exam 2 Flashcards
(332 cards)
1
Q
purpose and use of fetal monitoring in labor
A
- ID signs of fetal well-being or compromise
- assess both FHR and UC’s
- no method of fetal assessment can ID every compromised fetus
- poor predictive value
- low tech approach (intermittent auscultation (doppler)
- high tech approach continuous monitoring
2
Q
fetal monitoring as a major role for medical malpractice
A
- documentation is key (nurse’s must document and prove standard of care was met)
- nurse should identify abnormal/non-reassuring findings, intervene and report to MD/CNM in timely manner
3
Q
types of fetal and uterine monitoring
A
- auscultation and palpation for intermittent auscultation
- ultrasound and tocodynamometer (TOCO) external EFM
- internal spiral electrode (FSE) and intrauterine pressure catheter (IUPC) (internal EFM)
4
Q
fetoscope or doppler
A
- peform leopold’s manuevers and place doppler over area of maximal intesity of fetal heart tones
- palpate maternal artery at same time
- determine relationship of contraction and FHR by palpating for contractions during the FHR auscultation
- count FHR between cotraction for at least 30-60 seconds to determine baseline
- determine differences between baseline FHR and response to contraction
5
Q
external fetal monitor parts
A
- ultrasound transducer: recevies waveforms from fetal heart interpreted by the computer in the fetal montior to produce sound and visual tracing to reflect FHR
- toco- strain gauge that detects skin tightness or contour changes resulting from UC’s
- monitor paper
6
Q
internal electronic fetal and uterine monitoring
A
- uses fetal scalp electrode (FSE) or internal scalp electrode applied to fetus presenting part to directly detect FHR
- internal electronic uterine monitoring involves an IUPC placed in uterine cavity to directly measure contractions
- membranes must be ruptured
- needs this when troubleshooting methods that do not alter the quality of tracing, maternal obesity, lack of progress in labor
- contraindication: infections, placenta previa, undiagnosed vaginal beleding
7
Q
monitoring fetal paper
A
- each dark vertical line represents 1 minute and each lighter vertical line represents 10 seconds
- FHR recorded on top fird in bpm while UC recorded on lower grid in mmHg with IUPC and relative height for TOCO
- thin vertical lines (or boxes) = 10 seconds apart
- heavy vertical lines = 1 minute apart
8
Q
interpretation of FHR baseline
A
- baseline rate
- baseline variability
9
Q
interpreetation of periodic and episodic changes
A
- accelerations
- decels
10
Q
interpretation of uterine activity
A
- frequency
- duration
- intensity
- resting tone
- relaxation time between UCs
11
Q
category I FHR
A
- normal
- predictive of well-oxygenated nonacidotic fetus w/ normal fetal acid-base balance
- routine following and no action needed
12
Q
category II FHR
A
- intermediate
- do not predict abnormal acid-base balance status
- requires eval, continued surveillance, and reevaluation in context of clinical circumstances
13
Q
category III FHR
A
- abnormal
- predictive of abnormal acid-base balance
- requires prompt intervention and depending on situation efforts to resolves should be expedited include intrauterine resuscitation or immediate birth
14
Q
FHR baseline
A
- mean FHR in 10 minute period rounded to nearest 5pm
- should be between 110-160
15
Q
fetal tachycardia
A
- FHR above 160bpm that lasts for at least 10 minutes and often accompanied by a decreased or absent baseline variability
- may be a sign of early fetal hypoexmia
- if persists above 200-220bpm, fetal demise may occur
16
Q
causes of fetal tachycardia
A
- maternal: fever, infection, anxiety, dehydration, anemia, meds, ilicit drugs
- fetal: compensatory effort following acute hypoexmia, infection, activity or stimulation, chronic hypoxia, tachyarrythmia, cardiac abnormalities, anemia
17
Q
treatment for fetal tachycardia
A
- treat underlying cause
- assess variability and consider position change or O2 to promote oxygenation
- assess maternal VS
- initiate interventions to decrease maternal temp (meds, ice packs)
- assess hydration and admin IVF or water
- reduce anxiety by explaining, reassuring, and encouraging
- decrease or discontinue o2
- notify HCP
18
Q
fetal bradycardia
A
- baseline FHR <110bpm
- unresolved may result in fetal hypoxia and needs immediate intervention
- sudden profound bradycardia (>80bpm) obstetrical emergency
- with normal variability may be beginning
- with loss of variability or late decels is associated with current or impending fetal hypoxia
19
Q
causes of fetal brady cardia
A
- maternal: supine position, dehdyration, hypotension, acute maternal cardiopulmonary compromise, uterine rupture, placental abruption, medications (anesthetics, adrenergic receptors)
- fetus: fetal response to hypoxia, umbilical cord compression, acute hypoxemia (late or profound), hypothermia, hypokalemia, chronic fetal head compression, fetal bradyarrythmias
20
Q
treatment of fetal bradycardia
A
- medical: cause related, consider delivery
- confirm FHR vs MHR
- assess fetal movement
- assess fetal response to fetal scalp stimulation
- perform vaginal exam and assess for prolapsed cord
- assess maternal VS
- assess hydration and hydrate prn
21
Q
depending of FHR variability and other characteristics…
A
- change maternal postion (left or right lateral) to promote fetal oxygenation
- discontinue oxytocin to reduce UC
- give oxygen 10L/min via nonrebreather face mask to promote fetal oxygenation
- modifying pushing to every other contraction or stop pushing until the FHR recovers to promote fetal oxygenation
- encourage open glottis pushing efforts
- discourage prolonged or sustained breath holding while pushing
- provide support
- notify HCP
22
Q
assessing baseline variability
A
- most important characteristic of FHR presence implies that both branches of autonomic nervous system are functioning
- beat to beat changes/variations/fluctuations in FHR baseline
- described by undetectable, observed at fewer than 5bpm, 6-25bpm, 25bpm
23
Q
absent variability
A
- 0-2bpm
- looks like flatline
- non-reassuring
24
Q
minimal variability
A
3-5bpm
25
causes of absent or minimal variability
- fetal acidemia secondary to uteroplacental insufficiency
- cord compression
- preterm
- maternal hypotension
- uterine hyperstimulation
- abruptio placentae
- fetal dysrhythmia
26
interventions for absent or minimal variability
- lateral positioning of mother
- increase IVF rate
- administer oxygen at 8-10L/min via mask
- consider internal F montioring
- report to HCP and document
- prep for possible C-section in case no changes occur
27
moderate variability
- 6-25
- indicates autonomic and nervous system of fetus are well developed and well oxygenated
- considered a GOOD sign of fetal well0being and correlates with absence of significant metabolic acidosis
- this is NORMAL and fetus can utilize o2
28
marked variability
>25bpm (excessive)
29
causes of marked variability
- cord prolapse or compression
- maternal hypotension
- uterine hyperstimulation
- abruptio placenta
30
interventions for marked variability
- determine cause
- lateral positioning
- increase IVF rate
- administer o2 at 8-10L/min by mask
- discontinue oxytocin
- observe for changes in tracing
- consider internal fetal monitoring
- notify HCP and prep for surgical birth if no change
31
determining if accel's are present
- transitory abrupt increases in FHR above baseline that last <30 seconds from onset to peak
- determine if present or absent
- always reassuring, occurs with fetal movement or stimualtion
- if present and 15x15 (abrupt increase by at least 15 beats above baseline for at least 15 seconds) it is reactive
- this strip has a FHR baseline of 145 and is reactive because FHR baseline has increase to at least 160 for minimally 15 seconds
32
decelerations
- decrease in FHR caused by stimulation of the parasympathetic nervous system
- describe by their shape and association to uterine contractions
- determine if present or absent, if absent GREAT
- can be early, variable, late, prolonged
33
early decels
- occur early with onset of the contraction
- mirrors the shape and timing of contraction (therefore need a ontraction to determine the type of decel)
- appearance is shallow and cuplike
- reassuring: caused by vagal stimulation that occurs with pressure on fetus' head
- NO intervention needed
34
variable decels
- can occur or be ID'd with or without contraction
- often ABRUPT, with a U, V, or W shape, return to baseline is also abrupt
- non-reassuring especially if deep or prolonged
- results from compression of umbilical cord!!!!!
35
interventions for variable decels
- change maternal position
- perform sterile vaginal exam to eval cord
- admin oxygen at 10L/min via nonrebreather
- prep for possible amnioinfusion
- decrease or discontinue oxytocin
- consider need for tocolytics to reduce UC
- consider internal fetal monitoring
- modify pushing
- provide support
- notify HCP
- plan for delivery and care of neonate
36
late decels
- occur late or after onset of contraction
- need contraction to determine kind of decels
- apperance is shallow and cuplike
- NON-reassuring especially if seen with absent or minimal variability
- results of uteroplacental insufficiency (fetus isn't getting o2)
37
treatment for late decels
- change the maternal position
- discontinue oxy and consider terbutaline
- assess hydration and give IV bolus
- consider fetal scalp stimulation
- administer o2 at 10L/min via nonrebreather
- consider internal fetal monitoring
- provide support
- notify HCP
- plan for delivery and care of baby
38
prolonged decels
- a "long & late" 15bpm drop below baseline testing >2minutes but <10 minutes
- non-reassuring
- result of uteroplacental insufficiency with or without cord compression
- interventions same as the rest
39
VEAL CHOP
- Variable decels = Cord compression
- Early decels = Head compression
- Accels = Ok
- Late decels = Placental insufficiency
40
contractions
- frequency measured in minutes, beginning of one contraction to beginning of next
- duration measured in seconds beginning to end of each contraction
- intensity (toco-palpation, mild moderate, strong) (IUPC-subtracting resting tone from strongest (tallest UC) and weakest (shortest UC) for a range in mmHg
- resting tone, pressure of uterus at rest/between UC (external palpation soft or firm, internal in mmHg (do NOT want >35mmHg)
41
assessing intensity of contractions
- place fingertips on fundus of uterus to assess degree of tension as the contraction occurs
- intensity measured at peak of contraction and rated as mild, moderate, or storng
- resting tone is measured between contraction and listed as soft, firm, uterine tone
- subjective and can be biased by fat distribution of client's abdomen
42
assessing intensity
- resting tone
- weakest contraction (highest point - resting tone = x)
- strongest UC (strongest UC - resting=x)
- UC intensity range from weakest and strongest with resting tone
43
dystocia
- abnormal progression of labor
- characterized by a slow and abnormal progression of labor
- fatiguining for both mother and fetus
- leading indicator for C-section
- because cannot be predicted for diagnosed w/ certainty, the term "failure to progress" is often used
- abnormalities involve the powers, passengers, and psyche
44
what problem is associated with powers
- hypertonic uterine dysfunction
- hypotonic uterine dysfunction
45
hypertonic uterine dysfunction
- uncoordinated uterine activity
- contractions frequent and painful but ineffective in promoting dilation and effacement
- risk for maternal exhaustion and fetal intolerance of labor and asphyxia due to decreased placental perfusion
46
assessment of hypertonic uterine dysfunction
- painful
- frequent contractions with inadequate relaxation inbetween
- little cervical changes
47
medical management of uterine dystocia / hypertonic uterine dysfunction
- evaluate progress
- determine cause
- hydrate
- provide pain management
48
nursing care for hypertonic uterine dysfunction/uterine dystocia
- promote rest
- admin pain meds as ordered
- promote relaxation
- hydrate with IV or PO fluids
- assess FHR and UC's
- evaluate labor progress via sterile vaginal exam
- support and explain
- notify HCP
49
hypotonic uterine dysfunction
- occurs during active labor (dilation >5-6cm)
- contractions become poor in quality and lack sufficient intensity to dilate and efface the cervix
- MAJOR risk for postpartum hemorrhage as the uterus cannot contract effectively to compress blood vessels
50
clinical manifestations of hypotonic uterine dysfunction
- weak contractions that become milder
- uterine fundus that can be easily fingertip pressure at peak of each contraction and contractions that become more infrequent and brief
51
medical management of hypotonic uterine dysfunction
- evaluate labor progression
- determine cause
- consider interventions (starting oxy, performing amniotomy, c-section, etc)
52
nursing interventions for hypertonic uterine dysfunction
- assess uterine activity
- assess maternal and fetal status
- ambulate and change position
- hydrate w IVF or po fluids
- augment labor with oxy per protocol
- provide support and keep woman and family informed
- notify HCP of response and progression
53
precipitous labor
entire labor and birth within 3 hours
54
risks for precipitous labor
- maternal: cervical laceration, potential for uterine rupture
- fetal: head trauma (i.e., intracranial hemorrhage, nerve damage), hypoxia due to rapid progression of labor
55
nursing management for precipitious labor
- promote safety
- monitor VS and UCs q15 min
- provide support
- anticipate complications
- prep for delivery
56
problems with passenger
- should dystocia
- breech/positioning
- preterm labor
57
shoulder dystocia
- difficulty during delivery of shoulder after birth of head which often occurs when passage of anterior shoulder is obstructed by symphysis pubis
- first sign is retraction of fetal head against the maternal perineum after delivery of head, sometimes called turtle sign
- increased suspicion with prolonged second stage of labor
- risk factors not clearly ID'd but associated with birth weight >4000g (fetal macrosomia)
- EMERGENCY!!!
58
management of shoulder dystocia
qplace women's legs upward and pressing down on abdomen
59
nursing management for shoulder dystocia
- call for help
- explain the situation to client and family
- urge NOT to push
- help client assume position
- assist HCP w/ manuevers and techniques during birth
- document maneuvers including amount of time required to resolve shoulder dystocia
- provide encouragement and support
- assess newborn for clavicle or humerus fracture, brachial plexus injury, and asphyxia
- assess mother for early hemorrhage and trauma to vagina, perineum, and rectum
60
positoning of fetus
- single footing breech (one foot out)
- frank breech (buttocks is presenting part)
61
preterm labor
- occurence of regular contractions accompanied by cervical effacement and dilation before end of 37 weeks gestation
- if not halted, results in preterm birth
62
signs of preterm labor
- uterine contraction q10 min or less w/ or w/o pain
- mild menstrual like cramps felt low in abdomen
- constant or intermittent feelings of pelvic pressure that may feel like the baby pressing down
- rupture of membranes
- low, dull, backache, constant or intermittent
- change in vaginal discharge
- urinary frequency, urgency, hesitancy, or hematuria
- abdominal cramping w/ or w/o diarrhea
63
primary interventions for preterm labor
- diagnosis and treatment of STIs, UTIs, and bacterial vaginosis
- admin hydroxyprogesterone 100mg 2x/daily vaginally
- cervical cerclage
64
secondary prevention of preterm labor
- administer antibiotics to treat infection if needed
- placement of emergency or rescue cerclage in early 2nd trimester
- tocolysis
- if woman is btwn 24-34wks and candidate for tocolysis, admin corticosteroids (betamethasone or dexamethasone) for benefit of fetal lung maturity
65
tocolytic medications
- terbutaline
- magnesium sulfate
- nifedipine (procardia)
66
terbutaline
- admin subq (0.25mg normally)
- use not exceeding 48-72hrs
- often used for breakthrough contractions in a patient not currently in active labor
- sometimes used in labor for tachysystole
67
magnesium sulfate
- tocolytic choice
- do not admin if on CCB
- loading dose 4-6g IV 100mL of IVF over 20 minutes (maintenance 2-4g/hr)
- maintain for 12-24 hrs at lowest rate
68
nifedipine (procardia)
- calcium channel blocker
- PO or IV
- acts by reducing flow of calcium ions into intracellular space of myometrial smooth muscle cells inhibiting contractile activity
- check BP before
69
health promotion ot prevent preterm labor
- teach to recognize s/s of preterm labor
- teach to evaluate contractions
- ensure pt knows when to report and notify HCP
70
hospital based nursing care for preterm labor
- promote rest
- monitor vitals and I&Os
- continuosuly monitor FHR and UCs
- admin tocolytics
- keep informed, provide explanations, allow expression of feelings and concerns
71
post-term pregnancy
- extends >294 days or 42 completed weeks past the first day of LMP
- associated with deterioration of placenta and related problems for baby (reduced blood supply, decreased fetal oxygenation, reduced nutritional supply
- 20% of postterm fetuses experience dysmaturity syndrome (associated with uteroplacental insufficiency resembling IUGR, meconium aspiration, and short term neonatal complications)
72
maternal risks after post-term pregnancy
- increased discomfort of pregnancy
- anxiety
- insomnia
- C-section
- operative vaginal birth (forceps, vaccum)
- perineal trauma or damage
- maternal hemorrhage
73
clinical interventions for post-term pregnancy
- HCP will begin specialized monitoring when completing 40th weeks (nonstress and biophysical profile)
- if problems occur, induction of labor recomended
74
nursing care for post-term pregnancy
- assess EDOB and criteria to establish date
- evaluate FHR during NST or during care of laboring patients
- be preped to intervene for non-reassuring FHR
- assess fluids for presence of meconium once membranes are ruptured
75
induction of labor
- deliberate stimulation of UCs before onset of spontaneous labor to facilitate a vaginal delivery
- induction of labor refers to techniques for stimulation UCs to accomplish delivery before osnet of spontaneous labor
- maternal indications: preeclampsia, eclampsia, fetal death, chorioamnionitis
- fetal indications: IUGR, isoimmunizations, premature rupture of membranes with established lung majority)
76
contraindications of labor induction
- complete placenta previa
- placental abruption
- transverse lie
- floating presenting part
- fetal distress
- previous uterine surgery that prohibits trial of labor
77
management for induction
- u/s to evaluate fetal size, position, and GA along with locating placenta
- engaged fetal part
- pelvimetry to rule out fetopelvic disproportion
- NST to evaluate fetal well being
- phosphatidyl glycerol levels to assess fetal lung maturity
- confirmation of category I FHR
- vaginal exam to eval cervix and inductability
- labs: CBC, UA
- methods to induce: mechanical, cervical, pharmacologic
78
bishop score 0
- closed
- effaced 0-30%
- -3 station
- firm cervix
- posterior cervical position
79
bishop score 1
- 1-2 cm dilated
- 40-50% effaced
- -2 station
- medium cervical consistency
- cervix in midposition
80
bishop score 2
- 3-4 cm dialted
- 60-70% effaced
- -1 fetal station
- soft cervix
- anterior positioning
81
bishop score of 3
- 5-6 cm dilated
- 80% effaced
- +1/+2 station
82
pharmalogical method for induction
misoprostol
83
action of misoprostol
ripens cervix making it softer and causing it to begin to dilate and efface, stimulating uterine contractions
84
indication for misoprostol (cytotec)
- used for preinduction cervical ripening (ripen cervix before oxytocin induction of labor when bishop score is 4 or less)
- used to induce labor or absortion
85
misoprostol dosage and admin
- 25mcg as initial dose
- insert intravaginally into posterior vaginal fornix using tips of index and middle fingers without use of lubricant
- redosing is permissible if cervix remains unfavorable
- FHR normal and have at least 3hrs since last dose
86
nursing management for misoprostol
- explain procedures to client and family
- assess VS, FHR, and pattern and perform bishop score
- have woman void before insertion of med
- admin as ordered
- monitoring for tachysystole, fever, chills, vomiting, diarrhea
- prep to admin terbutaline 0.25 mg SQ if adverse effects occurs
- document all findings and admin procedures
87
oxytocin indications
- used primarily for labor induction and augmentation
- can be used to control postpartum bleeding
- goal: use lowest dose possible to achieve adequate labor evidence by progressive cervical effacement and dilation (0.5-1cm/hr) after active labor has been acheived
88
dosage and admin of oxytocin
- admin IV through secondary line via infusion pump
- start at 1-2miliunits/min
- increase rate by 1-2milliunits/min no more frequently than 30-60 minutes based on response
89
adverse effects of oxytocin
- maternal: uterine tachysystole, placental abruption, uterine rupture
- fetal: fetal compromise, progressive decrease in fetal oxygen status, neonatal acidemia
90
nursing management for oxytocin
- HIGH alert
- education and support
- assess uterine activity and FHR continuously using EFM
- evaluate tracings q15min during first stage and during passive stage
- evaluation tracing q5min during active pushing
- contractions shouldn't occur >q2min
- titrate to lowest dose that acheieves labor progres
- document time, each time increased, decreased, or discontinued, assessment and communication w/ HCP
91
prolpased umblical cord
- precedes fetal presenting part
- trapped between preenting part and pelvis
- pressing part not firmly against cervix
- potential obstruction of blood flow through cord
- variable or prolonged decels
92
nursing management of prolpased cord
- MEDICAL EMERGENCY
- if loop of cord palpated on vaginal exam, push presenting part up off cord and hold
- call for help
- notify HCP
- explain to client what is happening
- place client in knee chest position or trendelenburg
- admin O2 at 10L/min via mask
- admin IVF
- discontinue oxytocin
- prep for immediate delivery
93
forceps assisted birth
- used to apply traction to fetal head or provide method of rotating fetal head during birth
- are stainless steel instruments, similar to ongs, with rounded edges that fit around fetus's head
- applied to side
- type determined by HCP
94
vaccum assisted birth
- cup shaped instrument attached to suction pump for extraction
- suction cup placed against occiput
- pump used ot create negative pressure
- HCP applies traciton until fetal head emerges
95
indicateds for forcep or vaccum
- prolonged 2nd stage
- distress FHR
- failure of presenting part to rotate and descend into pevlis
- limited senstation and inability to push effectively from anesthesia
- presumed fetal jeporady or distress
- maternal heart disease, pulmonary edema, intrapartum infeciton, maternal fatigue
- trend to use vaccum over forceps
96
nursing interventions for forceps
- assess woman's anesthesia level and comfort level
- insert straight cath
- provide emotional support
- document type of forceps, # of applications, and time
- anticipate potential complications
97
nursing interventions for vaccum extraction
- assess woman's anesthesia level and comfort
- educate and reassure
- anticipate potential complication
- pump vaccum to appropriate level
- pressure should be released during contractions
- document pump was used
- time how long cup is on fetal head
98
maternal complications of forceps or vaccum
- lacerations of cervix, vagina, or perineum
- hematoma
- extension of episiotomy incision into anus
- hemorrhage
- infection
99
fetal complications of forceps and vaccum assist
- ecchymoses
- facial and scalp lacerations
- facial nerve injury
- cephalohematoma
- caput succedaneum
100
cesarean birth
- surgical birth of fetus through incision in abdominal wall
- most commonly performed surgery in US
- indicated for abnormal presentation, previous uterine surgery, placenta previa, non-reassuring fetal status, active herpes infection, dystocia
101
complications of c-section
- infection
- hemorrhage
- aspiration
- PE
- urinary tract trauma
- thrombophlebitis
- paralytic ileus
- atelectasis
- fetal injury and transient tachypnea of newborn
102
spinal anesthesia (block)
- anesthetic solution containing local anesthetic alone or in combo w/ opiod
- injected into 3rd,4th, or 5th lumbar interspace into subarachnoid space
- mixes with CSF
- provides anesthesia from nipples to feet
- lasts 1-3hrs depending on type and amougn
103
advantages of spinal block
- immediate onset on anesthesia
- relative ease of admin
- smaller drug volume
- maternal compartmentalization of drug
104
disadvantages of spinal block
- primary intense blockage of synthetic fibers
- uterine tone is maintained
- short acting
105
complications of spinal block
- hyoptension
- high level complete spinal or total spinal block
- spinal headache
106
nursing care during spinal anesthesia
- assist with positioning
- provide support and encourage breathing and relaxation
- provide o2 via nasal cannula or face mask
- record baseline
- admin fluid bolus
- palpate uterus to detect contractions
- after procedure assist to supine with wedge
- keep client informed
- assess fr hypotension and difficulty breathing
107
lumbar epidural block
- provides adequate pain relief, does not pass placenta
- allows woman some sensation to feel pressure and push
- preferred method of pain relief
- most common technique used in labor is continuous infusion pump (PCEA)
- side effects: hypotension, pruritus, patchy blocks, shivering
108
advantages of lumbar epidural block
- produces good analgesia
- woman fully awake
- does not enter fetal bloodstream
- once pump stopped, wears off within 1-2hrs
- if fails to profress, epidural can be used for c-section
109
disadvantages of lumbar epidural block
- maternal hypotension secondary to peripheral vasodilation
- can be prevented by preloading with rapid infusion of IVF (500-1000cc) and then providing IVF continuously until birthq
110
maternal hypotension
- caused by spinal blockade which lowers peripheral resistance which decreases venous return to heart and lowers cardiac output causing decreased BP
- will lead to uteroplacental insufficiency in fetus presenting as late decels
- to minimize: preload with IVF and continue IVF
111
when complication occurs you want to
1. flip: reposition on side
2. flush: increase fluids
3. O: administer 10L o2 via nonrebreather
112
nursing care for epidurals
- assess maternal VS and FHR
- ensure O2 and resuscitative equipment ready and function
- start IVF and admin
- encourage rest when tired
- assist with procedure
- help reposition and monitor BP and FHR
113
general anesthesia
- achieved throrugh combination of IV analgesics and inhaled agents
- IV anesthetics used: propofol, ketamine
- inhaled meds: nitrous oxide and halogenated agents
- major complications: fetal respiratory depression, uterine relaxation, vomiting, aspiration
114
nursing care for general anesthesia
- administer antacids prophylactically
- position with wedge under hip
- preoxygenate
- start IVF
- assist anesthesiologist and other surgical team members
- provide emotional support
- encourage breastfeeding when awake
115
preop teaching for C-section
- provide education, clarification and support (explain why and what for)
- prepare for postop period (breastfeeding, pain management, ambulation)
- emergency c-section (support partner)
116
postop care
- assess dressing, stitches, and staples
- perineal pad check q15min
- fundus palpated
- determine if remaining firm
- IV oxytocin
- assist with cough and deep breathing
- newborn safety
- promote bonding
117
propsoed causes of preeclampsia
- placental implantation with abnormal trophoblasts invasion in uterine wall
- immunological maladaptive tolerance between maternal, paternal (placental), and fetal tissues
- maternal maladaptation to cardiovascular changes or inflammatory changes of pregnancy
- genetic factors including inherited predisposing genes and epiegnic influences
118
preeclampsia signs/symptoms
- sevre headache
- swollen face
- visual disturbances
- epigastric/chest pain
- high BP
- swollen hands/fingers
- swollen legs/feet
- proteinuria
119
risks for woman w/ preeclampsia
- cerebral edema, hemorrhage, or stroke
- disseminated intravascular coagulation (DIC)
- pulmonary edema
- congestive HF
- maternal sequelae resulting from organ damage including RF, HELLP sundrome, thrombocytopenia, disseminated intravascular coagulation, pulmonary edema, eclampsia, (seizures), and hepatic failure
- placenta abruptio
- 1.5-2x more likely to develop heart disease
120
risk for fetus and newborn with preeclampsia
- uteroplacental ischemia including fetal growth restriction, oligohydraminos, placental abruption, and nonreassuring fetal status
- fetal intolerance to labor due to decreased placental perfusion
- still birth
121
medical managemet for preeclampsia
- control of BP and prevention of seizure activity and cerebral hemorrhage
- induced brith is indicated for women at less than 34weeks gestation with severe features of preeclampsia or unstable maternal or fetal status at any gestation
122
nursing management of preeclampsia
- accurate assessment and monitoring for labs
- admin antihypertensives
- admin mag sulfate
- assess for CNS changes (headache, visual changes, DTRs, clonus)
- assess for epigastric pain or RUQ pain showing liver involvement
- maintain accurate I&Os to eval kidney fxn
- perform atenatal fetal testing for FHR monitoring
- provide adequate environment to decrease CNS stimulation
- maintain bedrest in lateral recumbent position
- provide information to woman and her family
- report decline in maternal or fetal status to HCP
123
magnesium sulfate dosage and admin
IV access: load 4-6g 10% mag sulfate in 100mL solution over 20 minutes, maintenance dose 1-2g/hr
no IV access: 10grams of 50% solution IM (5g in each buttock)
124
antihypertensive meds dosage and admin
- for SBP >160 or DBP >110
- labetalol: 10-20mg for more than 2min, 40mg, 80 IV over 2minutes
- hydralazine (5-10mg IV over 2 min, repeat q20min until BP is reached
- nifedipine: 10-20mg capsules prn may repeat in 20 minutes
125
anticonvulsants admin and dosage
- for recurrent seiures
- lorazepam (ativan): 2-4mg IV, may repeat 10-15min
- diazepam (valium): 5-10mg IV q5-10min
126
contraindications for mag sulfate
- pulmonary edema
- renal failure
- myasthenia gravis
127
labetalol contraindications
- avoid in asthma or HF
- can cause neonatal bradycardia
128
hydralazine contraindications
- mitral valve disease
129
DTR scale
0 = no response
+1 = sluggish or diminished
+2 = active or expect
+3 = more brisk than expect, slightly hyperactive
4+ = brisk, hyperactive, with intermittent or transient clonus (spasms)
130
eclampsia
- may be triggered by cerebral vasospasm, cerebral hemorrhage, cerebral ischemia, or cerebral edema
- often preceded by premonitory signs of cerebral irritation like severe headaches, blurred vision, photophobia, and altered LOC
- during eclamptic seizures, prolonged FHR decels, even fetal bradycardia, and increase in uterine contractility may occur
- after a seizure due to maternal hypoxia and hypercarbia, FHR tracing may show recurrent decels, tachycardia, and reduced variability
131
care during seizures
- remaining with pt
- call for help
- providing pt safety and assessing airway and breathing
- prevent maternal injury
- record time, lengthm and type of seizure activity
- notify HCP
132
after seizure care
- rapidly assess maternal and fetal status
- assess airway, suction if needed
- admin O2 (10L via mask)
- ensure IV access
- admin mag sulfate
- provide quiet environment
133
HELLP syndrome
- variant of preeclamspai (sevre form) involving hemolysis, thrombocytopenia, liver dissunfction
- life threatening
134
HELLP
Hemolysis: causes anemia and jaundice
Elevated Lfts: ALT and AST increase, epigastric pain, n/v
Low Platelets: thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly disseminated intravascular coagulopathy
135
nursing care for HELLP
- perform thorough assessment
- evaluate lab tests
- notfiy HCP if HELLP syndrome suspected
- admin platelets as per orders
- note assessment and management are sam efro women diagnosed with HELLP
- provide woman and family info
- provide emotional supprot
136
gestational diabetes
- group of metabolic disease showing hyperglycemia resulting from effects insulin secretion, action, or both
- caused by impaired insulin secretion or inadequate insulin action
- most common endocrine disorder of pregnancy
- can be successfully managed with multidisciplinary approach
- goal to maintain glucose levels
137
target blood sugar
fasting: <95
premeal: <100
1hr after meals: <140
2hrs after meals <120
A1C: <6
138
nursing managment of GD
- maintain glucose levels throughout pregnancy
- teach how to test levels using 3 checks/day
- educate importance of maintenance
- teach signs of hypoglycemia, hyperglycemia, and DKA
- reinforce diet and exercise
- assess behavior and mental health
- reinforce plan of care related to self management and fetal surveillance (daily kick counts)
139
intrapartum care for GD
- glucose monitoring hourly (80-110 is desired)
- insulin infusion may be needed to maintain levels
- avoid dextrose
140
after birth/postpartum care of GD
- most return to normal
- high risk for future GDM
- increase risk of type II
- reassess at 6-12 weeks PP
- contraceptives
141
postpartum assessment of mother
- based on thorough assessment
- designed to meet needs of woman and new family as well as dtect and treat complications
- nurse uses knowledge to guide assessment
- also assessment time is an excellent opportunity for pt education
142
postpartum assessment principles
- select time
- consider needs
- provide explanations
- ensure relaxation
- perform procedures gently
- document and report results
- take appropriate precautions
143
typical assessments in postpartum period
- 1hr: q15 min
- 2nd hour: q30min
- first 24hrs: q4hrs
- after 24hrs: q8hrs
144
vitals PP
- temp: slightly elevated during first 24hrs, normal afterward
- pulse: 60-80 bom, pulse >100 needs further investigation
- respirations: 12-20 and clear
- BP: WNL, no higher than 140/90 or lower than 85/60
- pain: goal btwn 0-2
145
BUBBLELE
- breasts
- uterus
- bladder
- bowels
- lochia
- episiostomy/lacerations
- lower extremities
- emotional status
146
breasts
- assess fit and support of bra
- provide information on selecting bra
- examine shape, size, abnormalities, reddened areas or enorgement, check for cracked blistered or bleeding nipples, erect, flat or inverted
- note dischage and doument
- palpate breast lightly for softness, slight firmness associated with filling or tightness of engorgement, warmth or tenderness
147
breast teaching
- characteristics
- breast feeding: use supportive bra, keep nipples dry and watch for fissures or cracks, watch for reddened or tender spots, additional teaching while breastfeeding prn
- nonbreastfeeding: use supportive bra, avoid breast stimulation, apply cold, raw cold cabbage leaves, allow water in shower to flow over back not breasts
148
uterus
- have her void before exam
- palpate position of fundus in relation to umbilicus
- note for boggy, firm, or midline
- inspect abdominal incision of c-section for REEDA
- excessive pain may indicate infection
149
bladder
- monitor during hours after birth
- 1st few voids need to be measured and documented (should be between 150-200mL)
- assess frequently for distention, frequency, burning, or urgency
- catheterization may be needed
- encourage frequent voiding, increase amount of water drinks
150
bowel
- assess bowel sounds and abdomen
- movements return within 2-3days
- constipation can increase pressure on perineal sutures and increase discomfort
- educate on how to return to normal BMs, use of stool softners, not to be scared to have one, dangers of constipation
151
lochia
- assess character, amount, odor, and presence of clots
- assess for rubra, serosa, and alba
152
lochia education
- normal changes in color and characteristics
- effect of position changes
- hygienic measures: use of peribottle, hand hygiene with changing pad, wiping front to back
153
episiotomy/perineum
- inspected in Sim's position
- lift buttocks to expose perineum and anuse
- inspect episiotomy site and for presence of hemorrhoids
- usually edematous and slightly bruised
- can take up to 4-6months to heal
- alsp inspect for hemorrhoids
154
lacerations
- classified based on severity and tissue involement
- 1st degree: involves only skin and superficial structures above muscle
- 2nd degree: extends through perineal msucules
- 3rd degree: extends through anal sphincter muscle
- 4th degree: continues through anterior rectal wall
155
care of lacerations and episiotomies
- assess q8hrs
- large areas of swollen bluish skin with sevre pain indicate hematomas
- redness, swelling, increased discomfort or purulent drainage indicates infection
- white line running down length of episiotomy is sign of infeciton as well as swelling or discharge
156
inspecting epidural
- visually inspect
- perform I&Os
- assess for side effects of injected medications (i.e., itching, n/v, or urinary retention)
157
episiotomy and perineum teaching
- discuss type
- care of sutures
- cleansing perineum
- comfort measures
- kegels
158
lower extremities
- assess for redness, swelling, heat, tenderness or pain in legs
- determine degree of sensory and motor fxn by asking if they can feel sensation and ambulate
159
emotional status
- observe interactions, independence, energy levels, eye contact, posture, etc/
- be alert for mood swings, irritability, or crying episodes
160
emotional education
- rest
- gradually return to normal activity
- proper nutrition
- ask for help
- infant safety
161
nursing interventions in postpartum period
- provide optimal cultural care
- determine client's preferences before intervention
- may include dietary restrictions, certain clothes, taboos, activites for mental health, use of silence, prayer or meditation
- restoring health may involve folk medicine or conferring with tribal healer
162
nursing interventions to promote comfort
- ice packs within first 24hrs to reduce perineal edema and prevent hematoma formation
- peribottle filled with warm water prayed over perineal area after voiding
- sitz bath after first 24hrs using room temp water to reduce swelling and promote comfort
- topical prep: benzocaine spray, witch hazel spray and dibucaine or hydrocortiisone for hemorrhoids
- analgesics: acetaminophen, iburopen, naproxen,
163
nursing interventions continued
- assess voids
- admin stool softners as ordered
- encourage to ambulate
- encourage increase in fluids and fiber
- encourage adequate rest periods
- encourage exercise
164
immunizations given postpartum
- tdap (tetanus, diptheria, pertussis)
- MMR II (measles, mumps, rubella)
- flu vaccine
- Rhogam
165
points to remeber about PP care
- best postpartum care is individualized, family0centered, and disrupts family as little as possible
- knowledge of normal and abnormal helps recognize problems and begin interventions
- communicating information helps family adjust
- pt education is vital to prevent further complications
166
postpartum complications info
- can be life thretening and require collab management
- somtimes requires readmission
- need to be aware of physical or emotinal complications during birth
- need to teach s/s of PP complication, when to notify HCP, and how to prevent complicatiosn
167
most common PP complications
- hemorrhage
- infections
- thromboembolic disease (clots)
- postpartum psychiatric disorders
168
postpartum hemorrhage
- >500mL following vaginal birth
- >1000mL following C-section
- any amount of bleeding that places mother in hemodynamic jeporady
- primary hemorrhage occurs within first 24hrs
- late hemorrhage ocurs 24hrs to 12weeks after birth
169
causes of hemorrhage
- uterine atony (failure to contract)
- lacerations of genital tract
- episiotomy
- retained placental fragments
- uterine inversion
- coagulation disorders
- hematoma of vulva, vagina, or subperitoneal areas
170
pathophysiology of PPH (4 Ts)
1. tone: uterine atony, distended bladder
2. tissue: retained placenta and clots
3. Trauma: vaginal, cervical, or uterine injury
4. Thrombin: coagulopathy (preexisting or acquired)
171
nursing interventions for hemorrhage
- review maternal hx to ID risk factors
- regular and frequent assessment of fundal position and tone or contractility, if boggy MASSAGE
- monitor bladder for distension, immediately inttervene if present
- assess for bleeding
- examine perineal area for hematomas
- monitor VS, LOC, I&Os, and O2 sats
- if suspected PPH, cal for help and notify HCP STAT
172
oxytocin
- given to stimulate contraction of uterus
- 20-40units in liter IV or 10 units IM
- monitor fundus for contraction
- monitor for bleeding q15min
- monitor vitals q15
- monitor uterine tone, assure client, offer explanation, provide nonpharmacologic comfort measires, set up IV infusion
173
misoprostol
- stimulates uterus to contract reducing bleeding
- 800 mcg PR
- contraindications: undilued as bolus injection IV
- don't give with allergy, active CVD, hepatic disease, or asthma
174
dinoprostone
- helps contract uterus to stop bleeding
- 20mg vaginal or rectal
- monitor BP (hypotension common), vomiting, diarrhea, nausea, and temp elevation
175
methylergonovine maleate
- stimulates uterus to prevent and treat postpartum hemorrhage due to atony
- assess baseline bleeding
- offer explanation
- monitor for adverse effects of HTN, seizures, uterine cramping, n/v, and plapitations
- report chest pain
- don't give if HTN
176
prostaglandin or carboprost
- stimulates uterine contractions to treat PPH when uncontrolled by other methods
- 0.25 mg IM
- monitor vitals, contractions, comfort, and bleeding
- monitor for adverse effects like fever, chills, headache, n/v, diarrhea, flushing, and bronchospams
- don't give w/ asthma or active CVD, renal or hepatic disease
177
don't give oxytocin or ptiocin as
undiluted bolus injection IV
178
don't give cytotec with
- allergy
- active CVD
- pulmonary disease
- hepatic disease
179
dont give prostin E2
- active cardiac, pulmonary or renal disease
180
don't give methergine if
woman is hypertensive
181
don't give hemabate if
asthmatic
182
nursing care after PPH
- monitor vitals
- evaluate for s/s of anemia (fatigue, headache, thirst, orthostatic hypotension)
- evaluate effectives of treatment
- monitor I&Os
- notfy HCP of UO <30mL/hr
183
venous thromboebolic conditions
- potentially serious complication of PP
- one of the leading causes of maternal mortality and morbidity
- inflammation of blood vessel lining
184
most common types of thromboembolic conditions
- superficial thrombosis: confined to lower leg
- deep vein thrombosis: LE, varies from foot to iliofemoral region
- pulmonary embolism: complications of DVT in blood
185
PE s/s
- dyspnea
- pleuritic chest pain
- cough w/ or w/o blood
- cyanosis
- tachypena
- tachycardia
- panic
- sudden hypotension
- diaphoresis
- wheezing, rales, friction rub
186
nursing care for SVT
- admin NSAIDs for analgesia
- facilitate rest
- elevate affect leg
- apply warm compress to promote healing
- use antiembolic stockings to promote circulation
187
nursing care for DVT
- bed rest or limited ambulation
- elevate affected leg
- apply antiembolic stockings or SCDs
- admin LMWH
- monitor aPTT, PTT, and platelets
- apply warm compresses
- administer analgesics
- expect to admin oral analgesics for several days
188
nursing care of PE
- institute emergency measrues immediately
- admin O2
- initiate LMWH IV
- maintain bed rest
- admin analgesics
- be preped to admin thrombolytics
189
postpartum infection
- any clinical infection of gential tract within 28days after miscarriage, abortion, or birth
- defined as fever >100.4 after 1st 24hrs
- organsisms usually those of normal flora
- most common, endometritis, surgical site infections, UTIs, and mastitis
190
endometritis
- uterine infection typically developing within 2-4 days to as late as 6wks PP
- involves endometrium, decidua, and adjacent myometrium of uterus
- broad spectrum antibiotics, measures to restore and promote fluid and electrolytes and analgesic pain relief
191
surgical site infection
- may not show until 24-48hrs
- s/s: weeping or purulent drainage, separation, edema, erythema, tenderness, discomfort, fever, elevated WBCs
- therapuetic management: opening of wound to allow drainage, aseptic wound management, hydration, frequent perineal pad changes, ambulation, antibiotics, analgesics
192
urinary tract infections
- urinary frequency, urgency, dysuria, lower abdominal pain, cloudy urine w/ strong odor
- can be prevented by timely removal of catheters
- therapuetic management: fluids to prevent dehydration, antibiotics
193
mastitis
- inflammation of mammory gland
- occurs within 2days to 2wks PP
- s/s: flu like symptoms, tender, hot painful areas of one breast, inflammation of breast, tenderness, cracking of skin around nipple or areola, breast distention w/ milk
- management: increase frequency of breastfeeding, antibiotics, ice or warm packs, analgesics
194
nursing assessment and management
- play role in ID s/s of infection
- assess risk factors by reviewing hx
- ID early subtle s/s
- BUBBLEEE
- REEDA
- inspect wounds
- maintain aeseptic technique while performing invasive procedures
- monitor labs and VS
- monitor frequency of vaginal exams and length of labor
- encourage rest, adequate hydration, and healthy eating habits
- provide education on preventative measures
195
PP psych disorders
- baby blues
- postpartum depression
- postpartum psychosis
- posttraumatic stress disorder
196
baby blues
- mild
- occurs in 50-70% of mothers
- typically occurs within 2-4 days
- lasts about 2weeks
- assure mother it is normal
197
postpartum depression
- similar to baby blues but includes feelings of worthlessness, lack of concern of overall apperance, irritability or hostility toward baby and suicidial ideation
198
PP depression management
- individaul group therapy
- antidepressants
- continue to breastfeed
199
postpartum psychosis
- sleep disturbances
- depersonalization
- confused, irrational, or disorganized thinking
- bizarre behavior
- psychomotor disturbances (stupor, agitation, rapid and incoherrant speech)
200
nursing management for PP psych issues
- review hx and ID risks
- be alert for physical findings through activity level, fatigue, sleeping habits
- observe anxiety and ability to conentrate
- assess nutritional intake
- educate about enormous changes that occur during PP period and provide material about PP emotional disorders
- assist in learning how to ask for help
- have resources
201
transition to extrauterine life
- neonatal period: first 28 days of life
- transition begins when umbilical cord is cut and neonates take first breath
- nruses role is to assess, moitor, and support neonates as they go through changes
202
respiratory system fetus vs newborn
fetus: fluid filled, high pressure system causing blood to be shunted from lungs through ductus arteriosus to rest of body
newborn: air-filled, low pressure system encouraging blood flow through lungs for gas exchange, increased o2 content in blood of lungs contributing to closing of ductus arteriosis
203
gas exchange fetus vs newborn
fetus - placenta
newborn - lungs
204
circulation throuhg heart fetus vs newborn
Fetus:
- pressures in RA > LA
- encourages blood flow through foramen ovale
Newborn:
- pressures in LA > RA causing foramen ovale to close
205
hepatic portal circualtion fetus vs newbron
Fetus:
- ductus venosus bypassess; maternal liver performs filtering functions
Newborn:
- ductus venosus closes (becomes a ligament)
- hepatic portal circualtion begins
206
thermoregulation fetus vs newborn
fetus:
- body temp maintained by maternal body temp and warmth of intrauterine environment
newborn: body temp maintained through flexed posture and brown fat
207
thermoregulation
- process maintaining balance between heat loss and heart production in order to maitnain body's core internal temperature
- neutral thermal environment needed to support neonate during transition
- newborns dependent on environment for maintenance of body temp immediately after birth
- maintaining stable temp is critcial to survival
208
characteritiscs predisposing newborns to heat loss
- thin skin; blood vessels close to surface
- lack of shivering ability
- limited use of volutnary muscles
- large body surface area relative to weight
- lack of subq fat
- no ability to adjust own clothing or blankets to acheive warmth
- infants cannot communicate they are too cold or too warm
209
heart production
primarily through non-shivering thermogenesis which is metabolism of brown adipose tissue
- located in neck, thorax, axillary area, intrascapular aras and sround adrenal glands
- metabolism of borwn tissue promotes heat production through lipid breakdown and transfers heat to peripheral system
- limited amount in premature infants
210
convection heat loss
- involves flow of heat from body surface to cooler surrounding air to air circulating over body surface
- ex. cool breeze, room, outside air
211
strategies to prevent convenction
- increase temp in delivery room
- move away from air conditioning
- use radiant warmer
- monitor temp frequently until neutral thermal conditions are established
212
conduction heat loss
- involves transfer of heat loss from one object o another when two objects are in direct contact
- refers to heat fluctuation between newborn's body surface while in contact with other solid surfaces
213
prevention of conduction
- prewarm bed or cover with several layers of warm blankets
- cover scale with a prewarmed blanket
- position nebworn in flexed position
- place blanket over chemical mattress
- limit use of hot water bottles
- educate parents
- NEVER RAPIDLY WARM INFANT
214
radiation heat loss
- involves loss of body heat to cooler, solid surfaces that are not in direct contact but within proximity
- placed next to cold window, using cold equpment
215
prevention of radiation heat loss
- prewarm incubator
- move away from windows
- use radiant warmer with servo control
- use heat lamps as last resort
216
evaporation heat loss
- involves heat loss when liquid is converted to vapor
- ex. baby covered in amniotic fluid, bathing
217
prevention of evaporation
- place newborn skin to skin
- dry with warm blankets
- warm room
- bathe quickly and dry and dress
- avoid overheating adn rapid rewarming which can cause vasodialtion
- avoid situations contibuting to cold stress which can cause vasoconstriction
218
cold stress
- excessive heat loss resulting in utilization of compensatory mechanisms
- occurs when there is a decreased environmental temp causing decrease in neonates body temp causing respiratory distress and other serious outcomes
- consequences of cold stress: hypoglycemia, hypoxia, metabolic acidosis, decreased surfactant, respiratory distress, increased bilirubin and jaundice, poor feeds and weight loss, apnea, death
219
s/s of cold stress
- temp <97.7
- cool skin
- restlessness
- crying
- pale ro mottled
- acrocyansosis
- tachypnea
- grunting
- hypoglycemia
- hypotonia
- lethargy
- jittery
- weak suck
220
prevative measures for cold stress
- dry neonate thoroughly after birth
- place cap on head
- provide skin to skin
- use prewarmed blankets
- prewarmed equipment
- delay bath until temp is stable
- bathe infant under radiant warmer
- place infant away from air vents
- open windows
- place infant away from outside walls and windows
- educate parents on keeping newborn warm
221
if cold stress is suspected
- monitor temo
- place cap on head and place in skin to skin
- assess and correct environmental conditions
- reassess temp in 30 min
- obtain heel stick to asses for hypoglycemia
- place under warmer if temp doesn't regulate within 30in
222
hepatic system of newborn
- slowly assumes function after birth (iron storage, carb metabolism, conjugation of bilrubin)
223
GI system of newborn
- not fully mature at birth but can rapidly adapt to demands
- bowel sounds heard within 1st hour of life
- gastric size 6mL/g 15-24 mL for most infants
- intake of colostrum is 2-10mL/feed for first 24hrs
- after first 24hrs, 30-60mL/feed by day 4
- stomach emptying is 2-4hrs
- cardiac sphincter and nervous system control of stomach immature leading to regurgitation and uncoordingated peristaltic activity
- breast milk digested faster than formula
- breastfed infants feed q2-3hrs
- formula infants feed q3-4hrs
224
newborn stool
- meconium, then transitional stool, than milk stool
- breast-fed newborns: yellow gold, losse, stringy, pasty, sour-smelling
- formula: yellow, yellow-green, loose, pasty, or formed, unpleasant odor
225
renal system in newborns
- control fluid and electrolyte balance and excretion of waste
- kidneys are initally immature which puts neonate at risk for overhydration, dehydration, electrolytes, or drugs
- full term excrete 15-60mL/kg of urine/day
- all newborns need to void within first 24hrs
- usually lose 5-10% of birth weight during first week
226
meconium is expected days
1-2
227
transitional stool expected days
3-4
228
breast fed stool or formula fed stool expected days
3-4
229
immune system of infants
- essential to newborn's survival and ability to respond to hostile environment
- immune system begins workin in early gestation peaking at 32-33wks relying on passive immunity from mom
- risk for acquiring infection
- being to produce own antibodies at 2-3months of life
- immune system response: natural immunity (physical barriers, chemical barriers, resident nonpathological organisms), acquried immunity (development of circulating immunoglobulins, formation of activated lymphocytes and absent until after first invasion)
230
skin of newborn
- protective barrier
- limtis water loss
- prevents absorption of harmful agents
- protects thermoregulation
- fat sotrage
- protects against physical trauma
- accelerated epidermal development with expoure to air for newborns
- improper handling can cause damage, prevention of healing, and interance with normal maturation process
231
neurological adaptations
- development follows cephalocaudal and proximal distal patterns
- acute senses of hearing smell tase tocuh and vision
- adaptations of respiratory circulatory thermoregulatory and MSK systems indirectly indicating CNS transition
- reflexes are indication of neuro function
232
behavioral patterns
- 1st period of reactivity birth to 30 minuts to 2hrs after birth, alert, moving, appears hungry
- period of decreased responsiveness: 30-120min old, period of sleep or decreased activity
- 2nd period of reactivity: 2-8 hours, newborn awakens and show interest in stimuli
233
care of vigorous newborn
- skin to skin with warm blankets
- APGAR done at 1-5 minutes
- VS
- mother and baby give 1-1.5hrs of uniteruptred bonding
- breastfeeding
- delayed cord clamping for 30-60seconds
- lightweight clamp placed after 1/2-1inch from newborn skin
- do not suction unless absolutely necessary
234
signs indicating problem in newborn
- nasal flaring, chest retractions
- grunting on exhalation, labored breathing
- generalized cyanosis, flaccid body posture
- abnormal breath sounds
- abnormal RR
- abnormal HR
- abnormal size of newborn
235
APGAR scores rated on
- HR
- RR and effort
- muscle tone
- reflex irritability
- skin color
236
complete newborn assessment
- review prenatal hx
- done after intial bonding period
- requries head to toe along with length, weight, gestational age assessment
- length is 44-55cm normally and weight is 2500-4000g (5lb 8oz-8lb 8oz) full term
- low birth weight <2,500g (<5.5lb)
- very low birth weight <1,500g (<3.5lb)
- extremely low <1,000g (<2.5lbs)
237
gestational age assessment
- established from mothers LMP, ultrasound, and neonatal age assessment
- use of ballard scale helps estimate gestational age
- calculated using 6 physical and 6 neuromuscular characterstics
- examination determines weeks of gestation
- score uses gestation age based on weight length head circumfrence to determine if AGA, SGA, LGA
238
phytonadione
- privdese newborn with vitamin K for clotting facors
- prevents vitamin K deficiency bleeding
- give 1-2hrs after birth
- give IM injection (90) to outer middle third of vastus lateralis muscle
- use 25 gauge 5/8in needle
- hold leg firmly and inject meds slowly
- adhere to precautions
- monitor for bleeding
239
erythromycin
- prevents against bacterial eye infections
- be alert for s/s of conjunctivits
- wear glovesand open eyes by placing thumb and finger above and below eye
- gently squeeze tube or ampoule to apply meds to eye from inner to outer eye
- don't touch tip of med to eye
- close eye to make sure med permeates
- wipe off excess after 1 min
240
physical exam
- done within first 24hrs
- should not be initiated if crying
- begin w/ least invasive first
- early recognition is key
- ensures proper evaluation and care
- each clinician has own approach
- want to look for normal vs abnormal findigns
241
normal skin findings
- pink, warm, acrocyanosis present
- milia present on bridge of nose and chin
- lanugo present on back, shoulder, and forehead
- peeling or crackin often noted >40wks gestation
- slate gray patches (mongolian spots)
- hemangiomas (stork bites), nevus flammeus (port-wine stain), strawberry hemangiomas
- stork bites often at nape of neck
242
abnormal skin findings
- central cyanosis after 10minutes of life
- jaundice within 24hrs
- pallor occuring w/ anemia, hypothermia, shock, or sepsis
- greenish or yellowish vernix indicating passage of meconium
- persistant ecchymosis or petechiae occuring with thrombocytopenai, sepsis, or congenital infection
- abundant lanugo in preterms
- thin and translucent skin
- nails >40week
- pilonidal dimple
243
nevus flammeus
portwine stain
244
nevus vasculosus
strawberry hemagliomas
245
head
should be symmetric and round
- inspect and palpate fontanells (should be soft, flat, and open
- palpate skull (should be smooth and fused except for fontanelles and sutures
- assess size of head
- measure head circumference
246
molding
change in head shape as a result of birth
247
caput succedaneum
build up of fluid that crosses suture lines
248
cephalematoma
bleeding under head causing hematoma of head that crosses suture line
249
face and nose
- observe for fullnes and symmetry
- should have full cheeks and be symmetric
- inspect nose for size, symmetry, position, and lesions
- nose should be midline with patent and equal size nares and intact spetum
- are preferential nose breathers and sneeze to clear if needed
250
mouth
- inspect
- lips should be pink, intact, positioned midline with no lesions
- inside of mouth should show alignment of mandible, intact soft and hard palate, sucking pads inside cheecks, midline uvula, free mvoing tongue, working gag, swallow and sucking reflex
- mucous memranes should be pink and most with minimal saliva present
- normal variation: epsetin pearls
251
normal eyes
- position should be midline with ears
- open, symmetrical, can follow objects
- edema may be present
- iris is blue gray or brown
- sclear is white or bluidh
- subconjunctival hemorrhage may be rpesent from birth
- pupil PERRLA
- + red light reflex and blink reflex
- no tear production
- transient strabismus and nystagmus related to immature muscular control
252
abnormal eye findings
- absent red light reflex indicating cataracts
- unequal pupil reactions (neuro trauma)
- blue sclera (linked with osteogenesis imperfecta)
253
normal ears
- top of pinna aligned with external canthus of eye
- pinna without derformities
- neonate responds to noises and startles
- hearing becomes more acute as eustachian tubes clear
- neonates respond to high pitched vocal sounds
254
abnormal ear findings
- low set ears (linked with down syndrome)
- absent startle reflex
- skin tags, dimpling, other lesions can be associated with kidney abnormalities
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neck
- inspect for head movement and ability to support head
- neck creasing is normal
- should move freely in all directoins
- can hold head midline
- inspect clavicle, should be straight and intact
- abnormal: webbing
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chet and lungs normal findings
- barrel shaped
- symmetrical
- breast engorgment normal
- clear or milky fluid from nipples ormal
- lung sounds are clear and equal
- scattered crackles normal first few hours after birth
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abnormal chest and lung findings
- pectus excavatum (funnel chest)
- pectus carinatum (pigeon chest)
- chest retractions
- persistent crackles, wheezes, stridor, grunting, paradoixal breathing, decresed breath shounds, apnea (>15-20 seconds)
- decreased or absent breath sounds (often related to meconium aspiration or pneumothorax)
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normal abdominal findings
- soft, round, protuberant, symmetrical
- bowel sounds present, may be hypoactive
- passage of meconium stool within 48hrs
- cord is opaque or whitish blue with 2 arteries and one vein covered in wharton's kelly
- skin around imbilical cord should be assess for infection and have no redness, swelling, drianage, or foul smell
- cord becomes dry and darker in color within 24hrs and falls off within 2wks
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abnormal abdominal findings
- assymetric
- hernias
- one umbilical artery and vein (common with heart or kidney malformations)
- failure to pass meconium stool (common w/ perforated anus or meconium ileus)
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female GU normal
- anus is patent
- passage of stool within 24hrs
- labia majora covers minora and clitoris
- may be swollen
- blood tinged vaginal discharge related to abrupt decrease in hormones
- whitish vaginal discharge observe in response to hormones
- urine may be dark with red color crystals (normal in first few days) called brick dust
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abnormal female GU
- imperforated anus
- anal fissures or fistulas
- prominent clitoris and small ,visibile minora
- ambiguous genitalia
- no urination after 24hrs (can indicate urinary tract obstruction, polycystic disease, or renal failure)
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male GU normal
- urinary meatus at tip of penis
- scrotum large, pendulous, and edematous with rugae
- both testes are palpateed
- neonates urine within 24hrs
- brick dust may be present
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abnormal male GU
- hypospadis (urethra on ventral surface)
- epispadias (urethral opening on dorsal surface)
- undescended testes (cryptorchidism)
- hydrcele (enlarged scrotum
- no urination after 24hrs (can indicate urinary tract obstruction, polycystic disease, or renal failure)
- ambiguous genitalia
- inguinal hernia
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MSK normal
- arms and legs symmetrical
- 10 fingers and toes
- full ROM in all extermities
- no clicks at joints
- equal fluteral folds
- C-shaped spine with no openings or dimpling
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MSK abnormal
- polydactyl (extra digits)
- syndactyly (webbed digits)
- unequal gluteal folds (+ barlow sign and ortolani manuevers signaling congential hip dysplasia)
- decreased ROM or muscle tone: birth injury, neuro disorder, preamturity
- swelling, crepitus, or neck tenderness = possible broken clavicle
- simian creases, short fingers, wide space between big toe and second are common with down syndrome
- vertebrae openings may indicate spin bifida
- dimpling of sinuses may indicate pilonidal cyst or more serious neuro disorder
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neuro normal
- flexed position
- rapid recoil of extremities
- + reflexes
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abnormal neuro
- hypotonia: floppy, limp, related to possible nerve injury related to birth, CNS depression related ot maternal meds, fetal hypoxia, prematurity, or spinal cord injury
- hypertonia: tightly flexed arms and stiffly extended legs with quviering indicate drug withdrawl
- paralysis indicating birth trauma or spinal injury
- tremors due to hypoglycemia, drug withdrawl, or cold stress
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blinking reflex disappears
NEVER
stays into adulthood
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moro reflex reflex disappears
- 3-6months
- startle reflex
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grasp reflex disappears
- 3-4 months
- grasp onto hand or figer
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stepping reflex
- disappears 1-2 months
- steps down when placed upward
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tonic neck
- fencing position
- disappears 3-4 months
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sneeze reflex
- persists
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rooting reflex
- leaves 4-6 months
- baby turns toward stimulation near mouth
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gag reflex
- persists
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cough reflex
persists
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babinski sign
- leaves around 12 months
- curling of toes when palpated
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nursing interventions for newborns
- montior VS
- monitor I&Os
- perform newborn screenings
- educate parents on care
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circumcision care
- assist w/ circ
- assess after for bleeding
- for gumco, change vaseline gauze with each void
- note first void
- educate parents on care
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hearing screening
- screened before discharge
- must be conducted in quiet room
- those who fail need follow up at 1 month
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congenital heart disease screening
if fail the first one, perform second after 1hr, if failed 2nd perform another after 1hr, if failed again contact cardio
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hyperbilirubenemia
- extreme levels can be toxic causing kernicterus (acute bilirubin encephalopathy) causing sever and permanent neurological daamge
- levels interpreted according to infants age in hours
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hyperbilrubienmia information
- results from overproduction of bilirubin which is end product of hemoglobin breakdown
- newborn is at risk for higher RBC mass to bodyweight, shorter RBC lifespan, higher bilrubin production, lack of intestinal bacteria, decreased GI motility, and increased beta-flucuroidase, decreased hepatic uptake of plasma, diminished conjugation of bilrubin in liver to decreased glucuronyl transferase activity
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bilirubin levels showing jaundice
>5mg/dL
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clinical significance of bilirubin levels is based off
- gestational age
- hours of llife
- and TSB levels
286
complications of hyperbilirubenemia
- acute bilrubin ecephalopathy
- kernicterus
287
physiological jaundice
- appears AFTER 24 hours of life
- typically due to newborn's increased RBC and shorter RBC lifespan, slower uptake of bilirubin by liver, lack of intestinal bacteria ad hydration
- peaks at around 3-5days of life
288
pathological jaundice
- occurs BEFORE 24 hrs of life
- result of hemolytic disease or liver's inability to conjuagte and excrete excess bilirubin from hemolysis
- peak is variable
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common reason for hemolytic disease of newborn
ABO incompatiability
Rh incompatiabiltiy
290
Rh incompatibility
- Rh+ newborn with + Coombs test
- increase erythropoeisis with many immature RBCs
- anemia
- eleavted levels of bilrubin in cord blood
- reduction in albumin binding capacity
291
ABO incompatiability
- increase in reticulocytes
- direct coombs negative
- indirect coombs positive
292
coombs test
tests antibodies or complement proteins
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caring for infant under phototherapy
- position phototherapy lights 12-16 inches away
- measure irradiance 1x a shifrt
- protect eyes and gonads
- change position frequently
- monitor vitals
- maintain adequate hydration
- monitor I&Os
- weight infant daily
- discontinue eye patches for feeding and parent visits
- assess for side effects (loos stools, dehydration, skin rashes, hyperthermia, lethargy, dehydration)
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hypoglycemia
- blood glucose levels <40-45
- common during transition, especially in neonates with complications
- s/s: jitteriness, tremors, irritability, tachypnea, grunting, seizures, apnea, hypotonia, lethargy, hypothermia, cyanosis, poor feeds
- nurses responsibility to check
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assessment findings of IDM
- macrosomia
- fractured clavicle or brachial nerve injury
- hypoglycemia, calcemia, and magnesemia
- polycythemia (increase RBC)
- hyperbilirubinemia
- low muscle tone, lethargy
- poor feeds
- RDS
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nursing interventions
- early feeds within 1hr of life, recheck after 30minutes
- may need bolus of D10W and admission to NICU if symptomatic
- may need continuous IVF
- feed q2-3hrs and check glucose before each feeds for 12hrs
- new research recomending dextrose gel for asymptomatic infants with levels 20-40
296
infant of diabetic mother
- macrosomia occurs in 40-50% of diabetic pregnancies due to high levels of glucose crossing the placenta in response, fetal pancreas produces insulin resulting in increased production and growth
- large body and normal head circumference because insulin does not cross blood brain barrier
296
nursing management of IDM
- assess for s/s of respiratory distress, birth trauma, congenital abnormalities, hypoglycemia, hypocalcemia, polycythemia, hyperbilrubemia
- provide early and frequent feedings
- obtain labs
- maintain NTE to reduce energy levels
296
large for gestational age
- weight >90th percentile
- macrosomic >4000g
- leading cause is diabetic mother
296
LGA at risk for
- c-section or operative birth
- shoulder dystocia
- birth trauma
- hypoglycemia
- polycythemia and hyperbilirubinemia
- perinatal asphyxia
- respiratory distress
- meconium aspiration
296
risk factors for LGA
- maternal diabetes
- multiparity
- previous macrosomic baby
- prolonged pregnancy
- increased maternal weight gain in pregnancy ad maternal obesity
297
nursing management of LGA
- review risk factors and hx
- assess respiratroy status
- assess for birth trauma
- obtain and monitor glucose
- provide early and frequent feeds
- monitor labs
- assess skin color for signs of polycythemia
- perfom gestational age assesment
- observe for jaundice
298
small for gestation age
- weighs <10th perctile
- can be preterm, term, or post-term
- commonly seen with mothers who smoke or HTN
299
IUGR vs SGA
- all IUGR babies are small for gestational age
- NOT all small for gestational age babies are IUGR
- IUGR occurs in utero and is a result of uterine insult
300
symmetric IUGR
- refers to fetuses with equally poor growth rates of brain, abdomen, long bones, and thought to be from global insult
- all parameters of growth affected
- all body parts are symmetric in proprotion
- head does not appear overly large or length excessive in relation to body
- below normal size
- generally vigorous
301
asymmetric IUGR
- refers to infants who brain growth is spared in comparison to abdomen and internal organs
- results from maternal or placental conditions that occur later in pregnancy and impeded placental bloodflow
- appears long, thin, emaciated with loss of subq fat tissue and muscle
- may have loose skin folds and dry skin and thin meconium stained cord
- vigorous cry and appear alert and wide-eyed
302
SGA at risk for
- labor intoelrance
- meconium aspiration
- hypoglycemia
- hypocalcemia
303
nursing managemet for SGA
- review risks and hx
- perform gestational age assessment
- assess for respiratory distress
- maintain NTE
- monitor for hypoglycemia
- early and frequent feeds
- monitor labs
- daily weights
- monitor VS
304
premature infant facts
- 1/10 infants born premature
- any infant born before 37wks is considered premature
- premature infant is NOT SGA
- preamature infants are categorized by gestation age and weight
305
hx and assessment to ID premie
- mother: LMP, OB hx, med hx
- newborn: ballard or dubowitz
306
nursing management of premie
- maintain NTE
- provide respiratory support
- monitor vitals
- strict I&Os
- monitor labs and fluids and electrolytes as ordered
- admin IVF as rodered
- administer feedings
- admin meds as ordered
- encourage kangarro care and support parents
307
respiratory distress syndrome
- results from small underdeveloped alveoli and insufficient levels of pulmonary surfactant
- causes an alteration in alveoli surface ension that eventually results in atelectasis
- S/S: tachypnea, grunting, retractions, nasal flaring, lethargic, hypotonic, decreased breath sounds turning into crackles, increasing o2 demand, tachycardia
- medical management: surfactant, ABGs, repsiratory support, blood cultures, antibiotics
308
surfactant
- natural or syntehtic
- administered via ET
- can be administered iva thin catheter or laryngeal mask
- reduces surface tesnion of alveoli preventing collapse
- enhances lung complicance to allow easier breathing
- improves oxygenation
- adminsitered prophylactically within 15 minutes of birth or rescue therapy within 6hrs of birth
309
nursing management for RDS
- provide respiratory support as ordred
- monitor VS
- monitor labs and ABGs
- maintain neutral thermal environment
- monitor I&Os
- cluster care
- assist with admin of surfactant
- support parents
310
postterm infant
- inability of placenta to provide adequate o2 and nutrients to fetus after 42 weeks
- infant shows dry, cracked, wrinkled skin, possibly meconium stained
- has long thin extremities; long nails, creases cover entire soles of feet
- wide eyed and alert
- abundant hair on scalp
- thin umbilical cord
- limited vernix and lanugo
311
nursing management of postterm infants
- monitor for complications
- monitor for blood glucose
- initate early and frequent feedings
- monitor vitals
- maintain NTE
- monitor labs
- monitor I&Os
- support parents
312
transient tachypnea of newborn
- inadequate or delayed clearance of lung fluid leading to pulmonary edema
- experience a mild degree of respiratory distress requiring minimal intervention
- liquid removed slowly or incompletetly
- resolved by 72hrs of age
- CXR, mild symmetric lung hyperaeration, prominent erpihilar institial marks and streaks
313
s/s of transietn tachypnea of newborn
- maternal sedation or bith by cesaerean
- tachypnea
- expiratory grunting
- retractions
- labored breathing
- nasal flaring
- mild cyanosis
- tachypnea
- barrel shaped chest
- slightly lower breath sounds
314
nuring management of TTn
- supportive
- provide adequate oxygenation via oxygood or nasal cannula
- admin IVF
- admin gavage feedings
- maintain NTE
- monitor vitals
- support parents
315
meconium aspiration syndrome
- occurs when newborn inhales particulate meconium mixed with amniotic fluid into lungs while inutero or taking first breath after birth
- can result in obstruction of upper airways, if progresses to lower airways, air trapping and hyperinfalation of alveoli distant to obstruction increases risk of air leaks into surroundin tissue
- can also cause chemical pneumonitis and inhibit surfactant action
316
s/s MAS
- meconium stained amniotic fluid
- greenish or yellowish discoloration of skin, nailbeds, and umbilical cord
- respiratory distress at birth (requiring resuscitation) or within a few hours
- low APGAR
- barrel-shaped and overdistended chest
- extended expiratory phase of breathing
- diminished airmovement, presence of rales and rhonchi
- CXR: atelectasis and hyperinflated lungs
- ABGs: low PaO2 despite 100% O2 and possible respiratory and metabolic acidosis
317
nursing management of MAS
- maintain NTE
- cluster care
- administer o2 as ordered
- monitor vitals
- monitor labs and ABGs
- admin vasopressors and antibiotics as ordered
- provide support to parents
318
infection
- clinical syndrome of bactermia within first month of life
- neonatal sepsis: bacterial, fungal, or viral microorganisms of toxins in blood and other tisses
- congenital, early onset, or late onset
319
nursing assessment for infant infection
- early symptoms vague
- poor feeding
- breathing difficulty
- apnea
- bradycardia
- GI problems
- increased o2 requirement
- lethargy
- hypotension
- temp instability
- unusual skin rash or color changes
- persistent crying/irritability
- labs: elevated CRP, abnormal CBC, CXR, blood cx, urine cx, CSF
- initial treatment: ampicillin, gentamycin
320
nursing management of infant infection
- asses maternal and neonatal risk factors
- monitor vitals, I&Os, labs,
- daily weights
- monitor for s/s of infection
- assess with diagnostics
- admin antibiotics, IVF, and feedings
- support parents
321
hx of newborns exposed to illicit substances
- maternal hx of known drug abuse
- no prenatal care
- obtain meconium and urine
- physical assessment
322
abusing mothers
- most common: tobacco, alcohol, marijuana
- fetal alcohol syndrome: physical, mental disroder apperaing at birth and remaining problematic
- fetal alcohol sepctrum disorders
- alcohol related birth defects
- neonatal abstinence syndrome: drug dependency acquired in utero manifested by nero and physical behaviors
323
fetal alcohol spectrum signs
- small eyes
- thin upper lip
- short palpebral fissues
- flat midface
- short noise
- low nasal bridge
- ear abnormalities
- micrognathia
324
nursing management of FAS
- quiet, dim environment
- consistent caregivers
- provide adequate nutrition
- support parents and provide positive reinforcement
325
s/s of infant substance disorders
- tremors and irritability
- generalized seizures
- hyperactive reflexes
- restlessness
- exagerrated moro reflex
- hypertonic muscle tone
- shrill high pitched excessive cry
- disturbed sleep patterns
- fever
- yawning
- mottling of skin
- sweating
- frequent sneezing
- nasal flaring
- tachypnea >60breathpm
- apnea
- poor feedings
- franctic sucking or rooting
- loose or watery stools
- regurgitation or projectile vomiting
326
nursing management of NAS/NOWS
- provide quiet, dimly lit area
- perform neonatal abstinence scoring
- provide small ,frequent feedings
- admin meds as ordered
- swadlle with hands near mouth and provide pacifier
- gently, rocking infant if crying
- protect from excoriation using clothing with built in mittens
- apply protective barrier to groin area every diaper change
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