance of clear airway – Free flow Oxygen should be available – Bulb syringe • Maintenance neutral thermal environment – Perform assessments and interventions under a radiant warmer – Pre warn equipment and clothes – Cap on head Pre-warm all equipment. Usually put on “manual” setting. It is best to do your assessment under the warmer so that the baby doesn’t get cold. APGAR • A appearance (skin color) • P Pulse (heart rate) • G grimace (reflex irritability) • A activity (muscle tone) • R respiration Acrocyanosis- not uncommon in hands and feet. Reflex irritability- will see when you try to suction the nose or wipe their face, they will pull away. Muscle tone- extend arms, lay flat, let go and see if they curl back up. If respiratory distress, you will see: central cyanosis, periods of tachypnea/apnea, retractions, grunting, flaring of nostrils. “Golden minute” Knowing approximate gestational age is an important indicator of what you should get prepared for. If answers are no, go to “provide warmth”. No blankets or hat on the baby. Reposition the airway (do not hyperextend). Evaluate the respirations, heart rate, and color. Delivery Room Care • A brief physical examination is performed to check for obvious signs that the baby is healthy. : • temperature, heart rate, and respiratory rate • measurements of weight, length, head circumference Temperature- most hospitals use axillary temp. May be able to take heart rate at umbilical cord (6 second count and add a zero). • Cord care Clamp is secure, count number of vessels • Identification Bands and security • Footprints If cord is greenish-yellow, question how long baby was exposed to meconium. If thin cord, baby may not have been fed very well during pregnancy. Identification bands- usually one on hand and foot Nursing Care of the Newborn Infant • Eye prophylaxis - Erythromycin ophthalmic ointment 0.5% - Tetracycline ophthalmic ointment 1% Vitamin K prophylaxis - Newborn gut unable to produce it (Why??) - 0.5 – 1 mg given IM Try and hold off for a bit to give mom and baby some bonding time. Usually needs to be done within first couple of hours of birth. Vitamin K- given in vastus lateralis, IM, use a small needle, make sure you realize that you will only be able to hold onto needle with one hand. - Coagulation Factors II, VII, IX and X cannot be synthesized because sterile fetal gut cannot synthesize Vitamin K * persists for several days * Vitamin K must be given at birth Be sure to support the baby’s lead. Makes sure the needle is capped. Always wear gloves with babies (b/c they have been in mom’s amniotic fluid). Respiratory Adaptations • Fetal Lung Development • 20-24 weeks gestation alveolar ducts are formed • 24-26 alveolar responsible for surfactant manufacture available • Prior to 34 weeks Preterm infants administered through the endotracheal tube • L/S ratio – Lecithin (35 weeks) – Sphingomyelin L/s ratio= indication of lung maturity Initiation of Breathing • Reabsorb of fetal lung fluid ~2-24 hr • Thoracic squeeze • C/S • Hindered by respiratory depression – Narcotics – Meconium Initially the baby will expel most of the fluid and then absorb the rest of it. If they did not have a thoracic squeeze, they may have more fluids. Make sure mom knows how to use bulb syringe. Narcan is only used for opiate medications. If baby had meconium, was there any below the vocal cords? • - Newborn’s chest and abdomen rise simultaneously • - Pulmonary lymphatics remove large amounts of fluid from lungs during the first hour • - Alveoli are lined with surfactant – augmented with respiration • - Decreases surface tension and keeps alveoli open As baby takes it’s first breath in, the surfactant is what keeps the lung cells from collapsing upon itself. The alveoli are opened a little more with each breath. Respiratory Rate • Because of variations… count for 1 full minute • Periodic breathing = pauses of 5-15 seconds • Apnea = pauses of more than 20 seconds • RR 30-60 varies with state of newborn count for 60 seconds • Pattern may be irregular • Abdominal in nature • Pauses of 20 seconds or longer =apnea • Newborn is an obligatory nose breather Watch for signs of apnea (no breathing for more than 20 seconds). Babies are obligatory nose breathers. At delivery, suction mouth and then nose. After delivery, suction the nose first. Signs of respiratory distress • Nasal flaring • * Sternal retractions • * Grunting with respirations • Normal Rate 40- 60 • >60 Tachypnea Look for any substernal retractions, nasal flaring, cyanosis (look at mucous membranes). ● Cardiovascular System - Markedly changes at birth - Fetal lungs do not function for respiratory gas exchange so a special circulatory pathway (ductus arteriosus) bypasses the lungs - Fetal Circulatory Pathway * Oxygen-rich blood flows from placenta through umbilical vein to fetal abdomen With clamping of umbilical cord, you remove placental circulation and initially closes the ductus stenosis. The clamping of cord increases systemic vascular pressure, air enters into the alveoli and expands the lungs, decreases pulmonary vascular resistance, reduces reversal of blood flow acrosss the ductus arteriosus (that reversal leads to closure of ductus arteriosus). Increase in left atrium pressure and decrease in right atrium pressure, closes the foramen ovale. Nursing Care of the Newborn Infant • When PO2 level approaches 50%, ductus arteriosus constricts and later becomes a ligament • - When umbilical cord is clamped, umbilical arteries, umbilical vein and ductus venosus close * converted into ligaments • Fetal Circulation – PDA Fetal circulation- right atrium has blood crossing directly to left atrium via the foramen ovale. • Adult Circulation Heart rate • Check peripheral pulses • Common variations: • Heart rate range to 100 when sleeping to 180 when crying Color pink with Acrocyanosis Heart rate may be irregular with crying • Signs of potential distress or deviations from expected findings: • Although murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluation Check apical pulse. Check brachial and femoral pulses. Both femoral pulses should be assessed at same time and should be equal. If you hear a murmur (foramen ovale being “floppy” is the most common). More pathological if it doesn’t develop until a few days after birth. Temperature • Axillary • Body heat lost easily due to large body surface area in relation to weight • Normal axillary temperature is 97°F–99.5°F (36.5 to 37 C) • Common variations • Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery If rectal temp., be aware of how deep the thermometer is going in. Can cause lacerations. Low temp. can lead to problems with hypoglycemia. Thermal balance Radiation, Convection, Evaporation, Conduction • Four ways a newborn may lose heat to the environment 1st way they lose heat is evaporation and then conduction (don’t use or put anything on baby that is cold). Convection- when doing assessment, make sure you are not under air vent or fan. Teach moms about where to place cribs in relation to cold walls. Non-shivering thermogenesis • Heat is produced by increasing the metabolism especially in brown adipose tissue • Blood is warmed as it passes through the brown fat and it in turn warms the body Shivering is rarely operable in the newborn . Temperature Regulation • Neutral Thermal Environment • Brown Fat/Adipose Tissue • Thin Epidermis • Posture (flexed) • Usually present more in full-term babies. Pre-term babies may not have much brown fat and will get cold easier. Babies will try to curl into fetal position to stay warm and conserve energy. Hypoglycemia • Plasma glucose level below 40 mg/dl • Assessment findings – Jitteriness, tremors, apnea, cyanosis, lethargy • Risk factors – SGA, preterm, perinatal stress, IDM, sepsis • Management – Early feeding of infants at risk – Keep infant warm – Glucose by nipple, gavage, or IV – Recheck blood glucose 30 minutes after feeding Any baby we think may have a problem will get a heel stick. Babies, esp. breast fed babies, need to eat every 2-3 hours. A baby that sleeps long between times, we don’t know if their blood sugar is down and they are lethargic? If baby hasn’t awaken in 3-4 hourss since last feeding, need to wake them up and try to get them to eat. Risk factors: SGA (less brown fat), large amounts of variable decelerations can cause the baby stress after delivery. Get baby to breast during first 30 minutes of life. If there is a problem with hypoglycemia, they may give some glucose by nipple. Interventions: early feed, check blood glucose w/in 30 minutes. Hyperbilirubinemia (Jaundice) When looking at jaundice, travel down the body. The further down the baby starts to turn yellow, the higher their bilirubin level. Hepatic Considerations-Conjugation of Bilirubin • Immature liver • Fetal RBC • Bilirubin is a yellow lipid-soluble pigment • Conjugation refers to the conversion of bilirubin into a water-soluble pigment • Unconjugated bilirubin is toxic and is not readily excreted (destroyed rbc’s end-product) What causes bilirubin levels? Immature liver (esp. if you have an immature baby) and fetal RBC’s have shorter life span than adult RBC’s. Rh incompatibility problems not treated with Rhogam, ABO incompatibility or other pathological conditions can result in jaundice. Hepatic Considerations-Physiologic Jaundice • Pathologic if appears within the first 24 hours of life • Peak bilirubin levels reached between days 3-5 of life in the term and 5-7 in the preterm Preterm babies have more problems with jaundice. Breastfeeding Jaundice • Breastfeeding Jaundice- not enough fluid intake • Breast milk Jaundice- related to the composition of the breast milk, some free fatty acids compete with bilirubin for binding sites on albumin and inhibit bilirubin conjugation The colostrum is high in calories but not in fluid content. An ounce of formula is 20 calories per ounce while colostrum is 65-75 calories (so baby doesn’t need as much to maintain sugar so not getting as much fluid). May also be related to free fatty acids in breast milk that compete with bilirubin and inhibit bilirubin conjugation. Nursing Care of the Newborn Infant • - Phototherapy * Baby placed, unclothed (lights or bili- blanket) * Turned every 2 hours * Protect baby’s eyes * Temperatures q 4 hours * Maintain hydration Unclothed, under lights. Eyes must be covered. Are they maintaining their hydration? Biliblanket- can wrap around skin to skin (with this there are no problems with the baby’s eyes). GI Adaptations-Elimination • Meconium, road tar, . • Passed within 8-24 to 48 hours of life • Transitional stool • Frequency: 2-3 or as much as 10 per day • NOT constipated, if stool is soft 1st stool will be meconium= dark black, road tar. As baby gets formula or breast milk, it tends to be a little thinner and goes to a brownish color. Then goes to yellow color as the baby develops. Stool from breastfed babies has no odor. Cow’s milk/formula has a fragrance to it. Don’t give babies enemas or suppositories. Gastrointestinal System • Fetus in utero receive nutrition via placenta – Stomach of newborn has a capacity of approx. 2 oz – About the size of a walnut – Gastric emptying start within few minutes after feeding and takes 2-4 to be completed Stomach about size of walnut. Gastric emptying starts happening a few minutes after eating. Takes 2-4 hours to be completed (which is why you shouldn’t go more than 4 hours w/o feeding the baby). Urinary Function • Voiding after birth is an important event to DOCUMENT, it frequently goes un-noticed • Check with LD nurse about baby voiding in DR • Should void by 24 hours – 48 hours (renal or urinary disorders may be present otherwise) Post-circumcision spots. Pseudomenses (maternal hormone withdrawal). Document if baby voids during delivery. Voiding and Cord care • Teach mom that a well fed hydrated newborn should have 6-10 wet diapers per day • Clean cord are at each diaper change • Diaper below umbilical cord stump A well-fed hydrated baby should have 6-10 wet diapers per day. Make sure no urine has gotten on cord. Keep cord above the diaper. Keep it dry. It will fall off w/in 2 weeks. Measurements • Head circumference • Fontanels • Sutures • Molding • Chest • Length Put tape over ears, right across the eyebrows. Be sure to document in centimeters. Molding If you palpated this baby’s head, would probably find some overriding sutures (not uncommon). Anterior fontanel- diamond shape Posterior fontanel- triangular shape Depressed fontanel= dehydration Bulging fontanel= increased intracranial pressure Nursing Care of the Newborn Infant • Cephalohematoma • * Collection of blood between a skull bone and its periosteum • * Does not cross suture lines • * Comparison of Caput Succedaneum and Cephalohematoma Top picture= Caput (edema between scalp and periosteum; the edema crosses across the suture line!!! That fluid will be absorbed. Cephalohemtoma- blood; does not cross the suture line; may be due to rapid delivery or use of forceps. Face • Eyes -distance, drainage • Nose-patent • Neck (webbing) Are the eyes even? Any hemorrhage in the sclera? Are the eyes fully visible? “Sunset eyes”- only see half of eyes; sometimes happens with down syndrome Any drainage in the eyes? Is nose patent? Have baby suck on your finger and you should see movement of both nostrils. Palpate the neck. Any webbing? Are the clavicals straight? If you do feel any problems, make sure you have an equal moro reflex. • Ears - location, pits • Hearing test Pits are associated with hearing problems and skin tags may be tied off or surgically removed. Make sure baby has hearing test before being discharged. Skin tags are usually just sutured (circulation is cut off). The tissue will just fade away. Less scarring if you do at birth rather than later in life. (SEE PICTURE) Rooting Reflex Tickle the baby’s cheek and he/she should turn its head towards your finger. When teaching a mom how to breast feed, tell her not to stroke baby’s face b/c baby will turn away from her breast due to the hand stimulation. Mouth • Thrush = White patches cannot be removed • Due to Maternal yeast infections If breastfed baby, colostrum is yellow. Feel the palate. Is in intact? Good sucking pads on both sides of cheek? Any teeth? Chest • Respiratory Effort • Quality of RR and HR • Symmetry • Engorged breast- wnl R/T maternal hormones • Supernumerary Nipples Retractions, expiratory grunting symmetry. Supernumeraray nipples- usually blanches later on in life; usually has no breast tissue to go with it Anus • Patent • Tone • First stool? Check tone- wipe a 4x4 across anus and should see a wink with the rectal sphincter When did they pass first stool? Back • Straight? • Pilonidal dimple associated with spina bifida • Mongolian spots Spina Bifida After delivery, they would put a sterile saline cover on it and take baby to the NICU to evaluate for surgery. Extremities: Arms & Hands • Equal Movement • Symmetry, count digits • Polydactyly-extra digits • Syndactyly=webbing Single palmer crease-simian line R/T Down’s Brachial palsy-R/T trauma at brachial plexus during birth (Erb’s-upper arm most common) Talipes deformity=clubfoot-positional, fixed Symmetry of gluteal folds Count toes and fingers!!! If you see an extra digit, do you feel bone in it? Is it just skin? They may tie it off and ligate it (let it fall off). Feet/ Hips Deviations Do you have equal gluteal folds? Unequal gluteal folds is an indication of a possible congenital hip dysplasia. To further assess this, turn baby on back and do the Ordolani maneuver where you bring knees to chest and rotate hips out and listen for hip clicks. If you keep your fingers on trochanter as your rotate hips, you may feel a slippage of the hip. Extremity Reflexes • Moro=startle • Grasp=holds hand • Babinski=hyperextension of toes to heel stroke • Plantar Skin • Acrocyanosis=blue hands & feet • Lanugo=downy hair • Vernix caseosa – cheesy covering of old cells & sebum • Milia=white spots-sebaceous glands Do not try to scrub milia away. The tissue will be reabsorbed. Lanugo- some ethnicities have more hair (very fine) Vernix caseosa- nature’s baby lotion while in the uterus; should be absorbed by delivery in a full-term baby • - Desquamation (post-term infants)- peeling of skin • - Marks • * Mongolian spots * Stork bites * Erythema toxicum * Strawberry mark * Port wine stain Mongolian Spots • Mongolian spots=bluish-black spots over buttocks-back (fades spontaneously) • Fade by age 2 • Document Do not blanch. Document them so they are not confused with bruises. Port Wine Stain • Nevus flammeus =port wine stain – does not fade – does not blanch – does not grow It will be there for the rest of their life. Strawberry Mark • Nevus Vasculosus strawberry mark • Capillary hemangioma • Raised, rough borders, grow then shrink Do not pick at this b/c baby will bleed. Erythema toxicum • What are the symptoms? – Some splotchy red patches. Some have firm yellow or white bumps surrounded by a flare of red. – The rash tends to come and go, shifting its location across the body. The palms and soles are often left out. • Is it contagious? No Comes and goes fairly rapidly. It is not contagious. When removing umbilical cord clamp, assess the cord and make sure it is dry, crusty, and hard. Take the remover, insert it into the small ring, clamp the cord, and peel it apart. Document the removal of the cord clamp. Difficult Births • Forcep – May concern parents • Fx clavicle • Likely to develop jaundice Assess for forcep marks and fractured clavicles. Baby is more likely to get jaundice b/c of the bruising. Male Genitalia • Urinary meatus at tip of glans penis • Palpable testes in scrotum • Large, edematous, pendulous scrotum, with rugae Common variations • Prepuce covering urinary meatus • Erections • Edema and ecchymosis after breech delivery Use one hand to palpate testes. Baby’s born by breech, may have some bruising on the bottom. Male babies tend to have an erection prior to voiding. Circumcision • Informed consent • Restraints • Comfort measure • Assess for bleeding q 30 minutes • Apply petroleum jelly or antibiotic ointment • Document post procedure voiding • Do not rub during bathing • Teach parent s/s of infection Circumcision requires consent. Baby is put on a constraint board. May give them a sugar nipple. Afterwards, a pressure dressing with a couple of 2x2’s and vaseline or ointment will be applied. May initially have a little bit of bleeding. Be sure to follow up on any bleeding. Don’t have to remove the new pressure dressing unless there is blood. Teach mom the s/s of infection. Female Genitals • Edematous labia and clitoris • Labia majora are larger and surrounding labia minora Common variations: • Pseudo menstruation Ecchymosis and edema after breech birth If breech, may have some edema or bruising. Labia majora should be larger than labia minora. Periods of Reactivity • 1st period of reactivity: – after birth of baby, bursts of rapid movements. Quiet times during this period are ideal for breastfeeding & interacting • Deep Sleep - lasts 60-100 minutes • 2nd period of reactivity: occurs 4-8 hrs after birth lasts 10 min to several hours. Periods of tachycardia & tachypnea. Increased muscle tone, skin color, mucus production, pass meconium (first stool) 1st period of reactivity: around first 30 minutes of life; baby will go to breast and suck the best during this time. Behavioral states Brazelton • 2 sleep states – Deep sleep – Light sleep-REM sleep • Awake states – Drowsy – Quiet alert – Active alert – Crying • * Response to Environmental Stimuli • - Temperament * Consolability * Cuddliness * Irritability * Crying How easily can mom console the baby? Baby’s withdrawing from drugs will not be very cuddly (will be irritable). Behavioral Adaptations • Habituation=capacity to ignore repetitious stimuli • Orientation=ability to alert and attend to visual stimuli fixates on an image • Self-quieting ability- hand to mouth, sucking & attending to stimuli • Drug positive newborns often exhibit abnormal sleep patterns (may have excessive sucking; swaddle them tight and keep in a quiet environment) Baby will habituate to ignore repetitious stimuli. If mom keeps the house really quiet, the baby will get used to the silent state and will have problems once more activity and sound is introduced into the household. Can they self-quiet themselves? Teach the mom methods of self-quieting. Techniques for waking and quieting newborn • Loosen clothing • Hand express breast milk onto baby’s lips • Talk to baby while making eye contact • Baby sit ups • Patty cake • Stimulate rooting reflex • Check for soiled diaper • Swaddle • Use slow calming movements • Speak softly • Sing or music Screenings • PKU • Hearing • Glucose if ordered • Medications • Vitamin K • Hepatitis B Hearing screening- done in nursery Glucose- use lateral side of feet (not the bottom) Try and give vitamin K and hep B in opposite thigh Recommended Infant Nutrition • AAP recommends exclusive breastfeeding of human milk for the first 6 months and continued for at least 12 months • During the second 6 months, appropriate complementary solid foods are added to diet • If infants are weaned from breast milk before 12 months they should receive iron-fortified formula, NOT cow’s milk Can store breast milk in the freezer. Do not recommend that mom’s breast and bottle feed simultaneously. Considerations in Choosing a Feeding Method • Breastfeeding – Advantages • Do not introduce bottle feeding until breast milk is fully operational – Reasons for not breast-feeding • Formula – Reasons for formula feeding Teach them of ways to protect their privacy. Listen to her reasons for not breastfeeding. Make sure if she is formula feeding, be sure to address the type of bottles and making sure she burps the baby. • Calories – 110-110 kcal/kg daily – Breast milk/formula contain 20 kcal/oz – May lose less than 10% of birth weight – Weight regain • Nutrients – Carbohydrates – Proteins – Fats – Vitamins/minerals • Water • Breast changes during pregnancy • Milk production • Hormonal changes at birth – Prolactin – Oxytocin • Continued milk production • Preparation of breasts Prolactin- involved in milk production Oxytocin- involved in milk let down or excretion**Know these!!!! ****************************************CONTINUES************************************