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2010-03-01 14:55:17
Test 2

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  1. S&S of labor (premonitory signs)
    • braxton hicks contractions
    • lightening
    • cervical changes
    • energy burst/nesting behaviors
    • joint/back aches and pain; wt loss; GI upset
  2. signs of true labor
    • reg CTX; increasing frequency, duration and intensity shortening intervals
    • discomfort, usually from back to abdomen; increases with ambulation
    • progressive dilation and effacement; ctx do not decrease with rest or warm bath
  3. false signs of labor
    • irreg CTX; usually no change in intesity; lower abdominal pain
    • discomfort usually no change with walking
    • no change in dilation and effacement; rest and warm bath lessen ctx
  4. lightening
    the effects that occur when the fetus begins to settle into the pelvic inlet (engagement). with fetal descent, the uterus moves downward and the fundus no longer presses on the diaphragm, wich eases breathing.
  5. with increased downard pressure of the presenting part, the woman may notice: (effects of lightening)
    • leg cramps or pains due to pressure on the nerves that course through the obturator foramen in the pelvis
    • increased pelvic pressure
    • increased venous stasis leading to edema in the lower extremities
    • increased urinary frequency
    • increased vaginal secretions resulting from congestion of the vaginal mucous membranes
  6. Braxton Hick contractions
    the irregular, intermittent contracts that have been occuring throughout the pregnancy (may become uncomfortable when going in to labor) - may feel like drawing sensations
  7. ripening
    the softening of the cervix to allow fetal passage
  8. bloody show
    when the mucus plug is expelled resulting in a pink-tinged secretion (sign of impending labor usually within 24-48 hrs)
  9. Rupture of membranes (ROM)
    amniotic rupture - in 12% of women they will rupture before the onset of labor; after they rupture 80% of women will experience spontaneous labor within 24 hrs.
  10. if ROM occurs and labor does not begin in12-24 hrs what occurs
    labor may be induced to avoid infection (open pathway into cavity once they have ruptured) THIS WILL ONLY BE DONE IF PREGNANCY IS NEAR TERM
  11. stages of labor
    - first
    - second
    - third
    - fourth
    • beginning of true labor until full dilation
    • begins with full dilation until delivery of baby
    • after delivery of baby until expulsion of baby
    • 1-4 hrs after expulsion of placenta
  12. first stage of labor
    - work to be accomplished
    - forces
    - phases (3)
    • effacement and dilation of cervix
    • uterine ctx
    • latent - 0-4cm; active - 4-8cm; transition - 8-10cm
  13. latent phase
    - duration
    - ctx
    - show
    - behavior
    • avg is 5.3-8.6 hrs not to exceed 14-20 hrs
    • irreg; mild-mod; 3-30 min apart lasting 20-40 secs and 25-50mm Hg
    • clear plug to brownish/pinkexcitement
    • signpost; alert, follows directions, talkative, apprehensive
  14. active phase
    - duration
    - ctx
    - show
    - behavior
    • varies; should dilate 1.2-1.5cm/hr (2.4-4.6 hrs)
    • reg; mod-strong; 2-5 min apart; lasting40-60sec and 50-70mmHg
    • pink to bloody mucus
    • serious signpost; inner-focused; experiences pain/fatigue; desires companionship/support
  15. transition phase
    - duration
    - ctx
    - show
    - behavior
    • 1-2 hrs (3hrs if epidural in place)
    • strong-very strong; 1.5-2 min apart, lasting 60-90 sec and 70-100mmHg
    • increase in bloody mucus
    • self-doubt signpost; chaotic, difficulty focusing, irritable, N&V
  16. second stage of labor
    - work
    - forces
    - duration
    - ctx
    - station
    - show
    - discomfort
    - behaviors
    • expulsion of fetus
    • CTX + bearing down efforts15 min-2hrs
    • strong; may be decreased intesity and frequencycrowning
    • same or increase in amt
    • strong urge to push if no regional anesthesia; may feel "tearing/ripping apart" sensation
    • intense concentration: may doze between CTX; may express relief that end is
    • near; if prolonged; increase fatige and anxiety; decreased coping
  17. bearing down methods
    - valsalva
    - open-glottis
    • hold breath and push as long and hard as possible during the ctx
    • exhale gently while pushing with ctx
  18. pushing positions

    in order to restrain pushing
    • side squatting
    • lithotomy
    • standing

    • side-lying
    • pant-blow breathing
  19. positional changes of fetus (cardinal movements)
    • descent
    • flexion
    • internal rotation
    • extension
    • restitution
    • external rotation
    • expulsion
  20. descent
    head engages and proceeds down birth canal
  21. flexion
    head flexed to the chest as it meets resistance from soft tissues of pelvis
  22. internal rotation
    - occiput of fetal head
    - occipant
    meets resistance from levator ani muscles

    rotates to bring the back of neck under symphysis
  23. extension
    back of neck pivots under symphysis

    to negotiate pelvic curve; head must change from flexion to extension and ehad is born
  24. restitution
    head returns to normal alignment with the shoulders, presents smallest diameter of shoulders to outlet
  25. external rotation
    shoulders rotate to the anteroposterior position in the pelvis, head is turned farther to one side
  26. expulsion
    after shoulders born; rest of the body delivers quickly

    birth of neonate is complete
  27. third stage of labor
    - work
    - forces
    - duration
    - discomfort
    - behaviors
    • expulsion of placenta (separation and expulsion)
    • uterine CTX and pushing
    • 5-30 minslight cramping
    • excited; relieved; may cry; usually very tired
  28. signs of placental separation
    • globular-shaped uterus
    • rise of fundus in abdomen
    • sudden gush or trickle of blood
    • lengthening of umbilical cord
  29. placental expulsion
    - shiny shultz
    - dirty duncan
    - retained placenta
    • fetal side presents; separates from inside to outer margins
    • maternal side presents; separates from outer margins inward
    • if third stage is >30 min
  30. Assessment during the first stage of labor should include
    • antepartal history
    • past obsteteric history
    • lab results
  31. upon admission the nurse should assess/find:
    • emotional status
    • maternal VS
    • UA
    • fetal heart tones/contractions q 15-30 minutes
    • maternal response to labor
    • vaginal discharge
    • labor progress
  32. comfort measures provided by the nurse in the first stage of labor
    • maintain hydration
    • reduce dry lips
    • relieve backache
    • encourage particpation of coach
    • encourage ambulation if appropriate
  33. nursing care regarding physical needs in the first stage of labor
    • encourage frequent voiding
    • encourage relaxation
    • prevent compression of vena cava and promote placental perfusino
    • provide fluids if appropriate
    • manage discomfort
  34. nursing care regarding psychosocial needs during first stage of labor
    • verbalization of feelings
    • explain all procedures
    • reinforcement
  35. nursing care for latent phase of labor
    • provide encouragement
    • comfort measures
    • coach through contractions
    • encourage ambulation if appropriate
    • telephone guidance
    • admission procedures, orientation
    • establish rapport, trust
    • identify birth plan
    • provide teaching and information
  36. nursing care for active phase of labor
    • coach through contractions
    • comfort measures (focus on areas of tension)
    • keep aware of progress
    • offer analgesics if ordered
    • provide hygiene
    • monitor progress of labor and response
  37. nursing care for transition phase of labor
    • stay with patient
    • continue to coach through contractions
  38. second stage of labor assessment
    • maternal response to labor
    • FHT and contractions
    • VS
    • time elapsed
    • vaginal discharge
    • response to regional anesthesia
    • bearing down efforts
    • fetal position
  39. nursing care for second stage of labor
    • emotional suppport
    • safety
    • assistance with medical management
  40. assessment for third stage of labor
    • time elapsed
    • signs of placental separation
    • maternal response
  41. nursing care for third stage of labor
    • prevent uterine atony
    • facilitate infant parent bonding
    • health teaching
  42. assessment for fourth stage of labor
    • VS q 15 min for 1 hr then q 30 min for 1 hr then if stable q 4hr or q shift
    • location and tone of fundas
    • character and amount of lochia
    • bladder status
  43. nursing care for fourth stage of labor
    • comfort measures
    • nutrition/hydration
    • promote bonding
    • health teaching
  44. leopold's maneuvers (definition)
    useful for determining fetal position, presentation, lie and to locate FHT's
  45. lepold's maneuvers
    • what is in the fundus
    • where is the fetal back
    • what is presenting part
    • what is the first cephalic prominence (is head flexed or extended)
  46. vaginal examination

    done when?

    not done by a nurse
    • when symptoms indicate change
    • before administering meds/ tx
    • to reassess progress if longer than expected

    • in presence of active vaginal bleeding
    • unless indicated, especially if ROM
  47. immediate care of newborn
    • airway
    • thermoregulation
    • identification
    • physical assessment
    • facilitate attachement
  48. Normal FHR
    110-160 bpm
  49. possible causes of fetal tachycardia
    • early fetal hypoxia
    • maternal fever
    • betasympathomimetic drugs (retodrine, terbutaline, atropine and isoxsuprine - all cardiac stimulants)
    • maternal hyperthyroidism
    • fetal anemia
    • dehydration
  50. Fetal bradycardia caused by
    • late fetal asphyxia
    • maternal hyptension
    • prolonged umbilical cord compression
    • fetal arrhythmia
  51. changes in fetal heart rate baseline:
    - fetal tachycardia
    - fetal bradychardia
    baseline greater than 160 bpm for at least a 10 min period

    baseline less than 110 bpm for at least a 10 min period
  52. Which comment made by a client would indicate the client's ability for
    safe care during the last trimester of pregnancy with mild preeclampsia?The client state "I will:
    A. report any SOB to my MD
    B. report any HA or blurr vision to MD
    C. limit my fluid intake after 3 pm
    D. limit my salt intake during this time
  53. non-reassuring FHR pattern
    • severe variable deccelerations
    • late deccelerations of any magnitude
    • absence of variability, bradycardia (70 or less)
    • prolonged decceleration lasting 2 min but less than 10 min
  54. decelerations
    periodic decreases in FHR from the normal baseline; categorized by early, late and variable
  55. severe variable deccelerations consist of
    FHR below 70 lasting 30-45 sec accompanied by a rising baseline or decreasing variability
  56. interventions for non-reassuring tracing
    • document and report findings accurately and promptly to MD
    • continuous monitroing of mom/fetus
    • change position
    • provide O2
    • increase IV fluids
    • provide information to mom/family
    • admin tocolytic if ordered prepare for immediate delivery
  57. variable deccelerations
    - occurance
    - d/t?
    • occur anytime withing the ctx
    • due to cord compression
  58. with variale decceleration you should do what first

    if that doesn't work?
    • change position to move fetus off of chord
    • 1. give O2, 2. give fluid, 3. amnion fusion
  59. interventions for variable decelerations
    • d/c pitocin
    • change position
    • perform vag exam
    • O2 per face mask
    • amnionfusion
    • if uncorrected, deliver
  60. late decelerations
    - occurance
    - d/t
    • occur after the beginning, peak, and end of ctx
    • due to placental insufficiency
  61. late deceleration interventions
    - FIRST
    - SECOND
    - then...
    • D/C pitocin
    • put in side lying position
    • give O2
    • maintain or increase IV fluids
    • if hypotensive, correct
    • fetal pH sampling
  62. early decelerations
    - occurance
    - d/t
    • simultaneously with ctx
    • vagal nerve stimulation caused by the fetal head
  63. interventions for early decelerations
    position change
  64. nursing care for PIH
    • urine dipsticks for protein q shift
    • blood pressure eval q 1-4 hrs
    • daily weight
    • bed rest
    • corticosteroids
    • anticonvulsants
    • assess deep tendon reflexes and clonus
    • assess for HA, blurred vision and epigastric pain
    • if on mag sulfate chek urine output q 1 hr (should be more than 30cc/hr)
  65. first sign of mag toxicity
    decrease DTR
  66. fetal risks with HTN
    • preterm birth (15% of all preterm births are a result of preeclampsia)
    • small for gest age
    • placental abruption
    • may be over sedated at birth d/t maternal meds
    • may have hypermagnesmia d/t maternal tx w/ mag sulfate
  67. maternal risks with pregnancy induced HTN
    - can impact?
    - CNS changes include
    - intracerebral hemorrhage
    • most organ systems, causing serious complications
    • hyperreflexia, headache, eclamptic seizure
    • rare complication, but is the most common cause of death in women with severe preeclampsia and eclampsia
  68. eclampsia
    occurance of a seizure in a woman with preeclampsia who has no other cause for a seizure
  69. preeclampsia
    • defined as increase BP after 20 wks gestation accompanied by proteinuria
    • 140/90 or diff of 15 from norm
  70. Pregnancy induced hypertension
    - occurance
    - manifestations
    • occurs in 5-8% of all pregnancies (most common hypertensive disorder in pregnancy/second leading cause of maternal death)
    • preeclampsia and eclampsia
  71. episiotomy
    - def
    - protects
    - types
    • surgical incision reduces possibility of laceration
    • portects fetal head from pressure exerted by resistant perineum
    • midline, mediolateral
  72. oxytocin (pitocin)
    used to stimulate uterine contractions after birth and to reduce the incidence of third-stage hemorrhage/ uterine atony; used to induce labor at term and to augment uterine contractions in the first and second stages of labor;
  73. route, dosage and frequency of oxytocin(pitocin)
    - for induction of labor
    • add 10 units of Pitocin (1ml) to 1000ml of IV solution.
    • start at .5-1mU/min and increase by 1-2mU/min every 40-60 mins.
    • OR
    • start at 1-2mU/min and increase by 1mU/min every 15 min until a good contraction pattern is achieved.
  74. maternal contraindications of oxytocin
    • severe preeclampsia/eclampsia
    • predisposition to uterine rupture (nullipara over 35, multigravida 4 or more, overdistention of uterus, prev majory surgery of cervix or uterus)
    • cephalopelvic disproportion
    • malpresentation or malposition of the fetus and cord prolapse
    • preterm infant
    • rigid, unripe cervix; total placenta previa
    • presence of nonreassuring fetal status
  75. maternal SE w/ Pitocin
    • abruptio placentae
    • impaired uterine blood flow, leading to fetal hypoxia
    • rapid labor, leading to cervical lacerations
    • rapid labor and birth leading to lacerations of cervix, vagina or perineum, uterine atony; fetal trauma
    • uterine rupture
    • water intoxication
  76. pitocin effect on fetus/newborn
    • primarly associated with the presence of hypercontractility of the maternal uterus. hypercontractility decreases the oxygen supply to the fetus, which is reflected by irregularities or decrease in FHR
    • hyperbilirubinemia
    • trauma from rapid birth
  77. nursing considerations with pitocin
    • explaine iduction or aumentation procedure to client
    • apply fetal monitor and obtain 15-20 min tracing and NST to assess FHR before starting IV pitocin
    • for induction or augemtation of labor, start with primary IV and piggyback secondary IV with oxytocin and infusion pump
    • ensure continuous monitoring of the fetus and uterine ctx
    • max rate is 40mU/min
    • assess FHR, maternal BP, P, frequency and duration of ctx and uterine resting tone before each increase
    • record all assessment
    • record infusion rate
    • record on monitor strip all client activities
    • assess cervial dilation
    • apply comfort measures
    • d/c when nonreassuring fetal status is noted
    • I&O
  78. Magnesium Sulfate (MgSO4)
    acts as a CNS depressant; reduces the possiblity of convulsion; used in the treatment of preeclampsia; secondarily relaxes smoothe muscle decreasing BP; NOT an antihypertensive - THIS IS A SE; may decrease the frequency and intensity of uterine ctx, can be used as a tocolytic in preterm labor - THIS IS A SE TOO - PRIMARY purpose is to reduce seizure activity
  79. maternal contraindications with MgSO4
    maternal myasthenia gravis; hx of myocardial damage or heart block; extreme care when using in women with impaired renal funx b/c its eliminated by kidneys and Mg toxicity may develop quickly
  80. MgSO4 effects on fetus/newborn
    readily crosses placenta; decrease in FHR variability; may have neurologic depression or resp depression, loss of reflexes, and muscle weakness;
  81. nursing considerations with MgSO4
    • monitor BP
    • monitor serum Mg level (norm 4-8)
    • monitor respirations
    • assess knee jerk
    • determine output
    • antagonist of MgSO4 is calcium
    • monitor FHT
    • continue for 24 hrs postpartum as seizure prophylaxis
    • newborn should be monitored for toxicity
  82. pain relief methods
    - pharmacologic
    - nonpharmocologic
    • systmic analgesia
    • regional anesthesia
    • general " "

    • prepared childbirth
    • comfort measures; imagery, distraction, and support
  83. common themes in different methods/ educations programs ( pain mgt)
    - what to expect
    - presence of ________
    - relaxation:
    - basis:
    • normal labor/ delivery process; procedures
    • support person/ coach
    • breathing techniques, conditioning exercises
    • fear-tension-pain theory
  84. Fear-tension-pain theory
    • fear produces muscle tension; tension leads to pain
    • fear causes release of adrenaline which decreases effect of pitocin thus inhibiting effective labor
    • unprepared woman more likely to be afraid
    • edcuation and preparation breaks cycle by decreasing fear
  85. prepared childbirth claims
    undocumented (believed and promoted)
    • use of less meds
    • labor process may be shortened

    • enhances bonding; empowers parents
    • helps women deal with mastery issues
    • challenges care-givers to be more responsive
  86. non-pharmacologic pain mgt
    • relaxation
    • music assistes relaxation
    • imagery
    • hydrotherapy (warm bath or shower)
    • touch
    • massage
    • effleurage
    • sacral counter pressure
  87. what women need to know about pain meds
    • type
    • route
    • SE
    • fetal imp
    • safety
    • expected outcome
  88. systemic pain relief
    - analgesics
    - amnesics
    - sedatives
    - narcotics
    • morpine, demoral, stadol
    • scopolamine
    • barituates (seconal, ambien); benzo (valium, versed); H1-receptor antagonists (phenergan, vistaril, benadryl);
    • stadol, nubain, demerol, narcan
  89. regional pain relief
    epidural, spinal, pudendal, and local
  90. general pain mgt
    IV, inhaled
  91. analgesia
    - def
    - fetal liver and kindey
    - fetal brain
    - blood barrier of brain
    all systemic drugs cross placenta; alterations in woman affect fetal environment

    are inadequate to metabolize analgesic agents; so stay in the fetal cirulation longer

    receives an increased percentage of blood volume during stress; hypoxic infant receives an increased amt

    more permeable at birht; which increases the amt of drug carried to CNS
  92. maternal analgesia assessment
    • woman is willing to receive meds
    • vital signs stable
    • contraindications
    • knowledge of other meds being admin
  93. fetal anaglesia assessment
    • FHR is stable
    • ctx pattern
    • cervical dilation
    • fetal presenting part
    • station of fetal presenting part
  94. analgesia admin
    - too early
    - too late
    - gen guidelines
    • may prolong labor and depress fetus
    • no value to woman and may cause resp depression in neonate
    • base in maternal/fetal status and labor progress:
    • - nullipara: 5-6cm dilation
    • - multipara: 3-4 cm dilation
  95. analgesia considerations
    - poor?
    - give how?
    - can give with?
    - naloxone(narcan) used to ?
    • oral absorption
    • subQ, IM, slow IV
    • antiemetics: phenergan, vistaril
    • reverse resp depression in mother and newborn
  96. analgesia admin
    - IV preferred route advantages?
    - IM route disadvantages
    - give where?
    more predictable onset and duration of pain relief, smaller dose required

    • onset of relief delayed, higher doses required, unpredictable release from muscle
    • deltoid
  97. Stadol
    - class
    - dosage, route, freq
    - common Se
    - life threatening reax
    - contraindications
    • CNS agent, analgesic, narcotic agonest/antagonist
    • IM 1-4mg Q 3-4hrs; IV .5-2mg Q6-8 hrs; intranasal 1 mg (1 puff)
    • sedation
    • resp depression
    • narcotic dependency, breastfeeding
  98. nubain
    - class
    - dosage, route, freq
    - common Se
    - life threatening reax
    - contraindications
    • CNS agent, analgesic, narcotic agonist, antagonist
    • 10-20mg Q3-6hrs prn SC/IM/IV
    • sedation, sweaty, clammy skin; NV
    • resp depression
    • hypersensitivity to drug
  99. Demerol
    - class
    - dosage, route, freq
    - common Se
    - life threatening reax
    - contraindications
    • CNS agent, analgesic, narcotic agonist
    • IV 2.5-25mg Q4hrs; IM/SC 5-20mg Q 4hrs
    • pruitus, dizziness, sedation, nausea, constipation
    • resp depression, convulsions, cardiovascular collapse, cardiac arrest, respiratory depression in newborn, bronchoconstriction
    • hypersensitivity to the drug, convulsive disorders, breastfeeding, udx acute abdomen
  100. Morphine
    - class
    - dosage, route, freq
    - common Se
    - life threatening reax
    - contraindications
    • CNS agent, analgesic, narcotic, agonist
    • IV 2.5-15mg Q4hrs; IM/SC 5-20mg Q4hrs
    • pruitus, constipation, nausea
    • anaphylactic rx, resp depression; overdose, resp arrest, cardiac arresst
    • hypersensitivity to opiates, ICP, convulsive d/o, acute ETOHism, acute asthma, CPD, decrease resp, Pulmonary edema, biliary tract sx, anastomosis, pancreatits, acute UC, liver/renal insuff, addison disease, hypthyroidism
  101. phenergan
    - class
    - dosage, route, freq
    - common Se
    - life threatening reax
    - contraindications
    • GI agent, antiemetic, antivertigo agent, phenothiazine
    • 25-100mg q 3-4 hrs PO/PR/IM/IV
    • sedation, drowsiness, dry mouth, blurred vision
    • resp depression, agranulocytosis
    • hypersens to phehothiazines, glaucoma, peptic ulcer, pyloroduodenal obstux, bladder neck obtrux, epilepsy, bone marrow depressn, breastfeeding
  102. vistaril
    - class
    - dosage, route, freq
    - common Se
    - life threatening reax
    - contraindications
    • antihistamine, antianxiety, sedative, antipruitic, antiemetic
    • 25-100mg PO/IM q 6 hrs
    • sedation, dizziness, dry mouth, nausea, HA
    • seizures
    • hypersens to drug, use caution in glaucoma and urinary retention
  103. benadryl
    - class
    - dosage, route, freq
    - common Se
    - life threatening reax
    - contraindications
    • antihistamine, antiemetic, antivertigo, antitussive, sedative-hypnotic
    • 25-50mg Q 6hrs PO/IM/IV
    • drowsiness, sedation, dry mouth, hyptension, N/V, GI syx
    • anaphylaxis, seizures, coma, resp depression
    • hypersens to drug, use during acute asthma attack, use with caution in glaucoma, bladder obstrux, HTN, hypthyroidism, renal disease
  104. Pudendal block
    - what and where
    - relieves?
    - advantages
    - disadvantages
    • anesthetic is injected below pudendal plexus
    • perineal pain, but not ctx's
    • easy to admin, absence ot hypotension
    • systemic toxic reax if vascular inj occurs, broad ligament hematoma, trauma to sciatic nerve, perforation of rectum
  105. local anesthesia
    - def
    - advantage
    injections of anesthetic agent into the intracutaneos, subq and IM areas of perineum

    least amt of anesthetic agent

    large amt of solution must be used
  106. regional anesthesia
    - def
    - esters
    - amides
    - opiates
    • local anesthetic/analgesic agents injected into direct contact with nervous tissue
    • short-actiing; Novocain
    • long-acting; rovicaine, levbupivaine
    • fentanyl, morphine
  107. regional anesthesia
    - produces?
    - may be (#)?
    - administered by?
    • temp. reversible loss of sensation (regional block)
    • single or continuous injection
    • by trained profession; not staff nurses
  108. types of regional anesthesia
    • agent injected into the epidural space
    • agent injected directly into spinal fluid subarachnoid space between dura and spinal cord
    • injection below pudendal plexus
    • injection into sub and intracutaneous; IM areas of perineum
  109. spinal anesthesia
    • can be give faster than epidural
    • disadvantages similar to epidural
    • post spinal HA
    • epidural blood patch
  110. spinal
    - advantages
    - disadvantages
    mother fully awake, allow for diff blocking for each stage, dose can be adjusted to preserve the urge to bear down

    maternal hypotension, postdural puncture seizures, meningitis, cardiac arrest, vertigo
  111. epidural anesthesia
    anesthetic injected into epidural space between (above) dura matter and ligamentum falvum

    most popular and widely used in OB; the "cadilac of anesthesia"
  112. epidural advantages
    minimal risks when properly admin and monitored; good pain relief; awake for delivery; may be adjusted to allow reflex urge to push
  113. epidural disadvantages
    • requires specialized personel and setting
    • may slow labor progress, disturb urge to push, increase need of pitocin and C/S
    • risk of spinal headache d/t accidental perforation of dura matter
    • adverse SE
  114. adverse SE of epidural
    - range from mild to severe
    - serious comp
    - common comp
    • inadequate, block failure, "hot spot"; puritis, urinary ret, shivering, nausea
    • systemic toxic reax
    • materanl hypotn
  115. maternal hypotension
    results from spinal blockage:
    • vasodilation of blood vessels
    • lowers peripheral resistance
    • decreases venous return
    • decreases CO; lowers BP
    • decreases placental perfusion
    • can cause fetal hypoxia
  116. Maternal hypotension
    - Sx
    - maternal
    - fetal
    - prevention
    - tx
    • nausea, perpiration, faintness,
    • bradycardia, loss of variability, late decelerations
    • adequate fluid preload
    • IV fluids, side position, O2, ephedrine, trendelenberg
  117. nursing considerations for epidural
    • hydrate weel before; maintain IV access and adequate fluids post
    • assess materanl and fetal VS and FHR closely; monitor for comp
    • change woman's position q 1-2hrs
    • assess bladder; have woman void before procedure; catheter as necessary
    • avoid ambulation until full sensation and mobility returns
  118. other considerations for pain mgt
    maternal hypthermia - analgesics cause vasodilation/radiant heat loss; general anesthetics depress thermoregulation; keep woman dry and warm

    obese woman - special concerns
  119. epidural contraindication
    • lack of consent
    • localized skin infections
    • allergies to anesthetic agents used
    • coagulopathy: PIH, HELLP
    • increased ICP
  120. general anesthesia
    - inudced unconsciousness
    - inhaled
    • IV - pentothal; effects last 20-60 min; contraindicated in woman w/ PIH or CHTN
    • nitrous oxide, fetal tissue uptake in about 20 min; good choice for woman with aortic stenosis (cardiac stability throughout sx and no adverse fetal outcomes)
  121. general anesthesia: nursing care
    • prophylactic antacid therapy
    • hip wedge under left hip
    • preoxygenated
    • iv fluids
    • cricoid pressure
  122. always document what with any type of pain relief method
  123. puerperium or postpartum (4th trimester)
    - def
    - begins when
    - continues for how long
    • period in which the woman readjusts physically and psychologically from pregnancy and birth
    • immediately after birth
    • approximately 6 wks or until body retruns to near nonpregnant state
  124. PP reproductive systems changes
    • involution of the uterus
    • changes in fundul position
    • lochia
    • cervical changes
    • vaginal changes
    • perineal changes
    • reoccurance of ovulation and menstration
  125. uterine involution
    - def
    - ___________ is important aspect of involution
    - assessed by measuring
    • rapid reduction in uterine size and return to near nonpregnant state (slightly larger than before 1st pregnancy)
    • exfoliation
    • fundal height
  126. factors that enhance involution
    • uncomplicated labor and delivery
    • complete expulsion of amniotic membranes and placenta
    • breastfeeding
    • manual removal of placenta during cesarean birth
    • early ambulation
  127. factors that retard involution
    • prolonged labor
    • anesthesia
    • full bladder
    • difficult birth
    • grandmultiparity
    • incomplete expulsion of placenta or membranes
    • infection
    • overdistention of uterus
  128. changes in fudal position
    - after delivery
    - 6-12 hrs after birth
    - 1st pp day
    - until and on 10th day
    • situated midline 1/2 to 2/3 of way between symphysis pubis and umbilicus
    • rises to level of umbilicus, remains about 1/2 day
    • located 1cm below umbilicus
    • descends approx 1 fingerbreadth/day until descended into pelvis on 10th day
  129. Lochia
    - Rubra
    - Serosa
    - Alba
    • 1-3 days (dark red)
    • 3-10 days (pinkish color)
    • 10 days to 2 wks (creamy, yellowish)
  130. postpartal cervial changes
    may be spongy, flabby, formless and may appear bruised. original form should be regained within a few hours
  131. postpartal vaginal changes
    may appear bruised, edematous and gaping; ruge are gone. the vagina reduces in size and rugae return within 3 wks. non-lactating woman should have a normal appearing vagina by 6 wks
  132. postpartal perineal changes
    soft tissue may appear edematous with some bruising. episiotomy or laceration may be present
  133. postpartal reoccurance of ovulation and menstruation
    should return in non-lactating mothers between 6-10 wks after birth. the first cycle is anovulatory in about 50% ofmothers. in lactating mothers it can return as early as 2mos. or as late as 18 mos.
  134. postpartal changes to the abdomen
    • uterine liigaments are stretched
    • abdominal wall appears loose and flabby
    • striae (strech marks) may be present from stretching and rupture of elastic fibers of the skin
  135. postpartal abdominal assessment
    • assess bowel sounds
    • assess for diastatsis recti abdominis
    • assess uterine tenderness
  136. potpartal urinary tract changes
    - _________ bladder capacity, ________ and _________ of urethral tissues;
    _________sensitivity to fluid pressure and __________ sensation of bladder filling - all caused by _______ and ______

    - puerperal diuresis - (def)

    - more prone to ? (3)
    increased, swelling and bruising, decreased, decreased

    causes increased urinary output in the first 12-24 hrs

    UTI, hematuria, proteinuria
  137. postpartal vital signs
    - temp (after birth)
    - temp (after milk)
    - BP
    - HR
    • may be elevated to 38C (100.4F) for up to 24 hrs after birth
    • may be increased for 24 hrs after the milk comes in
    • rises early and then returns to normal
    • Bradycardia occurs during the first 6-10 days
  138. postpartal blood values
    - WBC
    - blood loss
    - plasma
    - platelets
    - cardiac output
    - will also have?
    • nonpathologic leukocytosis occurs in early PP
    • blood loss averages 200-500ml (vaginal), 700-1000ml (cesarean)
    • plasma levels reach the prepregnant state by 4-6 wks PP
    • returns to normal by 6-12 wks
    • diuresis
  139. Other normal PP changes
    - weight loss
    - postpartal chill
    - postpartal diaphoresis
    - afterpains
    • 10-12lbs (infant, placenta, fluid) diuresis accounts for 5lbs. should return to prepregnant weight by
    • 6-8 wks (if gained avg 25-30 lbs)
    • intense tremors that resemble shivering immediately after birth; common, self-limiting
    • sweating may occur at night
    • caused by intermittent uterine ctxs, occurs more often in multiparas, multiple gestations, and polyhydramnios
  140. "Taking In"
    - when
    - def"
    Taking hold"
    - when
    - def
    • PP days 1-2
    • mother tends to be passive, somewhat dependent, hesitant about making decisions, preoccupied with her needs (food and sleep major needs)

    • PP days 2-3
    • mother ready to resume control over her body, her mothering and her life in general
  141. Maternal Role Attainment (MRA)
    - def
    - Four Stages
    • process by which woman learns mothering behaviors and becomes comfortable with her identity as a mother
    • Anticipatory Stage
    • Formal stage
    • Informal stage
    • Personal stage
  142. Postpartum Blues
    - def
    - periods
    - what attributes to it
    • transient periods of depression; sometimes occurs during first few days PP
    • mood swings, anger, weapiness, anorexia, diff sleeping, feeling let down
    • changing hormones, lack of supportive environment
  143. principles of conducting a PP assessment
    • select time that will provide the most accurate data
    • provide explanation ensure woman is relaxed
    • record and report clear results
    • body fluid precautions
    • excellent opp for teaching
  144. PP Assessment tool
    • Breast
    • Uterus
    • Bowel
    • Bladder
    • Lochia
    • Episiotomy/Lacerations
    • Homans'/Hemmorhoids
    • Emotions
  145. PP Breast Assessment
    • Size and Shape
    • Abnormalities, reddened areas, or engorgement
    • prescence of brest fullness due to milk presence
    • assess nipples for cracks, fissures, soreness, or inversion
    • if breastfeeding, assess LATCH (audible, type of nipple, comfort, hold/positioning)
  146. PP abdominal assessment
    • position of fundus related to umbilicus
    • position of fundus to midline
    • firmness
    • assess incision for bleeding, approximation, and signs of infection
  147. PP Assessment of Lochia and Perineum
    • assess lochia for amount, color, and odor
    • presence of any clots
    • wound is assess for REEDA
    • presence of hemorrhoids
    • level of comfort/discomfort
    • efficacy of any comfort measures
  148. PP assessment of extremities, bowel and bladder
    • Homans's sign
    • assess calf for redness and warmth
    • adequacy of urinary elimination
    • bladder distention and pain during urination
    • intestinal elimination
    • maternal concerns regarding bowel movements
  149. PP assessment of psychological adaptation and nutrition
    • adaptation to motherhood
    • fatigue
    • nutritional status
    • cesarean birth - return of bowel function, tolerance of dietary progression
    • physical and developmental tasks - gain competence in caregiving, confidence in role as parent, return of all physical systems to prepregnant state
  150. PP Nursing interventions
    • activity/mobility - assist OOB 1st time, then prn; encourage frequent rest and ambulation nutrition
    • elimination
    • comfort - pericare, sitz bath, topical and PO analgesics
    • medications - Rubella vaccine, Rhogam
  151. Home Care Teaching
    • warning signs (when to call provider)
    • infant care
    • self care
    • contraception
    • resumption of sexual activity
  152. Postpartum Hemorrhage
    - Early
    - Late
    Immediate or Primary - occurs in 1st 24 hrs after childbirth

    Secondary - occurs from 24hrs to 6 wks after birth (less common)
  153. Causes of PP Hemorrhage
    • Uterine atony (relaxation of uterus)
    • - overdistention of uterus
    • - preeclampsia
    • - intra-amniotic infusion
    • - use of MgSO4 in labor
    • Retained placental fragments
    • Laceration of genital tract
    • Vulvar, vaginal, or subperitoneal hematomas
    • Coagulation disorders
  154. Signs of PP hemorrhage
    • excessive or bright red bleeding
    • boggy fundus that does not respond to massage
    • abnormal clots
    • unusual pelvic discomfort or backache
    • persistent bleeding in the presence of a firmly contract uterus
    • rise in the level of the fundus of the uterus
    • increased HR or decreased BP
    • hematoma formation or bulging/shiny skin in the perineal area
  155. Assessment of PP Hemorrhage
    • fundul height and tone
    • vaginal bleeding
    • signs of hypvolemic shock
    • development of coagulation problems
    • signs of anemia
  156. Nursing interventions for PP hemorrhage
    • uterine massage if a soft, boggy uterus is detected
    • encourage frequent voiding or catherize the woman
    • ice packs to perineum for lcient at risk for hematoma formation
    • vascular access
    • type and screen available assess lab results (esp Hct)
    • administer oxytocics, uterine stimulants per MD order
    • assess level of discomfort and administer analgesics as needed
    • assess urininary output
    • encourage rest and take safety precautions
  157. prevention and teaching r/t pp hemorrhage
    • adequate prenatal care
    • good nutrition
    • avoidance of traumatic procedures
    • risk assessment
    • early recognition and mgt of complications
  158. PP infection
    - reproductive tract or pueperal infections
    - wound infection
    - urinary tract infection
    - other
    • endometritis (metritis), pelvic cellulitis (parametritis)
    • perineal, ceserean
    • cystitis, pyelonephritis
    • mastitis
  159. mastitis
    - def
    - begins when
    - organisms
    • unilateral infection of breast connective tissue that occurs primarily in breast feeding women
    • when bacteria invade traumatized breast tissue
    • Staph, H influenza, E coli, Strep; candida albicans if baby develops thrush
  160. assessment of PP infection
    • REEDA
    • fever malaise
    • abd pain
    • foul smelling lochia
    • larger than expected uterus
    • tachycardia
  161. assessment of mastitis
    • breast consistency
    • skin color
    • surface temp
    • nipple condition
    • presence of pain
  162. Nursing intervention for pueperal/wound infections
    • Labs and cultures
    • IV/PO antibiotics
    • I&D if abscess present
    • sitz bath and localized heat
    • adequate PO/IV hydration
    • analgesic meds
    • wound packing
  163. nursing interventions for mastitis
    • encourage supportive bra, frequent breastfeeding, fluid intake, rest
    • antibiotics (may do C&S)
    • local application of heat
    • analgesics and NSAIDS as needed
  164. prevention and teaching for mastitis
    • proper feeding techniques
    • supportive bra worn at all times to avoid milk stasis
    • good handwashing
    • prompt attention to blocked milk ducts
  165. PP psychiatric disorders
    • potpartum blues
    • postpartum psychosis
    • postpartum depression
  166. assessment of PP psychiatric disorders
    • depression scales - edinburgh postnatal depression scale; beck pospartum depression prdictor inventory (PDPI)
    • anxiety and irritability
    • poor concentration and forgetfullnes
    • ssleeping dificulties
    • appetite change
    • fatigue and tearfulness
  167. nursing intervention for PP psychiatric probs
    • help parents understand the lefestyle changes and role demands
    • provide realistic info
    • anticipatory guidance
    • dispel myths about the perfect mother fo the perfect newborn
    • educate about the possibility of postpartum blues
    • educate about the symptoms of postpartum depression
  168. episiotomy
    - def
    - protects
    - types
    • surgical incision reduces possibility of laceration
    • portects fetal head from pressure exerted by resistant perineum
    • midline, mediolateral
  169. crieria for c-section
    • absence of labor when fetal status requires prompt delivery
    • premature fetus whose condition requires minimal stress
    • previous hx of perinatal death or child with birth injury
    • inadequate pelvis
  170. sore nipples
    try diff?
    wash with?
    use ? properly
    • may express milk before baby latches-on
    • try diff positions to improve latching-on and suction on nipples
    • wash w/ water; expose to air
    • tx with tea leaves, milk, warm compress
    • a&d ointment; lanolin
    • use electric pump/shields properly
    • r/o monilial infection
  171. engorgement
    - nonlactating women
    - lactating women
    support breast; ice packs, analgesia

    increase feeding frequency; massang and hand express orpump to empty breasts completely; warm shower or cool compresses before nursing; supportive bra at all times
  172. plugged duct
    - d/t
    - before feeding use
    - completely empty breast and?
    - report?
    • stasis, inadequate emptying
    • warm compress
    • start feedings on affected side, stroking lumps toward nipple
    • fever, increase in pain, flu-like sx
  173. mastitis
    - tx
    - fluid/ activity
    - comfort measure
    - pharm
    - report
    • continue BF frequently or pump; keep breasts empty
    • 2-3L/day; bedrest 1st 24 hrs
    • warm moist heat and analgesics
    • antibiotics
    • s/s indication abscess which may require surgical incision and drainage
  174. drugs and lactaion with BF
    - contraception
    - drugs
    delay progestin at least 6 wks avoid estrogen

    • avoid illegal street drugs
    • check before taking meds
    • do not smoke at least 2 hrs before BF
    • limit caffiene
  175. Newborn nutrition
    - formula-feeding infants lose
    - breastfeeding infants lose
    - a weight loss of ____ is excessive and requires eval and follow up
    - back to birthweight by
    - double their birthweight by ____, triple_____, quadruple______
    • 3.5% of their birthweight
    • 7%
    • more than 7%
    • 10-14 days of age
    • 5 mos; 1yr; 2 yrs
  176. dietary reference intake (DRI) for calories for NB

    dieatary reference intake for fluid for NB

  177. healthy full term infants derived half of required calories from?

    remaining calories derived from?

    lesser extent from?
    FAT (breast milk 52%, formula 49%)

    CARBS (breast milk 42% formula 43%)

    PROTEIN (breast milk 6%, formula 8%)
  178. breastmilk and formula contain how much water

    supplemental water not recommended until

    solid food
  179. breast milk
    - percentage water
    - weight gain
    - fat
    - primary carb
    • 90
    • same or greater during first 3-4 mos
    • variable
    • lactose, trace amts of other
  180. components of breast milk
    - whey/casein ratio
    - whey components include
    - low in, adequate in
    - mineral content
    - iron absorption
    • changes according to infant needs
    • alphalactalbumin, serum albumin, lactoferrin, immunoglobulins, lysozyme
    • Vit D, C and B complex
    • similar
    • 50-60%
  181. formula
    - percentage water
    - weight gain
    - carbohydrate
    • 90
    • greater weight gain after 3-4 mos
    • lactose is ONLY carbohydrate
  182. components of formula
    - whey/casein ratio
    - whey components
    - vitamins
    - mineral content
    • 60:40
    • beta-lactoglobulin and alpha-lactalbumin
    • adequate amounts
    • similar
  183. Breast vs bottle feeding: (bottle on flip side)
    Breast - Nutrtion
    breast milk is species specific
    contains higher levels of lactose, cystine and cholesteral which are necessary for brain and nerve growth
    proteins are easily digested and fats are well absorbed
    compostition varies according to gestational age and stage of lactation; therby meeting the changing nutritional requirements of individual infants as they grow
    infants determine the volume of milk consumed
    frequency of feeding is detmined by infant cues
    • Bottle:
    • formula is as close to human milk as possible, but nutrients are not as efficiently utilized
    • nutritional adequacy depends on proper perparation
    • some babies cant tolerat the fats or carbs found in regular formula
    • pediatrician or cargiver determines the volume consumed
    • overfeeding may occur if caregiver is determine that baby empty bottle
    • feeding is detmined by infant's cues
  184. Breast vs bottle
    Breast - anti-infective and antiallergenic properties
    contains immunoglubulins enzymes and leukocytes that protect against pathogens
    bacteriostatic properties permit storage at room temp up to 6 hrs; 24 hrs in fridge; 6 mos in freezer
    decreases the incidence of allergy by eliminating exposure to potential antigens (cow and soy)
    • Bottle
    • linked to an increased number of gastrointestinal and resp infections
    • potential for bacterial contamination exists during prep and storage
    • some baies are allergic to cow or soy
  185. breast vs bottle
    breast - psychosocial aspects
    skin to skin contact enhances closeness
    hormones of lactation promote maternal feelings and sense of well being
    the value system of an industrial society can create barriers to successful breastfeeding: - mother may feel ashamed or embarassed; after return to work may be difficult
    father is not able to breast feed but he can feed expressed milk from bottle and nurture the infant in ways other than feeding
    • bottle
    • provides an opportunity for positive parent-infant interaction
    • father can feed baby
  186. breast vs bottle
    breast - cost
    healthy diet for mother
    optional but recommended items include nursing pads, nursing bras
    breast pump may be needed
    refrigeration is necessary for storing expressed milk
    • bottle
    • formula is expensive
    • bottle or disposable nursers with plastic liners, nipples and caps must be purchased
  187. breast vs bottle
    breast - convenience
    milk is always the perfect temp
    no prep is needed
    mother must be available to feed or porvide expressed milk to be given in her absence
    if she misses a feeding the mother must express milk to maintain lactation
    mother may experience slight discomfort in early days of lactation
    maternal medication may interrupt breastfeeding
    • bottle
    • refrigeration system is necessary if mixing formula for more than one feeding at a time or using large containers of ready to feed formula
    • varying amounts of time are ivolved in formula prep
    • anyone can feed baby
  188. advantages of breast feeding
    • species specific
    • cholesterol in breast milk plays role in myelination and neurologic development
    • more efficient metabolism of cholesterol
    • composition varies according to gestational age
    • iron is more readily absorbed
  189. disadvantages of breastfeeding
    • pain d/t nipple tenderness
    • leaking milk when breast are full
    • embarassment
    • feeling tied down to the demands of breastfeeding
    • unequal feeding responsibilities/fathers left out
    • perceptions about diet restrictions
    • vaginal dryness
    • concerns about safety of meds
  190. lactogenesis
    during pregnancy
    once placenta expelled
    no stimulation by 3 -4 day;
    increased levels of estrogen stimulate duct proiferation and devel; elevated progesterone promote devel of lobules and aveoli in prep for lactation; increased prolactin levels; lactation suppressed by elevated progesterone

    progesterone decreases and milk production is triggered whether breast stimulated or not

    prolactin levels begin to fall and back to normal by 2 wks PP
  191. pysiologic control of breastfeeding
    - prolactin
    - oxytocin
    - foremilk vs hindmilk
    released from anterior pituitary in response to breast stimulation; stimulates milk secreting cells in alveoli to produce milk

    released from psoterior pituitary in response to stretching of nipple and compression of areola; let-down reflex acts on myoepithelial cells surrounding the aveoli in breast tissue to ctx, ejecting milk including the fat into the ducts
  192. stages of human milk
    - colostrum
    - transitional milk
    - mature milk
    begins secretion during midpregnancy; thick, creamy yellow; conc amts of PRO, fat soluble vit and min; lower amts of fat and lactose; contain antioxidants, lactoferrin and IgA

    comes in days 2-5; still yellow but more copious; contains more fat, lactose, vit and calories

    present by 2 wks PP; slightly blue tinged color
  193. guidlines for breastfeeding
    • frequent feedings best way to establish supply
    • supplementing too early may cause nipple confusion in neonate
    • place a baby's head directly in front of nipple
    • areola should be well withing baby's mouth
    • release suction to take baby off breast
  194. successfull breastfeeding eval
    getting enough milk if:
    • nursing at least eight times in 24hrs
    • in a quiet room, their mothers can hear them swallow while nursing
    • number of wet diapers increases daily until the fourth or fifth day after brith and there are at least six to eight wet diapers every 24 hrs after day 5
    • their stools are beginning to lighten in color by the third day after birth, or have changed to yellow no later than day five
    • offering a supplemental bottle is not a reliable indicator because mos babies will take a few ounces even if they are getting enough breast milk
  195. guidlines for bottle feeding
    • do not use cow's milk for first year of life
    • do not use low fat milk for 2 yrs
    • wash bottles/nipples in hot soapy water
    • used bottled water or check tap water for safety
    • do not leave bottle out of refrigerator between feedings
    • use microwave carefully; shake vigorously after heating
    • never prop bottle; hold are right angle
    • bubble, burp frequently
    • same readiness cues/adequate intake inicators as for breast except less stools
    • types: powdered, concentrated, ready-to feet
  196. characteristics of NB respirations

    normal resp rate for NB

    move from being primarily shallow, irregular and diaphragmatic to

    periodic breathing

    NB sleep state

    obligatory ______


    O2 sat
    30-60 breaths/min

    synchronous abdominal and chest breathing

    normal - will quit breathing for about 5 secs - at 15 seconds there is concern

    affects breathing patterns

    nose breathers

    normal - (when hands and feet are blue) - for about 12 hrs >24 hrs there is concern

  197. cardiovascular adaptations:
    - decreased pulmonary vascular resistance and _______
    - increase systemic pressure and _______
    - increase left atrium and _________
    - reversal of blood flow through ductus arteriosus and ___________
    - as soon as cord is clamed they go from ________ to ________
    - any problems will arise as cord is clamped - may be blue, not breathing then______
    - >60bpm give; <60 give
    • increased blood flow
    • closure of ductus venosus
    • decreased right atrium pressure - closure of foramen ovale
    • increased PO2 - closure of ductus arteriosus
    • fetal to newborn circulation
    • will give O2 first then notify MD; put on pulse ox and do not leave
    • blow by O2
    • bag and mask
  198. Apgar scoring
    one minute, five minute; if low then also at 10 min
  199. apgar scoring system
    heart rate
    resp effort
    muscle tone
    relex irritability
    • score:
    • absent - 0; slow - below 100 - 1; above 100 - 2
    • absent - 0; slow - irregular - 1; good crying -2
    • flaccid - 0; some flexion of extremities - 1; avtive motion -2
    • none - 0; grimace - 1; vigorous cry - 2
    • pale blue - 0; body pink, blue extremeties - 1; completely pink - 2
  200. NB VS
    blood glucose
    120-160; during sleep as low as 100, if crying up to 180; apical pulse counted for one full min

    30-60 resp/min; predominantly diaphragmatic by sychronous with abdominal movements; counted for one full min

    80-60/45-40 at birth 100/50 at day 10


    greater than or equal to 40

    less than 65-70% central venous sample
  201. physical assessment of newborn

    head circumfrence
    chest " "
    • 3405 G at term
    • 50cm (20inches)
    • 32-37cm
    • 30-35cm
    • pink-tinged
  202. skin variations:
    harlequine sign
    erythema toxicum
    vernix caseosa
    forceps marks
    telangietctatic nevi
    mongolian spots
    nevus flammeus
    nevus vasculosus
    • bluish discoloration of hands and feet
    • lacy pattern of dilated blood vessels under the skin
    • clown/ deep color develops over one side while other side remains pale
    • yellowish appearance after blanching
    • perifollicular eruption of lesions that are firm and consist of a white or pale yellow papule or pustule with an erythematous base "newborn rash" or "flea bite"
    • raised white spots on face
    • whitish cheeslike substance,
    • present after use of forceps
    • "stork bites" appear as pale pink or red spots and are freq found on eyelids, nose, lower occipital bone and nape of neck
    • macular areas of bluish black or gray blue pigmentations around butt
    • "port wine stain" red to purple spots
    • "strawberry mark" hemangioma; raised and dark red, rough surface
  203. NB head
    fontanelles - may bulge when they cry but should not at rest; if so could mean increased ICP; if depressed then dehydration
    • larger than body
    • anterior - closes within 18 mos
    • posterior closes within 8-12 wks
  204. cephalhematoma

    caput succedaneum
    collection of blood between surface of a cranial bone and the periosteum membrane - does not cross suture lines

    collection of fluid due to pressure of presenting part against cervix. CROSSES SUTURE LINES
  205. NB eyes
    can fixate on
    can perceive
    blink respones to
    pupillary reflex
    • tearless
    • peripheral
    • near objects
    • faces, shapes and colors
    • bright light
    • present
  206. NB eye variations
    • edema of eyelids
    • normal variations
    • subconjunctival hemorrhage
    • doll's eye - may be present for 10 days (they move in opposite direction of head)
    • transient strabismus - squinting
  207. NB
    small narrow, must breathe through nose

    lips pink; taste buds present
  208. mouth variations
    • cleft lip and palate
    • precocious teeth - need to be pulled will aspirate
    • epstein's pearls
    • thrush
  209. Ears

    soft and pliable; ready recoil; pinna parallel withinner and outer canthus

    short with skin folds
  210. ear and neck variations
    low set ears; webbing; fractured clavicle
  211. chest

    engorged, whitish secretion
  212. signs of resp distress in NB
    • nasal flaring
    • intercostal or xiphoid retractions
    • expiratory grunting or sighing
    • seesaw resp
    • tachypnea
  213. cardiac variation
    • heart is large
    • low pitched murmur
    • decreased strength or absence of femoral pulses
  214. NB abdomen
    • cylindrical and soft
    • bowel sounds present by one hr after birth
    • umbilical cord - initially white and gelatinous; two arteries, one vein; bleeding or foul odor from cord is NOT NORMAL
  215. genitalia: female/male

    • labia majora covers labia minora
    • testes descended, pendulous scrotum

    short, flexible, and move symmetrically; legs are equal in lenght with symmetrical creases
  216. genitalia variations
    vaginal tag; pseudomentruation (ok with 1st week); smegma (cheese like between labia, should be cleaned, puss or blood NOT NORMAL)

    hypospadias; phimosis; hydrocele; cryptorchidism
  217. variations in extremeties
    • gross deformities
    • extra digits or webbing - if no veins in extra digits tie of and will fall off
    • club foot
    • hip dislocation
  218. assessment of neuro status NB
    protective reflexes
    state of alterness; resting posture; cry; quality of muscle tone; motor activity

    blink; yawn; cough; sneeze
  219. common reflexes of NB
    blinking reflex
    pupillary reflex
    tonic neck
    plantar or toe grasping
    • evoking stimulus/ response
    • light flash/eyelids close
    • light flash/pupil constricts
    • light touch or finger on cheeck close to mouth/head rotates toward stimulation; mouth opens and attempts to suck finger; disappears by 4 mos
    • finger or nipple inserted into mouth/ rhythmic sicking occurs
    • infant lying on back; slightly raised head suddenly release; infant held horizontally, lowerd fquick about 6in and stopped abruptly/ arms are extended, head is thrown back fingers are spread wide; arms are then brought back to center convulsively with hands clenched; spine and lower extremities are extended; disappears by 6mos
    • loud noise/similar to moro relex flexion in arms; fist are clenched
    • finger placed in palm of hand/ infants fingers close around
    • head turned to one side whild infant lies on back/ arm and leg are extended on one side the infant faces opposite are and leg are flexed
    • tactile stimulation or tickling/ abdominal muscle contract
    • slight pinprick to the sole of the infants foot/leg flexes
    • infant supported in an upright position with feet lightly touching a flat surface/ rhythmic stepping movement disappears about 4-8 wks
    • gentle stroking on sole of each foot/ fanning and extension of the toes
    • pressure applied with finger against balls of infants feet/plantar flexion of all toes; disappears by first year
  220. Gestational age assessment
    sole (plantar crease)
    breast bud
    ear from and cartilage
    - preterm
    - term
    • decreases as gestational age increases
    • as gestation progresses, proceeds to the heel
    • term: tissue will measure between .5-1cm
    • relatively shapeless and flat, no recoil/ some cartilage and slight incuring of the upper pinna, good recoil
  221. gestational age assessment
    male genitals
    - preterm
    - term
    femal genitals
    - preterm
    - term
    • small scrotum, few rugae, testes are palpable in the inguinal canal
    • testes are generally in the lower scrotum wich is pendulous and covered with rugae

    • clitoris is prominent, labia majora are small and widely separated
    • labia majora cover the labia minor and clitoris
  222. sqare window sign
    - 90 degrees
    - 30 degrees
    - 0 degrees
    • elicited by flexing the baby's hand toward the ventral forearm until resistance is felt. the angle formed at the wrist is measured
    • - immature newborn 28-32 wks
    • - 38-40 wks
    • - 40-42 wks
  223. recoil
    test of flexion development. tested in legs; placed on back on flat surface with hand on NB knees and manipulating the hip, RN place baby's legs in flexion then extends them paralle to maneuver recoil of legs. preterm have less muscle tone than term - preterm less recoil
  224. popliteal angle
    degree of knee flexion; determined with NB flat on its back; thigh is flexed on abdomen and chest and RN place index finger of the other hand behind NB ankle to extend the lower leg until resistance is met. angle is measured; no resistance in very immature newborn; 80 degree angle in term NB
  225. scarf sign
    elicited by placing the newborn supine and drawing an arm across the chest toward opposite shoulder until resistance is met. location of elbow is noted in relation to midline of chest; no resistance is noted until after 30 wks; elbow at midline at 36-40 wks; beyond 40 wks elbow will not reach midline
  226. heel to ear
    performed by placing the newborn in a supine position and the drawing foot toward ear on same side till resistance is felt. allow knee to bend and hold butt down; preterm immature NB leg will remain straight and foot will go to ear or beyond; with advancing age, the NB has increasing resistance
  227. ankle dorsiflexion
    flexing the ankle on the shin; angle formed by foot and interior leg is measured; 45 degree angle indicates 32-36 wks; 20 degree angle indicates 36-40 wks; 0 degree at 40 wks or more
  228. head lag
    measured by pulling the baby to a sitting position and noting the dgree of head lag (neck flexors). total lag is common up to 34 wks; postmature 42+ wks hold head in front of body; full term able to support heads momentarily
  229. ventral suspension
    evaluated by holding the newborn prone on examiner's hand. position of head and back and dgree of flexion in arms and legs are noted; some flexion of arms and legs indicates 36-38 wks; fully flexed extremities with head and back even are term
  230. fetal lab value changes
    • decreased erythropoietin prod
    • rise of Hgb concentration
    • physiologic anemia of infancy
    • leukocytosis
    • decreased percentage of neutrophils
  231. hepatic adaptations in NB
    • iron content stored in liver
    • low carb reserves
    • main soource of energy is glucose
    • liver begins to coagulate bilirubin
    • lack of intestinal flora results in low levels of vit. K
    • will heel stick q hr x 4hrs unless abnormal then longer
  232. types of bilirubin
    • can cause brain damage if built up and untreated
    • cant be excreeted if not conjugated
    • sum of both
  233. physiologic jaundice
    • accelerated destruction of fetal RBC's
    • impaired conjugation of bilirubin
    • increased bilirubin reabsorption
    • normal biologic response - will rise and peak at 3-5days of age
  234. GI adaptations - NB
    - sufficient enyzmes except for
    - digests and absorbs
    - salivary glands
    - stomach has capacity of
    - bowel sounds present
    - cardiac sphincter is
    - pass stool within
    • pancreatic amylase
    • fats less efficiently
    • immature
    • 50-60ml
    • 1st 30-60 min of birth
    • immature causing regurgitation
    • 48 hrs; meconium - thick, tarry, black; transitional - thinner, brown to green; formula - pale, yellow, formed, pasty; breast - yellow-gold, soft, mushy
  235. NB urinary adaptations
    - less able to
    - limited tubular
    - limited excretion
    - limited dilutional
    - void by
    • concentrate urine
    • reabsorption of water
    • of solutes
    • capabilities
    • 48 hrs of birth
  236. NB immunologic adaptations - immature at birth
    S/S of infection
    3 major types of immunoglobulins
    • often subtle and nonspecific
    • IgG - only crosses placenta; elevated levels of IgM at birth may indicate intrauterine infection such as syplhilis or TORCH; breastfeeding affords passive immunity (IgA)
  237. periods of reactivity
    • first period
    • sleep phase
    • second period
  238. timing and types of NB assessment
    immediately after birth
    within 1 to 4 hrs after birth
    within first 24 hrs or prior to d/c
    need for resuscitation; if stable and can be placed with parents to initiate early attachment/bonding

    progress of NB adaptation to extrauterine life; determination of gestational age; ongoing assessment for high-risk probs

    complete physical exam; nutritional status and ability to formula or breast feed; behavioral state organization abilities
  239. brazelton's neonatal behavior assessment
    • habituation
    • orientation to inanimate and animate visual and auditory assessment stimuli
    • motor activity
    • variations
    • self-quieting activity
    • cuddliness or social behaviors
  240. phototherapy
    maximize exposure
    periodic assessment of
    protect NB eyes with
    measure irradiance levels with
    good skin care and reposition
    maintain an NTE and
    • of the skin surface to light
    • serum bilirubin levels
    • patches
    • a photometer
    • q 2 hrs
    • adequate hydration and nutrition
  241. phototherapy
    exposure of newborn to high intensity light; used alone or in conjunction with exchange transfusion to reduce serum bilirubin levels
  242. infants of diabetic mothers (IDM)
    - even though high maternal blood surgar supploy is lost...
    - also have decreased ability to...
    - incidence of hypoglycemia; contributing factors
    the IDM contiunues to produce high levels of insulin which deplete the infant's blood glucose withing hours after birth

    release glucagon and catecholamines (which normally stimulate glucagon breakdown and glucose release)

    30-50%; control of maternal DM, maternal BS at delivery, length of labor, class of DM, early vs late feedings of NB
  243. IDM
    - nursing dx
    - nursing care
    - monitor for
    - if serum glucose falls below 40....
    - if normal glucose levels cannot be maintained with PO feedings....
    - normoglycemicx 24 hrs, decreased IV rate as oral feedings...
    altered nutrition: less than body requirements r/t increased glucose metabolism 2 to hyperinsulinemia

    • hypglycemia
    • early feedings with formula or breast milk
    • IV D5W 6-8mg/kg/min
    • increased
  244. hypoglycemia signs in NB
    • lethargy or jitteriness
    • poor feeding and sucking
    • vomitting
    • hypothermia and pallor
    • hypotonia, tremors
    • sezure activity, high pitched cry, exaggerated moro reflex
  245. complications most often seen in IDM
    • hypoglycemia
    • hyperbilirubinemia
    • birth trauma
    • polycythemia (decreased EC fluid volumes)
    • resp distress syndrome
    • congenital birth defects
  246. Care of NB exposed to HIV
    - can be transmitted....
    - decrease risk in
    - avg age of dx is
    - tx NB with
    • trasplacentally, at birth, or in breast milk
    • vertical transmission if mother tx with Zidovudine(AVT) during pregnancy
    • 18 mos. when infected infants form their own antibodies
    • AZT
  247. possible manifestations of NB with HIV
    • recurrent infections
    • generalzied lyphadenopathy
    • splenomegaly, hepatomegaly
    • FTT
    • progressive developmental delays
    • chronic diarrhea
    • oral candidiasis
  248. issues for caregivers of infants at risk for HIV/AIDS

    for suctioning use a bulb syringe, mucus extractor or meconium aspirator with wall suction on low setting. use maks, goggles and gloves
  249. issues for caregivers of infants at risk for HIV/AIDS

    admission care
    to remove blood from baby's skin, give warm water-mild soap bath using gloves as soon as possible after admission
  250. issues for caregivers of infants at risk for HIV/AIDS

    thorough handwashing before and after caring for infant. hands must be washed immediately if contaminated with blood or body fluids. was hands after removeal of gloves
  251. issues for caregivers of infants at risk for HIV/AIDS

    with touching blood or other high risk fluids. should also be worn when handling newborns before and during theinitial baths, cord care, eye prophylactics and vit k admin
  252. issues for caregivers of infants at risk for HIV/AIDS

    mask, goggle, gown
    not routinely neededunless coming in contact with placenta or blood and amniotic fluid on skin of newbor
  253. issues for caregivers of infants at risk for HIV/AIDS

    needles and syringes
    used needles should not be recapped or bent; they should be disposed of in a puncture resistant plastic container belonging specifically to that baby. after newborn is d/c container d/c'd
  254. issues for caregivers of infants at risk for HIV/AIDS

    blood and other should be double bagged and or sealed in an impervious container and labeled according to agency protocol
  255. issues for caregivers of infants at risk for HIV/AIDS

    equipment and linen
    articles contaminated with blood or body fluids should be discarded or bagged according to isolation or institution protocol
  256. issues for caregivers of infants at risk for HIV/AIDS

    body fluid spills
    should be clean with a solution of 5.25% bleach dilute 1:10 with water apply for at least 30 seconds then wipe after minimum contact time
  257. infant of substance abuse mother (ISAM)
    - maternal sub abuse during pregnancy consits of....
    - intrauterine drug exposure can cause....
    - depends on....
    any use of ETOH or drugs during pregnancy

    anomalies, neurobehavioral changes, and signs of w/draw

    specific drug or combo, dosage, route, metabolism and exretion by mother and fetus, timing of exposure, and length of exposure
  258. Care of ISAM
    - observe for
    - decrease stimuli and provide...
    - be alert for...
    - position on side or...
    - admin meds i.e...
    • seizures
    • quiet environment during w/draw pd
    • poor feedings and provide small frequent feedings
    • or semi'fowler's to prevent choking
    • phenobarbital, morphine, methadone, diazepam, no narcan for opiate addicted mothers
  259. CNS signs of NB w/drawal
    • hyperactivity
    • hyperirritability (persistent shrill cry)
    • increased muscle tone
    • exaggerated reflexes
    • tremors and myoclonic jerks
    • sneezing, hiccups, yawning
    • short, unquiet sleep
    • fever
  260. Resp signs of NB w/draw
    • tachypnea (>60 breath per minute when quiet)
    • excessive secretions
  261. GI sign of NB w/draw
    • disorganized, vigorous suck
    • vomitting
    • drooling
    • sensitive gag reflex
    • hyperphagia
    • diarrhea
    • abd cramping
    • poor feeding (<15ml on first day of life; takes longer than 30min per feeding)
  262. vasomotor signs of w/draw in NB
    • stuffy nose, yawning, sneezing
    • flushing
    • sweating
    • sudden circumoral pallor
  263. cutaneous signs of w/draw in NB
    • excoriated butt, knees and elbows
    • facial scratches
    • pressure poin abrations