OB Exam 2

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allison06
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38681
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OB Exam 2
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2010-10-12 16:59:13
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OB Exam
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Breastfeeding, Maternal Changes, Discomfort, Labor, Newborn Care
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  1. What does mature milk consist of?
    • Protein and non-protein nitrogens
    • Carbs
    • Fats
    • Vitamins & Minerals
    • Live Cells: WBC & T cells to protect immune system
    • Not homogenized
  2. What are the overall benefits of Breastfeeding for the infant?
    • Best nutrition for appropriate growth and development
    • Active protection against infection (bacterial & viral); any illness less frequent & less severe
    • Lower risk of oral and dental problems
    • Builds trusting relationship with Mom
  3. What diseases does Breastfeeding protect the infant from?
    • SIDS
    • DM Type 1&2
    • Lymphoma/Cancer
    • Allergic dx/ skin dx
    • Chronic digestive dx (Crohns)
    • Childhood/adult obesity
    • Chronic high blood pressure
  4. What are benefits to the Mom for Breastfeeding?
    • Dec PP bleeding, rapid uterine involution
    • Lactational amenorrhea
    • Earlier to return to pre-pregnant wt
    • Improved bone remineralization PP
    • Reduced risk of breast & ovarian cancer (esp premenopausal)
    • Emotional linkage to baby
    • Lower costs for health care & food for baby
  5. What are the Barriers to Breastfeeding?
    • Physician apathy, misinformation
    • Insufficient prenatal breastfeeding education
    • Disruptive hospital policies, interruption of breastfeeding
    • Early hospital discharge: milk hasn't come in
    • Lack of timely routine follow-up: within 3-5 days
    • Maternal employment: not there
    • Lack of broad societal support
    • Normalization of not breastfeeding, Commercial promotion of ABM
  6. When and how should you discuss infant feeding?
    • At each prenatal visit
    • Open-ended questions
  7. What are "Mom's Concerns" with breastfeeding?
    • Lack of confidence
    • Embarrassment/ harrassment/ sexuality
    • Loss of freedom
    • Lifestyle restrictions
    • Influence of family and friends
  8. List counseling for Mom r/t breastfeeding
    • Has the right to research-based info: informed choice, not guilt
    • Target interests, expectations, and concerns
    • Id risk factors
    • Social, economic, practice issues important
  9. List Prenatal preparation for Breastfeeding
    • Breast exams: 1st tri- nipple trauma; 3rd tri- glandular growth
    • C-sec, multiples, premature
    • Breastfeeding classes
    • Groups and community support
  10. What is the Milk ridge or milk line?
    Additional breast tissue in a line pattern extending from armpit to vagina that can leak with breastmilk
  11. What diseases is it okay to breastfeed with?
    • Acute infectious disease
    • Venereal warts
    • Toxoplasmosis
    • Mastitis
  12. What diseases is it okay to breastfeed with after treatment?
    • Hepatitis A,B,C
    • Tb
    • Herpes viruses
    • Lyme disease
  13. What diseases should you never breastfeed with?
    • HIV
    • HTLV-1
  14. Discuss metabolic disorders and breastfeeding
    • PKU: monitor closely
    • Galactosemia: cannot bf, cannot digest
  15. Discuss meds/ prescription drugs and bf
    • Drug-by-drug assessment
    • The more protein based the better
    • Take things baby would nmlly get
    • No pseudoephedrine, estrogen: dry up milk
  16. Discuss Lactogenesis 1
    • Conception to Stage 3 Labor
    • Breast cellular growth
  17. Discuss Lactogenesis 2
    • Stage 3 to Day 3-4
    • Endocrine driven: does not rely on sucking
    • Drop in progesterone releases prolactin, driving milk synthesis, dev of prolactin receptors
  18. Discuss Lactogenesis 3
    • Aka Galactopoeisis
    • Day 7 until you stop
    • Autocrine driven "supply and demand"
    • Develops gradually
    • Infant sucking, cellular pressure of milk, important in supply
    • Continues even as prolactin levels dec
  19. What events during delivery can negatively impact bf?
    • Medications
    • Overhydration: edema, engorgement, excessive fluid (false wt loss in baby), impacts milk supply
    • Cranial trauma can pinch sucking nerves: inside FHR mon, forceps
    • C-section: mom cannot sit up to nurse
  20. What can retained placenta and depo do to bf?
    • Inhibit development of full milk supply
    • Give depo at least 1 week after
  21. At how many weeks gestation is the mom and baby ready to bf?
    What happens to the baby is younger?
    • 40 weeks
    • Less stamina, fewer fat reserves
    • Underdeveloped neurologic reflexes
    • Underdeveloped critical organs (lungs, GI)
    • Inc risk for re-admit r/t feeding
  22. What are the goals of the Steps for Baby-Friendly Hospital?
    • Promote good birth
    • Maternal baby bonding
    • Breastfeeding
  23. What are the hunger signals?
    • Early: rooting, sucking on hands, other objects, mewling cry
    • Late: crying, breast fullness
  24. How often to bf infants feed?
    • q1.5-3h during day
    • At least 1x/ night
    • Minimum 140 minutes active feeding per 24h
    • Stomach grows up to 1.5 to 2 oz by 10 days of age (feed small)
    • Finish first breast first for fat
    • 15-30 minutes feeding, 10-15 min audible swallowing
  25. What are signs of Adequate Intake for bf infants?
    • 1 stool day 1, 2 on 2, 3 on 3
    • Stool: size of a quarter
    • Void: 1-3 tbsp liquid
    • Slows as gut matures
    • After first week: 3-5 void, 1 stool minimum
    • 7-10% wt loss, back to birth wt by 2 weeks
  26. Discuss aggressive measures in 3rd wk for FFT
    • Pumping
    • Supplementing with hindmilk at breast
    • Lactation Counseling
  27. Discuss treatment for Engorgement
    • Frequent, effective feeds
    • Soften breasts with massage, expression, warmth
    • Soft breast easier for latch
    • Cold compress after feed to reduce edema
    • Wear supportive bra
  28. What causes Sore Nipples?
    • Bad position and latch
    • Tongue tie
    • Yeast- tx mom and dad if systemic
    • Other skin infections: eczema, rashes
  29. Discuss Mastitis
    • Unresolved engorgement leads to plugged duct leads to mastitis
    • Problem of stasis
    • Move milk out of breasts and tx with antibiotics
    • May have ductal pain after
    • Staph, MRSA more common
  30. What are the baby centered factors for slow wt gain?
    • Medicated birth
    • Oral anatomy, tongue tie
    • Oral trauma
    • Oral imprint to non-breast
    • Physical discomfort
    • Slow/weak suck
  31. What are the mom centered factors for slow wt gain?
    • Breast anatomy
    • Hormones interfering
    • Prolonged severe engorgement causing shutdown
    • Metabolic issues: DM, hypothyrodism (delay large milk)
    • Mother low fat stores or intake
  32. List 4 ways to Resolve Feeding Issues
    • Do not delay
    • Determine factors limiting milk transfer
    • Train baby back to breast: avoid bottles, supplement at breast, early signs
    • Stimulate milk production: massage and pump
  33. Discuss the Vagina & Perineum PP
    • Vagina is relaxed
    • Perineum is edematous, nml in 6-10 wks
    • Hematoma may be present
    • Episiotomy & tears heal in 2-3 wks
    • Hemorrhoids shrink w/in 6 wks
    • Sex in 6-8 wks, use lube
  34. Discuss menstruation PP
    • Ovulation can occur in 27 days for bottle feeding moms
    • 2-3 months for breastfeeding
    • Menstration starts in 3 months
  35. Discuss Urinary System PP
    • Bladder tone returns to nml 5-7 days
    • Inc BUN, 1+ protein, trace ketones present 1-2 days
    • Kidney fxn returns to nml w/in 1 mo
  36. What 3 things must occur before C-sec pts can have solid food?
    • Passing gas
    • Bowel sounds
    • Holding down fluids
  37. Discuss Breasts PP
    • Soft and fill 24-48 hrs up to 4-5 days
    • Engorged 3-4 days
    • No soap on bf pts nipples
  38. Discuss Cardiovascular system PP
    • Blood volume dec 300-400mL in vag, 1000mL in c-sec
    • Inflammatory values elevated up to 12 wk
    • No utero-placental circulation
    • Temp may be elevated from dehydration, and when milk comes in
  39. Discuss VS PP
    • Requires careful monitoring
    • Report tachycardia, low & high blood pressure, oral temp 100.4 or greater
  40. Discuss lab values/ blood components PP
    • Very low H&H: excessive blood loss
    • Elevated clotting factors
    • WBC: 20-25 first 10-12 days
    • Varicosities & hemorrhoids regress after 6 wks
  41. Discuss Neurological PP
    • Diuresis leads to alleviation of carpal tunnel syndrome
    • Numbness & tingling of the hands resolves
    • H/A: epidural-blood patch, PIH or ecclampsia
  42. Discuss Joints PP
    • Relaxation and hypermobility of joints reverse to nml
    • Joints stabilized by 6-8 weeks
    • Feet joints never go back, always bigger
  43. Discuss D/C teaching & care
    • C-sec delay abdominal exercise for 4 wks
    • Rubella vaccine if not immune and no prego w/in 3 mo after
    • Document referrals: social services, hearing visits
  44. Discuss Lamaze Method
    • Focused breathing and relaxation techniques
    • Slow abdominal-paced breathing (latent)
    • Pattern-paced breathing (transition) avoid hyperventilation
  45. Discuss Bradley Method
    • Husband coached
    • "Natural" darkness, solitude, quiet
  46. List Alternate Pain Mgt therapies non-skin related
    • Water therapy
    • Hypnosis
    • Biofeedback
    • Aromatherapy
    • Position change
    • Application of heat & cold
  47. List Alternate Pain Mgt therapies r/t skin
    • Effleurage: gentle stroking mom's belly
    • Counter pressure: pressure applied to sacral area
    • Acupressure
    • Touch & massage
    • Healing touch
    • TENS
  48. Discuss relaxation & breathing techniques
    • Based on gate control theory
    • Focusing & feedback
    • Music
    • Breathing patterns
  49. Discuss mothers view on Latent phase and interventions
    • Mild contractions
    • Alternate periods of excitement & rest
    • Encourage upright position and support
    • Plant seed for meds
  50. Discuss mothers view & interventions in Active phase
    • Senses urge to push
    • Tries to find adequate breathing pattern
    • Inc irritability
    • Frequent positioning
    • Minimize stress
    • Discourage holding breath
  51. Discuss mothers view & interventions in Transition phase
    • Extreme pain & powerlessness
    • Burning sensation
    • Inc urge to push
    • Encourage "blowing away"
    • Warm compress to perineum
    • Provide mirror
    • No pushing!
  52. What causes Pain during Stage 1?
    • Uterine muscle hypoxia
    • Cervical & lower uterine segment
    • Stretching
    • Pressure on bony pelvis
  53. Discuss Sedatives in labor
    • Does not relieve pain, induces sleep & dec anxiety
    • Rarely used due to neonatal CNS effects
  54. Discuss Opioid Agonist-antagonist in labor
    • Stadol: used more, q3-4h
    • Nubain: used less
    • Do not give close to delivery- neonatal narcosis, resp depression
  55. Discuss Potentiatores (pain relief) in labor
    • Phenergan- good for nausea
    • Vistaril
    • Enhances opioid effects
  56. Discuss Opioid antagonists after labor
    • Narcan
    • Infant: neonatal narcosis, low RR
    • Mom: itching, CNS depression
  57. List SE of Epidural
    • Hypotension- early
    • Prolong labor- give in Active phase
    • Inc need for Oxytocin
    • Maternal fever
    • Inc risk for C-sec
    • Inc use of Operative delivery
    • Itching reported
    • Bladder distension- late, foley
  58. Discuss Epidural vein
    • Risk in epidural
    • Tachycardia
    • Numbness of tongue
    • Metallic taste
    • Inc BP or tinnitus w/in 2-3 min
    • Intervention: lie down, place elsewhere
  59. Discuss Subsarchnoid space
    • Risk in epidural
    • Immediate upper thoracic sensory loss
    • Severe lower extermity motor blockage
    • RESP ARREST
  60. Discuss Spinal H/A
    • Risk in epidural
    • Tx: blood patch, caffeine, supine, rest
  61. List Nsg Considerations r/t tx
    • Assess FHR & Uterine activity w/ narcotics- expect some nonreactivity
    • Maternal vaginal exam
    • Observe for resp depression, give narcan
    • Enhance opioid effects with vistaril or phenergan
  62. Discuss Pudendal Block
    • Used for Pain relief in Stage 2
    • Blocks nerve for relief in lower vagina, vulva, perineum
    • Used in complications
  63. What is the inital assessment on Mom
    • Leopolds for PMI
    • Fetal status
    • Contractions: frequency, length, strength
    • Membranes
  64. Discuss appearance of Membranes (amniotic fluid)
    • Color
    • Thin or thick fluids could cause resp problems
    • White flecks in fluid is vernix, okay
    • Ferning pattern under microscope: indicative of protein
    • Pooling in vaginal vault
  65. List continuous assessment of Mom (not r/t progression of labor)
    • VS
    • Pain
    • Coping
    • Psychosocial
  66. Discuss blood work during labor
    • Platelets at least 100,000 before epidural
    • WBC elevated during labor, up to 20,000 after delivery
  67. List Special Orders during labor
    • Monitoring frequency
    • Diet
    • IV therapy
    • Activity
    • VS
    • Consults
    • GBS
  68. Discuss contractions for each phase
    • Latent: 5-30 min, irregular, mild to moderate
    • Active: 3-5 min, regular, moderate to strong (if irregular, inc petocin)
    • Latent: 2-3 min, strong to very strong (goal is strong 90-100 mmHg)
  69. What is the purpose of the Vaginal Exam?
    • Dilation, effacement
    • Presenting part
    • Membrane status
    • Stool in rectum
    • (sterile glove if ruptured, ky jelly if not)
  70. What is the best position for occiput posterior?
    • Squatting position
    • Inc pelvic diameter & gravity
  71. How can a baby "fall off the curve"?
    • Doesn't descend (inc petocin)
    • Mom doesn't dilate
    • Malpresentation
    • Baby too big
    • Doesn't deliver after 3-4 hrs in Stage 2
  72. What are potential complications during labor?
    • Meconium- no cry
    • Arrest of Progress
    • Vaginal Bleeding
    • Infection: GBS status (antibiotics), maternal temp, FHR
  73. List Emergency complications during labor
    • Amniotic fluid embolism/ PE
    • Prolapse cord: knee-chest position to get pressure off cord, watch for bradycardia
    • Vaginal bleeding: PP hemorrhage
    • Nonreassuring FHR: 5 min brady, rep late decel (C-sec)
  74. List potential complications of Episiotomy
    • Infection
    • Tear extension
    • Hematoma
  75. Discuss Nsg care of episiotomy
    • During labor: warm compress, perineal massage
    • After labor: ice packs
  76. List 4 signs of Placental Separation
    • Firmly contracting fundus
    • Sudden gush of blood from introitus
    • Lengthening of umbilical cord (delivered before placenta)
    • Membranes at introitus- gentle push
    • -Must be delivered in 30 min
  77. Discuss Nsg Interventions for delivering placenta
    • Bolus Oxytocin
    • Fundal massage
    • S/S hemorrhage
    • VS
    • LOC
  78. List interventions if Bleeding doesn't stop
    • 1. Oxytocin inc & fundal massage
    • 2. Methrogen, hemobait
    • 3. Emergent hysterectomy
  79. List Care throughout all stages (psych)
    • Intergration of family
    • Cultural beliefs
    • Support of adolescents
  80. List Infants major tasks at birth
    • Breathing
    • Adjusting from fetal to nml circulation
    • Maintaining body's temperature
    • Later: breath, suck, swallow
  81. What is the first breath a result of?
    • Changes in pressure (fluid out of lungs)
    • Changes in temperature
    • Environmental stimuli (noise, lights)
  82. What does indocin do?
    • Infants: closes up PDA (ductus arteriosus)
    • Mom: stop preterm labor
  83. List 4 ways Infants can loose heat
    • Convection: baby to air
    • Radiation: baby to distant object
    • Evaporation: baby tries to evaporate cold moisture, keep baby dry
    • Conduction: baby to object in direct contact
  84. Discuss infant Renal System nmls
    • Voiding may be delayed up to 24 hours
    • Red brick dust/ uric crystals: nml
    • 40-60 mg/kg/day first 2 days
    • 100-150 mg/kg/day after

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