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With a 5 day old infant, how should the mother’s lochia be?
A mother’s vital signs are 136/54, Pulse
118, respiratory rate 32, temperature is 99.8 two hours after birth. Her fundus is firm and 4 fingerbreaths above the umbilicus, and there is clear urine in her Foley. What should the first action be?
Press firmly on the fundus (She may have clots)
48 hours after birth, the patient states that she is sweating and urinating a lot.What is the reason for this?
Loss of increased blood volume associated with pregnancy
Postpartum hemorrhage is defined as:
Blood loss of 1000mL (FYI: hemorrhage after vaginal birth is 500mL, and 1000mL with CS. A pad saturated in 1 hour IS NOT hemorrhage. If the Hct is >25, it IS NOT hemorrhage)
What is a risk factor for postpartum hemorrhage?
Operative hemorrhage (when forceps, vacuum applied)
What is a nursing intervention for uterine atony?
A preeclamptic patient with a healthy newborn starts to bleed excessively. What order would you question?
Methergine IM stat (FYI: this should not be given if patient has a HTN disorder or HR>120)
The nurse suspects a genital tract laceration because..
The patient has a steady trickle of bright red blood (FYI- her uterus will be firm)
CS patient has a DVT. What should you do for care management in the acute phase?
Apply TED hoses??
Know DVT discharge instructions
Pt given oral anticoagulant with treatment & possible SEs. If SQ given, taught how to give & rotate site. Taught how to prevent bleeding: use of soft toothbrush & an electric razor. Follow up with DR to monitor clotting times. Use of reliable form of contraceptive (if warfarin taken - teratogenic)
Thrombophlebitis is suspected 24 hours postpartum. Which order would you NOT question?
elevating extremity (No ice or massage! Can apply warm, moist heat)
Adverse effects of postpartum affective disorder include all EXCEPT:
a healthy appetite (pt will have a decreased appetite)
Know about postpartum depression symptoms
- Persistent sadness
- Loss of interest or pleasure in activities
- Feelings of guilt
- Appetite changes & wt loss
- Insomnia, fatigue
- Difficulty concentrating
- Thoughts of suicide, death
Know postpartum psychosis
- Delusions, phobias
- Emotional lability
- Bizarre or violent behavior
- Changes in appetite
- Pyschomotor agitation
- Suicide or infanticidal ideation
What is NOT a risk factor for neonatal hypoglycemia?
Maternal administration of mag sulfate
What order do you assess a neonate’s vital signs?
- BP (FYI-BP not usually done unless indicated, such as with heart murmur which can be heard on a preterm baby)
What is not a risk factor for hyperbilirubinemia?
Caput succedaneum (this is an accumulation of fluid not blood that will be broken down into heme and build more bilirubin)
Know what to look for if an infant has facial paralysis
the affected side eye will not shut
What will reduce hyperbilirubinemia?
Frequent feeds (will cause increased urine, stooling that will push excess bilirubin out the body)
Care for an infant with hyperbilirubinemia include:
Eyeshields(class debated that we should assume that the baby is under bili-lights to assume the best answer is “eyeshields”)
Know that chest and abdomen rises and falls at the same time with infant breathing
see-saw motion is a danger sign
What to include in circumcision teaching?
Use petroleum jelly dressings (yes, the other big things are to watch for bleeding and infection)
Know the infant transition period
- 1st period of reactivity:1st hour baby is most alert and RR ishigher
- Period of decreased reactivity
- 2nd period of reactivity:
What scenario would put the mother/baby at risk for Rh incompatibility?
What is an appropriate nursing diagnosis for an infant with diaphragmatic hernia?
Impaired gas exchange (abdominal contents displace lung)
What is an example of a perinatal loss? (Select all that apply)
- Stillbirth at 33 weeks gestation spontaneous abortion at 7 weeks gestation
- therapeutic abortion,
- and infant with cleft lip. **The correct answer was all choices. Trick question. Remember that a perinatal loss is not just fetal demise. It can be a birth that does notmeet expectations. **
What is NOT a risk factor for uterine inversion?
Previa.(Other options are uterine atony, abnormal adherence of placenta, fundalpressure)
A patient that received an epidural is being assessed 30 mins after vaginal delivery for a vulvar hematoma. What would you observe?
Bluish discoloration of the vulva (another option was something about the patient having pain, but patient’s epidural still working because the affects usually won’t wear off for 1-2 hours after birth)
What is an intervention for a perinatal loss?
Give the family the clothing the infant wore in the pics taken in the hospital. (other options were: share your experience of loss with the family, tell the family they can try for another baby)
Pt just delivered and needs to use the bathroom, what should you do?
Assess the fundus for firmness and clots, THEN assist the patient to the restroom if she tells you she needs to void.
Therapeutic measures in developmental care of infants include everything EXCEPT:
Prolonged laying (avoid this so that the baby does not suffocate. Another option was not to leave blankets in the crib)
Know cold stress symptoms
- Body cold to touch
- Temp <97.7F
What is NOT a symptom of hypoglycemia?
An overvigorous suck
IDDM who is breastfeeding baby blood sugar is 43, its mottled, jittery, and apnic.Which order should you question?
- Enfamil 30cc PO now,
- then recheck blood sugar (Blood sugar should be over 40, so the option to recheck blood sugar is incorrect)
An infant is 20 hours old and has yellow sclera. What should you do
Call the doctor!!!!
Prioritize the following actions which the nurse should do following birth (Listed in the correct order)
- Provide warmth,
- position correctly
- give O2 PRN,
- dry and stimulate,
- (wanna place baby in warm bed after its delivered, lay them on their back and give O2 if needed, dry and stimulate them if not crying, O2 prn)
All are consequences of hypothermia EXCEPT:
peripheral vasodilation (other options were hypoxia, metabolic acidosis, increased O2 consumption)
List reasons for labor induction
- Severe preeclampsia
- Maternal medical diseases (DM, renal dis, chronic pulmonary dis
- Suspected fetal jeopardy
- Fetal Demise
- Postdate pregnancy (after 42 wks)
- STOP syndrome
List risk factors for labor induction
- Greater incidence of cesarean birth
- Tachystole (too many contractions)
- Non-reassuring FHR patterns
- Failure to progress in labor
- Induced labors generally longer than spontaneous
- Increased costs of care
Medications & dosages used for labor induction
- Pg Gel (cervical ripening agent): 0.5-3mg into cervica os or posterior vaginal fornix
- Cervidil (cervical ripening agent): 0.3mg/hr inserted in the into posterior vaginal fornix for 12hrs
- Cytotec (cervical ripening agent): 25mcg into posterior vaginal rpt q 3-6hrs up to 6 doses in 24hrs
- Oxytocin: 0.5-1.0 milliunits/min, then titrate 1-2mU//min q15-30 min, titrate to ctx, Max dose: 40 mU/min
What are the priorities in a precipitous delivery and the steps needed to assist a woman with a vaginal delivery in the absence of a healthcare provider?
- Call for Help!
- Supplies: gloves, bulb syringe, scissors, cord clamps
- **Emergency steps* ROM prn, Deliver head with Ritgen manuever
- Gently rotate head to one side
- Bulb suction nose, then mouth
- Check for nuchal cord: Attempt manual reduction or clamp & cut if not reducible
- Hook finger gently under ANT shoulder & deliver shoulder
- Then gently Hook finger gently under POS shoulder & deliver shoulder
- Suction mouth prn
What interventions are taken if a prolapsed cord occurs?
- Call for help!
- Notify MD immediately
- Exert upward pressure against the presenting part to relieve compression on the cord
- Modified Sims or knees to chest
- O2 by mask
- IVF bolus
- Turn off pitocin
- If cervix is dilated, forceps/vacuum assisted birth may be performed or else CS is necessary
List the steps needed to assist the healthcare provider with a shoulder dystocia at delivery.
- Lower HOB
- Call for help
- McRobert's maneuver (Knees to ears)
- Suprapubic pressure (NVR FUNDAL PRESSURE
- Gaskin maneuver (Pt is on Knees leaning over bed)
State what medications can be given to the woman experiencing prolonged latent phase of the first stage of labor to help her to rest/relax/sleep (therapeutic rest).
- Sleeping meds (Ambien)
What are the actions of oxytocin, its use, side effects and when discontinuation of the medication is needed.
- Action: stimulates uterine smooth muscle. also has a vasopressor and antidiuretic effect
- Use: labor induction & PP control of bleeding
- Maternal SEs: uterine tachystole & water intoxication (causes Na retention & H2O retention)
- Fetal/Neonatal SEs: Iatrogenic prematurity, Hyperbilirubinemia
- Discontinue tx if TACHYSYSTOLE occurs - <60 sec relaxation between ctx, >5 ctx in 10min, Ctx >2 min duration, Ctx doubling/tripling may signal of onset
Causes for excessive uterine bleeding in the postpartum period
- Retention of placental fragments
- Disorders of coagulation - thrombin
- Trauma during delivery - genital tract trauma
- Uterine inversion
- Uterine atony
List interventions required to alleviate excessive uterine bleeding in the postpartum period
- Assess fundus
- Fundal massage
- Frequent VS
- Initiate IVF/oxytocics
- Pad count: 1 gram = 1 ml
Identify measures to provide comfort measures for the woman experiencing breast engorgement.
- Breast binder or well fitted supportive bra
- Ice packs
- Mild analgesics
- Fresh cabbage leaves
What are the medications that can be used for PP hemorrhage and their side effects.
- Oxytocin: watch for water intoxication, N, V
- Methylergonovine: HTN, N, V, HA
- Prostagladins: HA, N,V, F, D, tachycardia, HTN,
- Misoprostol: HA, N,V,D
Understand the psychosocial phases of recovery and adjustment after birth.
- Postpartum Blues: onset 3-4 dys after birth, Transient no tx, S/SX: mood swings, weepiness, anorexia, fatigue
- Postpartum Depression: onset 1-6 mos after birth, risk factors: hx pyschiatric disorders, poor social support, stressful life events. S/Sx: PERSISTENT SADNESS, loss of interest/pleasure in activities feelings of guilt, hopelessness, thoughts of death/suicide. TX: SSRIs-linked to PPH in neonate, Tricyclics, MAOIs, Pyschotherapy
- PP Psychosis: onset w/in days, S/SX: hallucinations, delusions, phobias, emotional lability, bizarre/violent behavior, chg in appetite, sleep pattern, suicidal/infanticidal ideation, TX: prevention w/estrogen postpartum, hospitalization, antidepressants, psychotherapy
What are the the signs and symptoms of a patient with a post delivery infection.
LOWER GENITAL TRACT INFECTION: F, Site red, warm to touch, drainage, dysuria, pain localized, edema, WBCs >30,000 (UTIs, Vag Infection)
UPPER GENITAL TRACT: (ENDOMETRITIS) PP Fever day 3/5, Uterine tenderness & lower ab pain, Tachycardia, Uterine subinvolution, Malaise, Chills, HA, bckache, FOUL SMELLING LOCHIA, wound dehiscence, GBS infection prior to deliver
Describe the nursing management of the patient with a DVT (deep vein thrombosis).
- Strict bed rest
- Elevate extremity
- Apply heat
- Analgesics, sedatives
- Antiocoagulant tx (Hep given 24-48 hrs, the Coumadin)
- Ted Hose
What are the four different methods of heat loss that a newborn can undergo?
- Convection: flow of heat from the body surface to cooler air - SHIELD baby from drafts
- Radiation: loss of heat from the body surface to a cooler SOLID surface - KEEP baby away from cold objects and outside walls
- Conduction: loss of heat from the body surface to cooler surfaces in direct contact - Keep surface warm & padded.
- Evaporation: loss of heat that occurs when a liquid is converted to a vapor - Keep baby dry and wrapped
What are signs/symptoms of cold stress in the newborn?
- Body cold to touch
- Temp <97.7F
What are the methods of prevention for cold stress in the newborn?
- DRY infant well - PREVENTS heat loss by evaporation
- Use warm blankets - PREVENTS heat loss by conduction
- Radiant Warmer with probe
- Wrap infant well
- Skin to skin contact with mom or dad
Identify normal newborn physical assessment for gestational age, as well as VS and glucose levels.
- BG: 40-60
- VS: HR 100-160 beats/min, RR 30-60 breaths/min, T: 96.8-99F, BPl 73/55 mm Hg
- Peripheral Pulses
- Gestational Age determination
Discuss medications given to the newborn in the transition period and the rationale for administration.
- Erythromycin opthalmic ointment - prophylactic measure to protect against gonorrhea & C. trachomatis
- Vitamin K - prophylaxis & treatment of hemorrhagic disorders
- Hep B - prevent Hep B, consent form required
What are cues that could indicate that an infant is overstimulated?
- Gaze aversion
- Regurgitation of food
- Holding hands in front of face
- Frowning, worried expression
- Stiffening & extending limbs
- Facial grimace
- Irregular RR
- Increased HR
What is PATHOLOGIC jaundice in the newborn?
- Total bilirubin rise >0.2mg/dl per hour
- Jaundice persisting more than 1 week
- Jaundice in first 24 hours
What is PHYSIOLOGIC jaundice in the newborn?
- Breakdown of fetal hemoglobin at birth
- Limited hepatic bilirubin clearance
- Immature enzyme systems
- Increased enterohepatic shunting
What is meconium aspiration syndrome?
- Occurs in term/post term newborns, meconium in the lungs
- Respiratory distress
- Nasal flaring
- NB's nails, skin, & umbilical cord may be stained yellow
- Chemical Pneumonitis
What is transient tachypnea of the newborn?
- Occurs following intrauterine asphyxia & with CS
- Failure to clear airway after birth
- Tachypnea noted by 6 hrs of age & peaks about 36 hrs of age
What is respiratory distress syndrome?
Serious lung disorder caused by immaturity & inability to produce surfactant, resulting in HYPOXIA & ACIDOSIS
Identify abnormal findings in a newborn assessment that would require the nurse to call the healthcare provider
List assessments and conditions that may alert the nurse to assess an infant for congenital anomalies.
What are the TORCH infections?
- TOXOPLASMOSIS: caused by parasites toxoplasma gondii acquired by: eating undercooked meat, exposure to cat feces, raw goat's milk, & insects in contact with cat feces.
- OTHER (gonorrhea, syphilis, varicella, hepatitis, HIV)
- CMV (Cytomegalovirus): common herpes virus transmitted by blood & body fluids, most common congenital infection
- Herpes simplex virus: genital herpes
What is Erb's palsy?
- Injury to upper Brachial plexus due to stretching or pulling the head away from the shoulder
- S/SX: flaccid arm with elbow extended & hand rotated, Absence of Moro reflex on affected side, Sensory loss over lateral aspect of arm, Intact grasp reflex
What is Klumpke's palsy?
- Damage to lower brachial plexus
- S/SX: Wrist & hand flaccid, DTRs present, dependent edema & cyanosis, ABSENT grasp reflex
What is the rationale for the Surfactant administration to the premature NB?
Replenishes surfactant & restores surface activity to the lungs to prevent & treat RDS
What are the signs/symptoms of sepsis in the newborn?
- Lethargy, irritability, hypotonia
- Color change
- Temp instability
- Feeding intolerance
- Tachycardia, then apnea, bradycardia
What are nonpharmacologic methods to reduce pain in a neonate?
- Positioning strategies
- Care clustering
How do you evaluate for pain in a neonate?
- Evaluate pain by physiologic & behavioral responses
- Increased HR
- Rapid, shallow respirations
- Decreased O2 sats
- Increased muscle tone
- Increased ICP
- Changes in sleep/wake cycle
- Brow bulge
- Eye squeeze
- nasolabial furrow
What is the frequency, length, amount of feedings and expected output in stools/urine for a BREASTFED baby.
- FREQUENCY: 8-12 feedings per 24 hrs, 2-3hrs during the day & 3-4hrs during the night
- LENGTH: avg of 30 minutes
- OUTPUT in stools/urine: 6-10 dirty diapers w/in 24hrs & urine is light colored. 2 to 3 stools per day / 3-4 golden yellow curdy stools per day
What is the frequency, length, amount of feedings and expected output in stools/urine for a BOTTLE FED baby?
- FREQUENCY: 6-8 feedings per 24 hrs, q 3-4 hrs
- LENGTH: 15- 30 ml per feeding
- OUTPUT in stools/urine: 6-10 dirty diapers w/in 24hrs & urine is light colored. 1 - 2 malodorous soft stool every 2-3 days
List those neonates who require blood glucose monitoring after birth and why.
- Neonates under 2500 (SGA) or over 4000 grams (LGA)
- Maternal DM
What is CAPUT SUCCEDANEUM?
- Scalp edema that extends the suture lines
- Resolves within 3-4 days
What is Cephalohematoma?
- Collection of blood between skull bone and periosteum caused by pressure from maternal pressure or OVD
- Does not cross suture line
- Resolves in 2-3 wks