Repro EXam 2 Flashcards
Care for non-lactation mothers
many women who do not breastfeed experience some degree of engorgement, accompanied by milk leakage and discomfort. Some women will report relief from non-pharmacologic means of suppression such as wearing a supportive bra continuously for the first week except when showering, avoiding breast stimulation and applying cold packs or cabbage leaves.
Signs of engorgement peak by day 4 and resolve by the 10th postpartum day.
Acetaminophen and ibuprofen can be used until the discomfort subsides.
Health Promotion Education for non lactating mothers
avoid any stimulation of breasts and nipples by baby, self, breast pumps or sexual partner until the sensation of fullness has passed. Stimulation will increase milk production and delay the suppression process.
heat is avoided for the same reason and the mother is encouraged to let shower water flow over her back rather than her breasts.
wearing of a 24 hour supportive bra, use of analgesics as prescribed and the use of cabbage leaved or cold compresses should be insightful during this period of time.
Postpartum fundal check positioning
have mother void before examining the abdomen.
have mother lie flat-supine position prevents falsely high assessment of fundal height. Flexing of the legs relaxes the abdominal muscles.
1) gently place one hand on the lower segment of the uterus. Palpate the abdomen until you locate the top of the fundus
2. ) determine whether the fundus is firm. If it is, it will feel like a hard round object; if it is not, massage the abdomen lightly until the fundus is firm.
3. )measure the top of the fundus in centimeters above, below or at the fundus.
4. ) determine the position of the fundus in relationt to the midline of the body. If it is not midline, locate it and then evaluate for bladder distention.
5. ) if the bladder is distended, use nursing measures to help the woman void; if she is not able to void after a specified period of time-catheterization may be necessary.
6. ) measure urine output for the next few hours until normal elimination is established.
7. ) assess the lochia
8. ) during the first few hours postpartum, if the fundus becomes boggy frequently or is located high above the umbilicus and the woman’s bladder is empty, the uterine cavity may be filled with clots of blood.
uterine involution during the postpartum period
Following separation of the placenta, the decidua of the uterus is irregular, jagged and varied in thickness. The spongy layer of the decidua is cast off as lochia and the basal layer of the decidua remains in the uterus to become differentiated into two layers within the first 48-72 hours after birth. The outermost layer becomes necrotic and is sloughed off in the lochia. The layer closest to the myometrium contains the fundi of the uterine endometrial glands, and these glands lay the foundation for the new endometrium. Except at the placental site, this process is completed approximately 3 weeks. The placental site can take up to 6 weeks to completely heal. Bleeding from the larger uterine vessels of the placental site is controlled by compression of the retracted uterine muscle fibers. The clotted blood is gradually absorbed by the body. Some of the vessels are eventually obliterated and replaced by new vessels with smaller lumens. The placental site heals by a process of exfoliation and growth of endometrial tissue. The placental site is undermined by the growth of endometrial tissue, both from the margins of the site and from the fundi of the endometrial glands left in the basal layer of the site. Infarcted superficial tissue then becomes necrotic and is sloughed off. EXFOLIATION is one of the most important aspects of involution.
Occasionally, oxytocic agents such as IV pitocin, or methylergonovine (methergine) need to be administered postpartum to maintain uterine contraction and prevent or treat hemorrhage.
After delivery, fundus should be midline-about the umbilicus and should more a finger breath a day.
Return for ovulation and menses for lactating mothers
usually prolonged and is associated with the length of time the woman breastfeeds and whether formula supplements are being used. If a mother breastfeeds for less than 1 month, the return of menstruation and ovulation is similar to the non breastfeeding mother.
In women who exclusively breastfeed, menstruation is usually delayed for at least 3 months. Average 6 mos return ca be delayed up to 3 years for mom who exclusively breastfeed. Sucking by an infant typically results in alterations in gonadotropin-releasing hormone, production, which is though to be the cause of amenorrhea. Although exclusive breastfeeding helps to reduce the risk of pregnancy for the first 6 months after delivery, it should be relied upon only temporarily and if it meets the observed criteria for lactational amenorrhes method.
Return for ovulation and menses for non-lactating mothers
Menstruation usually resumes as soon as 7 weeks in 70% of women and by 12 weeks in ALL non-lactating mothers. Return of ovulation is directly associated with a rise in the serum progesterone level. In non-lactating women, the average time to first ovulation can occur within 70-75 days with a meant time of 6 months.
Risk factors for uterine atony
- overdistention of the uterus due to multiple gestation, hydraminos or a large infant (macrosomia)
- prolonged or precipitous laor
- oxytocin augmentation or induction of labor
- grandmultiarity-because stretched uterine musculature contracts less vigorously
- use of anesthesia (especially halothane) or other drugs such as magnesium sulfate, calcium channel blockers (nifedipine) or tocolytics like terbutaline(Brethine)
- prolonged third stage of labor-more than 30 minutes
- preeclampsia
- asian or hispanic heritage
- operative birth
- retained placental fragments
- placenta previa or accreta
- Obesity
priority nursing care for postpartum perineal edema
REEDA Redness, Edema, Ecchymosis, Discharge and Approximation. Edema may still occur 24 hours after, but skin edges should be approximated so that gentle pressure does not separate them. Gentle palpation should elicit minimal tenderness and there should be no hardened areas suggesting infection. Foul odors associated with drainage indicate infection. Hematomas sometimes occur, although these are considered abnormal. Assess whether hemorrhoids are present, size, number and pain/tenderness. clean peri pads, ice packs.
Postpartum Lochia Assessment
Character, Amount, Odor and presence of clots.
1-3 days-should be rubra, a few small clots are normal and occur as a result of blood pooling in the vagina.
2-3 day PP-the lochia becomes serosa.
should never exceed a moderate amount (6 pads a day)
moderate lochia will saturate 4-8 pads in 24hrs but an average of 6.
ask when last pad change was
- passage of numerous clots is ABNORMAL
changes in lochia that cause concern
Presence of clots- inadequate uterine contractions that allow bleeding from vessels at the placental site.
Nursing action-assess location and firmness of fundus, assess voiding pattern, record and report findings
Persistent lochia with rubra-inadequate uterine contractions; retained placental fragments; infection; undetected cervical laceration.
nursing action-assess location and firmness of fundus, assess activity pattern, assess for signs of infection, record and report findings.
- if the woman is at an increased risk for bleeding or is actually experiencing heavy flow of lochia rubra, her blood pressure, pulse and uterus NEED to be assessed frequently and the physician may prescribe Oxytocin, methylergonovine or misoprostol.
gave birth with c section will experience less lochia than.
Expected vital signs in the postpartum period
B/P-should remain consistent with baseline during pregnancy. Decrease in blood pressure r/t hemorrhage-late sign of a hemorrhage if suspected do NOT rely on Blood pressure.
Pulse 50-90 bpm (may be bradycardia if 50-70bpm)
Respirations 16-24
Temperature 36.2-38C (97.1-100.4) dehydrated and milk is coming in
Abnormal V/S
High BP-preeclampsia, essential HTN, Renal Disease and anxiety.
Drop in BP (may be normal r/t blood loss during childbirth; uterine hemorrhage)
Tachycardia (difficult labor, birth hemorrhage) Marked tachypnea (respiratory distress)
Diminished respirations (long acting epidural narcotis)
After 24 hours temperature of 38*C or above suggests infection
Expected Lab Values in the postpartum period
Blood values should return to pre-pregnant state by the end of the postpartum period.
WBC-up to 25,000-30,000.
H+H difficult to interpret in the first 2 days following birth because of the changing blood volume.
average blood loss is 200-500mL.
Mobilization of interstitial fluid leads to an increase in plasma volume
platelet levels typically fall in relation to placental separation then begin to increase by the third/fourth postpartum day.
Psychological Assessment in the postpartum period for maternal infant adaptation
First 24 hours-passive; preoccupied with own needs; may talk about her labor and birth experience; may be talkative/elated or very quiet
Usually by 12 hours, beginning to assume responsibility; some women are eager to learn; others feel easily overwhelmed
Attachment- en face position; holds baby close; cuddles and soothes. Calls by name; identifies characteristics of family member in infant; may be awkward in providing care
Comfort and success with parent role
Parents interacts with infant and provides activities soothing, caretaking
Soothing, cuddling, and talking to infant. Appropriate feeding techniques
Eye to eye contact
Touching
Postpartum RhoGam Administration
Rh- mother who has no titer and who has given birth to Rh+ fetus is given an IM injection of 300mcg of Rh immune globulin within 72 hours so that she does not have time to produce antibodies to fetal cells that entered her bloodstream when the placenta separated.
provides temporary passive immunity for the mother which prevents the development of permanent active immunity.
Post Abortion RhoGam Administration
After childbirth or an abortion, the results of a blood test do not clearly show whether the mother is already sensitized to the Rh antigen. In such cases, Rh immune globulin should be given because it will cause no harm.
Care for Episiotomy/Laceration
normal: No redness, edema, ecchymosis or discharge; edges well approximated
nursing interventions: Assess size, apply ice glove or ice pack, analgesic and anesthetic sprays; report to physician or CNM
Encourage sitz baths, review perineal care, appropriate wiping techniques
Care for hemorrhoids
Encourage sitz baths; side lying position, astringent wipes, anesthetic ointments, manual replacement of hemorrhoids, stool softeners, increased fluid intake.
Care for After birth pains
Woman lie prone with a small pillow under the lower abdomen, explaining that the discomfort may be intensified for about 5 minutes but then will diminish greatly. The prone position applies pressure to the uterus and therefore stimulates contractions. When the uterus maintains a constant contraction, the after pains cease. Additional nursing interventions should include positioning, ambulation or administration of analgesic agents.
- the mothers description of the type and severity of her pain is usually the most reliable method of determining which analgesic agent will best promote the comfort she desires. Many women who breastfeed have concerns about the effects of medications on the infant. It is helpful to point out to concerned mothers that mild analgesics such as acetaminophen and ibuprofen pose little to no risk to their newborns.
Latching On
important to have the mother and baby positioned properly in order to achieve optimal attachment. The infants need to attach his/her lips onto the breast, far back onto the areola, not on the actual nipple. If the infants attaches just to the nipple, the mother will have sore nipples and pain may inhibit the let-down reflex. To obtain a deep latch, the mother needs to be taught how to elicit the infants rooting reflex, stimulating the infant to open his/her mouth as widely as possible.
Once the infant does this, the mother should quickly but gently draw her baby in toward her.
the four most common breastfeeding positions
- ) modified cradled position
- ) cradle position
- ) football (or clutch) hold position
- ) side-lying position
Uterine stimulants used to prevent and manage uterine atony
Oxytocin-no contraindications for use in postpartum hemorrhage. 10 units.
methylergonovine-women with labile or high blood pressure or known sensitivity to drug. use with caution during lactation
prostaglandin-women with active CV, renal, liver orr asthma.
Dinoprostone-avoid if woman is hypotensive or has asthma or acute inflammatory disease.
Misoprostol- Do not use if Hx of allergies to prostaglandins
Breast Engorgement`
distinction between breast fullness and engorgement. All lactating women experience a transitional fullness at first, initially because of venous congestion and later because of accumulating milk. Fullness generally lasts only 24 hours, the breasts remain soft enough for the newborn to suckle and there is no pain.
Severely engorged breasts are hard, painful, warm and may appear taut and shiny. Engorgement may be accompanied by a fever up to 101*.
May occur as a result from infrequent feedings, delayed initiation of feedings, improper latch, use of supplements, time-limited feedings and too quickly removing the baby from the first side to ensure feeding from both breasts at each feeding.
Tx: warm compresses or showers shortly before nursing, cold compress applied to breasts AFTER feedings, cabbage compresses, breast massaging and milk expression, ultrasound, anti-inflammatory medications, acupuncture and pumping.
can lead to involution and decreased milk synthesis.
160 minutes of nursing every 24 hours.
Nipple soreness
nipples may exhibit erythema, edema, abraisions, fissures, cracks, bruises, blisters and bleeding. Poor latch/suck are the primary causes of mechanical trauma.
most common complaint and frequent stopping of breastfeeding.
the babys position at the breast is critical in nipple soreness. nipples should be same shape at the end of feeding, but may be elongated. Nipples that are angled, creased or distorted at the end of feedings indicate anatomic variations or latch problems.
Tx: washing the breasts with warm water and avoiding drying soaps. Keep the nipples clean and dry. Warm water compresses can be applied followed by air drying. Gently massaging or pumping the breast before feedings stimulates let down and may be helpful in decreasing initial latch on pain related to vigorous nursing. HPA (lanolin) and or breast milk accompanied by air drying at the end of feeding is safe.
breastfeeding efficiency
infant should have rhythmic suckling pattern with only brief pauses lasting seconds between spurts of active feeding. Feeding sessions usually last 10-20 minutes on the first breast. Visually observe for swallowing and listen for the infant swallowing. infant will pull away from breast when satiated or will fall asleep. The mothers breasts should soften with feedings. Output will be adequate for infants who accurately/actively breastfeed.
expected vital signs of newborn
Pulse: 110-160 beats/min
deep sleep: 70 OK-stimulate–touch wake up
crying: 180 possible
Respirations: 30-60
abnormal breathing pattern
diaphragmatic
BP: 70-50/45-30 at birth
90/50 at day 10
Temp: 36.5-37.5
heavier newborns tend to have higher temperatures
expected vital signs of newborn
Pulse: 110-160 beats/min
deep sleep: 70 OK
crying: 180 possible
Respirations: 30-60
abnormal breathing pattern
diaphragmatic
BP: 70-50/45-30 at birth
90/50 at day 10
Temp: 36.5-37.5
heavier newborns tend to have higher temperatures
Respiratory Distress in the Infant
is the result of a primary absence, deficiency or alteration in the production of pulmonary surfactant.
Factors of RDS
Prematurity-all preterm newborns-no matter their size and especially infants of diabetic mothers are at risk for RDS. RDS risk increases with the degree of prematurity.
maternal and fetal factors resulting in preterm labor and birth, complications of pregnancy, indications for cesarean birth and familial tendency are all associated with RDS.
Surfactant deficiency disease
failure to synthesize adequate surfactant which is required to maintain alveolar stability. RDS is due to alterations in surfactant quantity, composition, function or production.
upon expiration, the instability increases atelectasis which causes hypoxia and acidosis because of the lack of gas exchange. These conditions further inhibit surfactant production and cause pulmonary vasoconstriction. the newborn must expend increasing amounts of energy to reopen the collapsed alveoli with every breath so that each breath becomes more difficult than the last. Preventing adequate gas exchange. Breathing becomes progressively harder as lung compliance decreases which makes it more difficult for the newborn lungs to inflate and breathe.
Classic RDS picture
increasing cyanosis tachypnea >60 RR grunting respirations nasal flaring significant retractions apnea
Tx: prevent preterm labor through aggressive treatment of preterm labor and administration of steroids to enhance fetal lung developments. Postnatal surfactant replacement therapy-endotracheal tube or CPAP. Blood gas monitoring, pulse ox monitoring, correction of acid base imbalance, environmental temperature regulation, adequate nutrition and protection from infection.
Cord Care
wash hands before and after handling the cord
keep cord clean and dry
keep the cord exposed to air or covered only loosely by clean clothes
keep the diaper folded below the cord to prevent contamination
clean the cord IF it becomes boiled with urine or stool
dry the cord thoroughly after each cleansing.
inspect the cord during each change and bath
*may smell earthy as it necroses.
contact physician IF drainage occurs, smells foul or notice any redness or swelling or other discoloration.
monitor for s/s of infxn-fever, inability to maintain temperature, poor feeding, lethargy. should fall off within 15 days-fails to heal within 2-3 days of separation.
Circumcision Care
educate parents on what happens during circumcision. clean with warm water with EACH diaper change. apply petroleum ointment for the next few diaper changes to help prevent further bleeding and to protect the healing tissue afterwards. If bleeding does occur, apply light pressure with sterile gauze pad to stop the bleeding within a short period of time. If this is not effective, contact the physician immediately or take the newborn to the health care provider. the glans normally has granulation tissue (a yellowish film) on it during healing. continued application of petroleum ointment (can help protect the granulation tissue that forms as the glans heals. Report to the care provider any signs and symptoms of infection, such as increasing, pus drainage and cessation of urination. When diapering, ensure that the diaper is neither too loose, which can cause rubbing with movement, nor too tight, which can cause pain. If the infant’s care provider recommends oral analgesics, follow instructions for proper measuring and administration.
Nutrition and normal weight gain and loss of the newborn
Infants weight should remain within 10% of his/her birth weight and the infant should be evaluated for breastfeeding problems if the weight loss exceed 7%. Most newborns lose and average of 5.5% of birth weight during the first week of life.
Nursing intervention: techniques to increase milk production and promote better milk transfer. Provide assistance with breastfeeding techniques as needed, encourage breastfeeding q 2 hours for the next 24 hours and recheck the newborns weight the next day.
infants who lose >7% may need supplemental nutrition. Expressed breast milk is the ideal intervention. If the mother is not making enough milk, then the nurse needs to assist the mother with preparation of formula until her supply is adequate and the baby is rehydrated
formula fed babies are going to gain weight back more quickly.
consistently gain about an ounce a day..half a pound a week
caloric intake 100-115kcal/kg/day
Ballard Scale Characteristic
estimation of gestational age by maturity rating.
resting posture-although a neuromuscular component, should be assessed as the baby lies undisturbed on a flat surface.
Skin (preterm)- appears thin and transparent with veins prominent over the abdomen in early gestation.
(term) skin appears opaque because of increased subcutaneous tissue. Disappearance of venix caseosa promotes skin dequamation and this is commonly seen in postmature infants (>40 weeks)
Lanugo decreases as gestational age increases. Lanugo is greatest 28-30 weeks. most abundant over the back, although it will be noted over the face, legs and arms. Lanugo disappears first from the face and then from trunk and extremities.
sole (plantar creases)-preterm infants will have faint red marks or anterior transverse creases. Full term babies will have sole creases covering the foot. (all over)
inspect areola and gently palpate breast bud.
Term-tissue will measure between 0.5-1 cm.
post term babies-might not have breast tissue r/t subcutaneous fat used up in utero
ear form and cartilage: Preterm-ear is relatively shapeless and flat; little cartilage so the ear folds over on itself and remains folded.
Term- cartilage and slight incurving of the upper pinna are present and pinna springs back when slowly folded. Pinna should be firm.
male genitals-Preterm-small scrotum, few rugae and testes are palpable in inguinal canal.
Term-testes are descended and rugae have developed over anterior portion of the scrotum.
female genitals-preterm- clitoris prominent and small labia.
term-labia major covers clitoris and labia minora.
heel-ear preterm-remains straight and the foot goes to the ear or beyond
term-increasing resistance to the maneuver.
scarf sign (preterm)- elbow will cross the midline of the chest, whereas full term infants elbow will not cross midline.
square window-preterm infants will have a greater * of angle whereas term will have lessened * of angle.
post term-totally flat.
thermoregulation and heat loss
maintain temp with minimum metabolic changes.
decrease respiratory distress.
Heat loss
Convection-loss of heat from warm body to cool air currents
radiation-body heat transferred to cooler surfaces, objects not in direct contact
evaporation-loss of heat when water converted to vapor
conduction-loss of heat to cooler surface by direct skin contact.
Jaundice and bilirubin levels in first 3 days
bilirubin levels >5mg/dL. Fetal unconjugated bilirubin is normally cleared by the placenta in utero, so total biilirubin at birth is usually less than 3mg/dL.
Newborn Findings (head + chest) normal values
head: 32-37cm (33-35cm on average)
approximately 2cm>chest
chest: 30-35cm (32cm on average)
length: 48-52cm
weight: 2500g-4000g→ loose about 5.5% of birth weight in the first week of life
Newborn Findings (head + chest) abnormal
Microencephaly, CID, rubella, toxoplasmosis, hydrocephalus, anencephaly (neural tube defect), head 3cm or more larger than chest circumference (preterm or hydrocephalus)
Barrel chest, runnel chest, continued protrusion of xiphoid cartilage
Less than 45cm: congenital dwarf
Less than 2748g (6lbs): small for gestational age (preterm), greater than 4050g (9lbs): large for gestational age or infants of diabetic mothers, a loss greater than 15% (low fluid intake, loss of meconium and urine, feeding difficulties, diabetes insipidus
Newborn Findings (skin) Normal
Consistent with ethnic background
Mottled when undressed
Minor bruising over buttocks if breach or eyes/forehead in facial presentations
smooth, soft, flexible (may have dry peeling hands and feet)
elastic: returns to normal shape after pinching
clear pigmentation, milia across bridge of nose, forehead or chin (will disapear)
cafe au lait spots
erythema toxicum
rashes
petechiae of head or neck
Newborn Findings (skin) abnormal
Acrocyanois (bluish discoloration of hands and feet), mottling, harelquin sign, mongolian spots, erythema toxicum, milia, lanugo, vernix caseosa
Newborn Findings (head and neck) Normal
general appearance, size, movements, round, symmetric and moves easily from left to right and up and down; soft and pliable.
circumference: 32-37cm
2 cm greater than chest circumference
head one fourth of body size
fontanelles: palpation of juncture of cranial bones
anterior fontanelle; 3-4 cm long by 2-3 cm wide, diamond shape
posterior fontanelle; 1-2 cm at birth, triangle shaped
slight pulsation.
moderate bulging noted with crying, stooling-pulsations with heartbeat.
NECK
short, straight, creased with skin folds.
posterior neck lacks loose extra folds of skin
clavicles: straight and intact
moro reflex elicitable
symmetric shoulders
Newborn Findings (head and neck) abnormal
asymmetric, flattened occiput on either side of the head. (plagiocephaly)
head at an angle (torticollis)
unable to move head side to side (neurological trauma)
extreme differences in size may be due to microencephaly (cornelia de lange syndrome, cytomegalic inclusion disease, rubella, toxoplasmosis, chromosome abnormalities, hydrocephalus (meningomyelocele, achondroplasia) anencephaly (neural tube defect)
head is 3cm or more larger than chest circumference (preterm, hydrocephalus)
cephalohematoma (trauma during birth, may persist up to 3 months)
caput succedaneum (long labor and birth; disappears in 1 week)
Overlapping of anterior fontanelle (malnourished or preterm newborn)
premature closure of sutures (craniosynostosis)
late closure (hydrocephalus)
moderate to severe pulsation (vascular problems)
bulging (increased intracranial pressure, meningitis)
sunken (dehydrated)
abnormally short neck (Turner Syndrome)
arching or inability to flex neck (meningitis/congenital anomaly)
webbing of neck (turner syndrome, trisomy 21 and 19)
knot or lump on clavicle (fracture during difficult birth)
unilateral moro reflex response on unaffected side. (fracture of clavicle, brachial palsy, Erb-Duchenne paralysis)
hypoplasia
Newborn findings (abdomen) normal
cylindric with some protrusion, appears large in relation to pelvis; some laxness of abdominal muscles
no cyanosis, few vessels seen
diastasis recti-common in infants of African descent
Umbilicus: no protrusion of umbilicus (protrusion of umbilicus is common in infants of African descent)
bluish white color
cutis naval (umbilical cord projects) granulation tissue present in navel
two arteries and one vein apparent
begins drying 1-2 hours after birth
no bleeding
Auscultation and Percussion: soft bowel sounds heard shortly after birth every 10-30 seconds
femoral pulses: palpable, equal, bilateral
inguinal area: no bulges along inguinal area
no inguinal lymph nodes felt
Bladder: Percusses 1-4 cm above symphysis.
emptied about 3 hours after birth; if not at the time of birth
urine-inoffensive mild odor
Newborn findings (abdomen) abnormals
distention, shiny abdoment with engorged vessels (GI abnormalities, infection, congenital megacolon)
scaphoid abdominal appearance (diaphragmatic hernia)
increased or decreased peristalsis (duodenal stenosis, small bowel obstruction)
localized flank bulging (enlarged kidneys, ascites, absent abdominal muscles)
umbilical hernia patent urachus (congenital malformation)
omphalocele (covered defect)
gastroschisis (uncovered defect
redness or exudate around cord yellow discoloration (hemolytic disease, meconium staining)
single umbilical artery (congenital anomalies)
discharge or oozing of blood from the cord
bowel sounds in chest (diaphragmatic hernia)
absence of bowel sounds
hyperperistalsis (intestinal obstruction_
absent or diminished femoral pulses
(coarctation of the aorta)
inguinal hernia
failure to void within 24-48 hours after birth
exposure of bladder mucosa (exstrophy of bladder)
foul odor (infection)
