Maternal Newborn

Newborn Assessment: Perform Focused Assessment of Newborn

A more extensive physical exam is performed on the neonate within 24 hr of birth. Vital signs are obtained. A head-to-toe assessment is performed. Neurological and behavioral assessments are completed by eliciting reflexes and observing responses. Laboratory data is monitored.

Assessment and Management of Newborn Complications: Phototherapy

Assessment ●● Subjective Data ◯◯ Painless, bright red vaginal bleeding during the second or third trimester ●● Objective Data ◯◯ Uterus soft, relaxed and nontender with normal tone ◯◯ Fundal height greater than usually expected for gestational age ◯◯ Fetus in a breech, oblique, or transverse position ◯◯ Reassuring FHR ◯◯ Vital signs within normal limits ◯◯ Decreasing urinary output may be a better indicator of blood loss ●● Laboratory Tests ◯◯ Hgb and Hct for blood loss assessment ◯◯ CBC ◯◯ Blood type and Rh ◯◯ Coagulation profile ◯◯ Kleihauer-Betke test (used to detect fetal blood in maternal circulation) ●● Diagnostic Procedures ◯◯ Transabdominal or transvaginal ultrasound for placement of the placenta ◯◯ Fetal monitoring for fetal well-being assessment

Contraception: Oral Contraceptive Therapy

Combined oral contraceptives Definition ›› Hormonal contraception containing estrogen and progestin, which acts by suppressing ovulation, thickening the cervical mucus to block semen, and altering the uterine decidua to prevent implantation. Client Instructions ››Medication that requires a prescription and follow-up appointments with the provider. ››Medication requires consistent and proper use to be effective. ›› A client is instructed in observing for side effects and danger signs of medication. Signs include chest pain, shortness of breath, leg pain from a possible clot, headache, or eye problems from a stroke, or hypertension. ›› In the event of a client missing a dose, the nurse should instruct the client that if one pill is missed, take one as soon as possible; if two or three pills are missed, instruct the client to follow the manufacturer's instructions. Instruct the client on the use of alternative forms of contraception or abstinence to prevent pregnancy until regular dosing is resumed. Advantages ›› Highly effective if taken correctly and consistently. ››Medication can alleviate dysmenorrhea by decreasing menstrual flow and menstrual cramps. ›› Reduces acne. Combined oral contraceptives Disadvantages ››Oral contraceptives do not protect against STIs. ›› Birth control pills can increase the risk of thromboses, breast tenderness, scant or missed menstruation, stroke, nausea, headaches, and hormone-dependent cancers. ›› Exacerbates conditions affected by fluid retention such as migraine, epilepsy, asthma, kidney, or heart disease. Risks/possible complications/ contraindications ››Women with a history of blood clots, stroke, cardiac problems, breast or estrogen‑related cancers, pregnancy, or smoking (if over 35 years of age), are advised not to take oral contraceptive medications. ››Oral contraceptive effectiveness decreases when taking medications that affect liver enzymes, such as anticonvulsants and some antibiotics. Minipill Definition ›› Oral progestins that provide the same action as combined oral contraceptives. Client Instructions ›› A client should take the pill at the same time daily to ensure effectiveness secondary to a low dose of progestin. ›› A client cannot miss a pill. ›› A client may need another form of birth control during the first month of use to prevent pregnancy. Advantages ›› The minipill has fewer side effects when compared with a combined oral contraceptive. ›› Considered safe to take while breastfeeding. Disadvantages ›› Less effective in suppressing ovulation than combined oral contraceptives. ›› Pill increases occurrence of ovarian cysts. ›› Pill does not protect against STIs. ›› Users frequently report breakthrough, irregular, vaginal bleeding, and decreased libido. ›› Increases appetite Risks/possible complications/ contraindications ››Oral contraceptive effectiveness decreases when taking medications that affect liver enzymes, such as anticonvulsants and some antibiotics. EMERGENCY ORAL CONTRACEPTIVE Definition ››Morning after pill that prevents fertilization from taking place. Client Instructions ›› Pill is taken within 72 hr after unprotected coitus. ›› A provider will recommend an over-the-counter antiemetic to be taken 1 hr prior to each dose to counteract the side effects of nausea that can occur with high doses of estrogen and progestin. ›› Advise a woman to be evaluated for pregnancy if menstruation does not begin within 21 days. ›› Provide client with counseling about contraception and modification of sexual behaviors that are risky. ›› Is considered a form of "emergency birth control." Advantages ›› Pill is not taken on a regular basis. ›› Can be obtained without a prescription by women 15 years and older. Disadvantages ›› Nausea, heavier than normal menstrual bleeding, lower abdominal pain, fatigue, and headache. ›› Does not provide long-term contraception. ›› Does not terminate an established pregnancy. ›› Does not protect against STIs. Risks/possible complications/ contraindications ›› Contraindicated if a client is pregnant or has undiagnosed abnormal vaginal bleeding. ›› If menstruation does not start within 1 week of expected date, a client may be pregnant.

Contraception: Managing Pain of Dysmenorrhea

Hormonal Methods Combined oral contraceptives Definition ›› Hormonal contraception containing estrogen and progestin, which acts by suppressing ovulation, thickening the cervical mucus to block semen, and altering the uterine decidua to prevent implantation. Client Instructions ››Medication that requires a prescription and follow-up appointments with the provider. ››Medication requires consistent and proper use to be effective. ›› A client is instructed in observing for side effects and danger signs of medication. Signs include chest pain, shortness of breath, leg pain from a possible clot, headache, or eye problems from a stroke, or hypertension. ›› In the event of a client missing a dose, the nurse should instruct the client that if one pill is missed, take one as soon as possible; if two or three pills are missed, instruct the client to follow the manufacturer's instructions. Instruct the client on the use of alternative forms of contraception or abstinence to prevent pregnancy until regular dosing is resumed. Advantages ›› Highly effective if taken correctly and consistently. ››Medication can alleviate dysmenorrhea by decreasing menstrual flow and menstrual cramps. ›› Reduces acne.

Contraception: Contraindications for Thrombophlebitis

Oral Contraception: ››Women with a history of blood clots, stroke, cardiac problems, breast or estrogen‑related cancers, pregnancy, or smoking (if over 35 years of age), are advised not to take oral contraceptive medications. Contraceptive vaginal ring (NuvaRing) Blood clots, hypertension, stroke, heart attack.

Complications Related to the Labor Process: Prioritize Care to a Client in Labor

Prolapsed Umbilical Cord ●● Nursing Care ◯◯ Call for assistance immediately. ◯◯ Notify the provider. ◯◯ Use a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. ◯◯ Reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the client's right or left hip to relieve pressure on the cord. ◯◯ Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow. ◯◯ Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia. ◯◯ Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation. ◯◯ Initiate IV access, and administer IV fluid bolus. ◯◯ Prepare for a cesarean birth if other measures fail. ◯◯ Inform and educate the client and her partner about the interventions. Meconium-stained Amniotic Fluid ●● Nursing Care ◯◯ Document color and consistency of stained amniotic fluid. ◯◯ Notify neonatal resuscitation team to be present at birth. ◯◯ Gather equipment needed for neonatal resuscitation. ◯◯ Follow designated suction protocol. ■■ Assess neonate's respiratory efforts, muscle tone, and heart rate. ■■ Suction mouth and nose using bulb syringe if respiratory efforts strong, muscle tone good, and heart rate greater than 100/min. ■■ Suction below the vocal cords using an endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and heart rate less than 100/min. Fetal Distress Patient-Centered Care ●● Nursing Care ◯◯ Monitor vital signs and FHR. ◯◯ Position the client in a left side-lying reclining position with legs elevated. ◯◯ Administer 8 to 10 L/min of oxygen via a face mask. ◯◯ Discontinue oxytocin (Pitocin) if being administered. ◯◯ Increase IV fluid rate to treat hypotension if indicated. ◯◯ Prepare the client for an emergency cesarean birth. Dystocia (Dysfunctional Labor) Patient-Centered Care ●● Nursing Care ◯◯ Dysfunctional Labor ■■ Assist with application of fetal scalp electrode and/or intrauterine pressure catheter. ■■ Assist with amniotomy (artificial rupture of membranes). ■■ Encourage client to engage in regular voiding to empty her bladder. ■■ Encourage position changes to aid in fetal descent or to open up the pelvic outlet. ☐☐ Assist client to a position on her hands and knees to help the fetus to rotate from a posterior to anterior position. ■■ Encourage ambulation to enhance the progression of labor. ■■ Encourage hydrotherapy and other relaxation techniques to aid in the progression of labor. ■■ Apply counterpressure using fist or heel of hand to sacral area to alleviate discomfort. ■■ Assist the client into a beneficial position for pushing and coach her about how to bear down with contractions. ■■ Prepare for a possible forceps-assisted, vacuum-assisted, or cesarean birth. ■■ Continue monitoring FHR in response to labor. ◯◯ Hypertonic Contractions ■■ Maintain hydration. ■■ Promote rest and relaxation, and provide comfort measures between contractions. ■■ Place the client in a lateral position, and provide oxygen by mask. ●● Medications ◯◯ Oxytocin (Pitocin) ■■ Therapeutic intent ☐☐ Used to augment labor and strengthen uterine contractions ■■ Nursing considerations ☐☐ Administer oxytocin if prescribed to augment labor. Oxytocin is not administered for hypertonic contractions. ◯◯ Administer analgesics if prescribed (for rest from hypertonic contractions). PrecipitOUS Labor Patient-Centered Care ●● Nursing Care ◯◯ Do not leave the client unattended. ■■ Provide reassurance and emotional support to help the client remain calm. ■■ Prepare for emergency delivery of the neonate. ◯◯ Encourage the client to pant with an open mouth between contractions to control the urge to push. ◯◯ Encourage the client to maintain a side-lying position to optimize uteroplacental perfusion and fetal oxygenation. ◯◯ Prepare for rupturing of membranes upon crowning (fetal head visible at perineum) if not already ruptured. ◯◯ Do not attempt to stop delivery. ◯◯ Control rapid delivery by applying light pressure to the perineal area and fetal head, gently pressing upward toward the vagina. This eases the rapid expulsion of the fetus and prevents cerebral damage to the newborn and perineal lacerations to the client. ■■ Deliver the fetus between contractions assuring the cord is not around the fetal neck. ■■ If the cord is around the fetal neck, attempt to gently slip it over the head. If not possible, clamp the cord with two clamps and cut between the clamps. ◯◯ Suction mucus from the fetal mouth and nose with a bulb syringe when the head appears. CHAPTER 16 Complications Related to the Labor Process RN Maternal Newborn Nursing 191 ◯◯ Next, deliver the anterior shoulder located under the maternal symphysis pubis: next, the posterior shoulder; and then allow the rest of the fetal body to slip out. ◯◯ Assess for complications of precipitous labor. ■■ Maternal ☐☐ Cervical, vaginal, and/or perineal lacerations ☐☐ Resultant tissue trauma secondary to rapid birth ☐☐ Uterine rupture ☐☐ Amniotic fluid embolism ☐☐ Postpartum hemorrhage ■■ Fetal/neonate ☐☐ Fetal hypoxia due to hypertonic contractions or umbilical cord around fetal neck ☐☐ Fetal intracranial hemorrhage due to head trauma from rapid birth Rupture of the Uterus ●● Nursing Care ◯◯ Administer IV fluids. ◯◯ Administer blood product transfusions if prescribed. ◯◯ Prepare the client for an immediate cesarean birth, which may involve a laparotomy and/or hysterectomy. ◯◯ Inform the client and her partner about the treatment. Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism) ●● Nursing Care ◯◯ Administer oxygen via a mask at 8 to 10 L/min. ◯◯ Assist with intubation and mechanical ventilation as indicated. ◯◯ Perform cardiopulmonary resuscitation if necessary. ◯◯ Administer IV fluids. ◯◯ Position the client on her side with her pelvis tilted at a 30° angle to displace the uterus. ◯◯ Administer blood products as prescribed to correct coagulation failure. ◯◯ Insert an indwelling urinary catheter, and measure hourly urine output. ◯◯ Monitor maternal and fetal status. ◯◯ Prepare the client for an emergency cesarean birth if the fetus is not yet delivered.

Nutrition During Pregnancy: Educating a Client About Weight Gain During Pregnancy

Recommended weight gain during pregnancy is usually 11.2 to 15.9 kg (25 to 35 lb). The general rule is that clients should gain 1 to 2 kg (2.2 to 4.4 lb) during the first trimester and after that, a weight gain of approximately 0.4 kg (1 lb) per week for the last two trimesters. Underweight woman are advised to gain 28 to 40 lb; overweight women, 15 to 25 lb. ◯◯ Excessive weight gain can lead to macrosomia and labor complications. ◯◯ Inability to gain weight may result in low birth weight of the newborn.

Medical Conditions: Provide Prenatal Care and Education

Recurrent Premature Dilation of the Cervix (Incompetent Cervix) Patient-Centered Care ●● Nursing Care ◯◯ Evaluate the client's support systems and availability of assistance if activity restrictions and/or bed rest are prescribed. ◯◯ Assess vaginal discharge. ◯◯ Monitor client reports of pressure and contractions. ◯◯ Check vital signs. ●● Medications ◯◯ Administer tocolytics prophylactically to inhibit uterine contractions. ●● Health Promotion and Disease Prevention ◯◯ Discharge instructions ■■ Place the client on activity restriction/bed rest. ■■ Encourage hydration to promote a relaxed uterus. (Dehydration stimulates uterine contractions.) ■■ Advise the client to refrain from intercourse and to monitor for cervical/uterine changes. ◯◯ Client education ■■ Provide client education about signs and symptoms to report to the provider for preterm labor, rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push. ■■ Instruct the client about using the home uterine activity monitor to evaluate uterine contractions. ■■ Arrange for the client to follow up with a home health agency for close observation and supervision. ■■ Plan for removal of the cerclage around 37 weeks of gestation. Hyperemesis Gravidarum Patient-Centered Care ●● Nursing Care ◯◯ Monitor the client's I&O. ◯◯ Assess the client's skin turgor and mucous membranes. ◯◯ Monitor the client's vital signs. ◯◯ Monitor the client's weight. ◯◯ Have the client remain NPO for 24 to 48 hr. ●● Medications ◯◯ Give the client IV fluids of lactated Ringer's for hydration. ◯◯ Give pyridoxine (Vitamin B6) and other vitamin supplements as tolerated. ◯◯ Use antiemetic medications cautiously for uncontrollable nausea and vomiting (ondansetron [Zofran], metoclopramide [Reglan]). ◯◯ Use corticosteroids to treat refractory hyperemesis gravidarum. ●● Health Promotion and Disease Prevention ◯◯ Discharge instructions ■■ Advance the client to clear liquids after 24 hr if no vomiting. ■■ Advance the client's diet, as tolerated, with frequent, small meals. Start with dry toast, crackers, or cereal; then move to a soft diet; and finally to a normal diet as tolerated. ■■ In severe cases, or if vomiting returns, enteral nutrition per feeding tube or total parental nutrition (TPN) may be considered. Anemia Patient-Centered Care ●● Nursing Care ◯◯ Prophylactic treatment using prenatal supplements with 60 mg of iron is suggested. ◯◯ Increase dietary intake of foods rich in iron (legumes, fruit, green, leafy vegetables, and meat). ◯◯ Educate the client about ways to minimize gastrointestinal adverse effects. ●● Medications ◯◯ Ferrous sulfate (325 mg) iron supplements twice daily ■■ Nursing Considerations and Client Education ☐☐ Instruct the client to take the supplement on an empty stomach. ☐☐ Encourage a diet rich in vitamin C-containing foods to increase absorption. ☐☐ Suggest that the client increase roughage and fluid intake in diet to assist with discomforts of constipation. ◯◯ Iron dextran (Imferon) ■■ Used in the treatment of iron-deficiency anemia when oral iron supplements cannot be tolerated by the client who is pregnant. Gestational Diabetes Mellitus Patient-Centered Care ●● Nursing Care ◯◯ Monitor the client's blood glucose. ◯◯ Monitor the fetus. ●● Medications ◯◯ Administer insulin as prescribed. ■■ Most oral hypoglycemic agents are contraindicated for gestational diabetes mellitus, but there is limited use of glyburide (DiaBeta) at this time. The provider will need to make the determination if these medications may be used. ●● Health Promotion and Disease Prevention ◯◯ Client education ■■ Instruct the client to perform daily kick counts. ■■ Educate the client about diet and exercise. ■■ Instruct the client about self-administration of insulin. ■■ Educate the client about the need for postpartum laboratory testing to include OGTT and blood glucose levels Gestational Hypertension Patient-Centered Care ●● Nursing Care ◯◯ Assess the client's level of consciousness. ◯◯ Obtain pulse oximetry. ◯◯ Monitor the client's urine output and obtain a clean-catch urine sample to assess for proteinuria. ◯◯ Obtain daily weights. ◯◯ Monitor vital signs. ◯◯ Encourage lateral positioning. ◯◯ Perform NST and daily kick counts as prescribed. ◯◯ Instruct the client to monitor I&O. ●● Medications ◯◯ Antihypertensive medications ■■ Methyldopa (Aldomet). ■■ Nifedipine (Adalat, Procardia). ■■ Hydralazine (Apresoline, Neopresol). ■■ Labetalol hydrochloride (Normodyne, Trandate). ■■ Avoid ACE inhibitors and angiotensin II receptor blockers. CHAPTER 9 Medical Conditions 102 RN Maternal Newborn Nursing ◯◯ Anticonvulsant medications ■■ Magnesium sulfate. ■■ Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS. ◯◯ Nursing Considerations ■■ Use an infusion control device to maintain a regular flow rate. ■■ Inform the client that she may initially feel flushed, hot, and sedated with the magnesium sulfate bolus. ■■ Monitor the client's blood pressure, pulse, respiratory rate, deep-tendon reflexes, level of consciousness, urinary output (indwelling urinary catheter for accuracy), presence of headache, visual disturbances, epigastric pain, uterine contractions, and FHR and activity. ■■ Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary output of 30 mL/hr or greater. ■■ Monitor the client for signs of magnesium sulfate toxicity. ☐☐ Absence of patellar deep tendon reflexes ☐☐ Urine output less than 30 mL/hr ☐☐ Respirations less than 12/min ☐☐ Decreased level of consciousness ☐☐ Cardiac dysrhythmias ◯◯ If magnesium toxicity is suspected: ■■ Immediately discontinue infusion. ■■ Administer antidote calcium gluconate. ■■ Prepare for actions to prevent respiratory or cardiac arrest. ●● Health Promotion and Disease Prevention ◯◯ Discharge instructions ■■ Maintain the client on bed rest, and encourage side-lying position. ■■ Promote diversional activities. ■■ Have the client avoid foods that are high in sodium. ■■ Have the client avoid alcohol and limit caffeine. ■■ Instruct the client to increase her fluid intake to 8 glasses/day. ■■ Maintain a dark quiet environment to avoid stimuli that may precipitate a seizure. ■■ Maintain a patent airway in the event of a seizure. ■■ Administer antihypertensive medications as prescribed.

Newborn Assessment: Identifying Alterations in Newborn

The nurse performs a quick initial assessment to review the newborn's systems and to observe for any abnormalities. ◯◯ External assessment - Skin color, peeling, birthmarks, foot creases, breast tissue, nasal patency, and meconium staining (may indicate fetal hypoxia) ◯◯ Chest - Point of maximal impulse location, ease of breathing, auscultation for heart rate and quality of tones and respirations for crackles, wheezes, and equality of bilateral breath sounds ◯◯ Abdomen - Rounded abdomen and umbilical cord for one vein and two arteries ◯◯ Neurologic - Muscle tone and reflex reaction (Moro reflex); palpation for the presence and size of fontanels and sutures; assessment of fontanels for fullness or bulge ◯◯ Other observations - Inspection for gross structural malformations

Prenatal Care: Caring for a Client who has Back Pain During Pregnancy

The pelvic rock or tilt exercise stretches the muscles of the lower back and helps relieve lower-back pain.

Fetal Assessment During Labor: Priority Intervention for Variable Decelerations

Variable deceleration of FHR (transitory, abrupt slowing of FHR less than 110 beats/min, variable in duration, intensity, and timing in relation to uterine contraction) ›› Umbilical cord compression ›› Short cord ›› Prolapsed cord ›› Nuchal cord (around fetal neck) ››Oligohydramnios ›› Reposition client from side to side or into knee-chest. ›› Discontinue oxytocin (Pitocin) if being infused. ›› Administer oxygen by mask at 8 to 10 L/min. ›› Perform or assist with a vaginal examination. ›› Assist with an amnioinfusion if prescribed.

Client Education and Discharge Teaching: Provide Postpartum Care and Education

pg 222- 224 Nursing Interventions for Postpartum Care ●● Provide client teaching on self-care. ◯◯ Perineal care ■■ Cleanse the perineal area from front to back with warm water after each voiding and bowel movement. ■■ Blot perineal area from front to back. ■■ Remove and apply perineal pads from front to back. ◯◯ Breast care ■■ Provide breast care for clients who are lactating. ☐☐ Wear a well-fitting, supportive bra continuously for the duration of lactation. ☐☐ Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection. ☐☐ To relieve breast engorgement, have the client completely empty her breasts at each feeding. Allow the infant to nurse on demand, which would be about 8 to 12 times in 24-hr period. Massaging the breasts during feeding can help with emptying. Allow the infant to feed until the breast softens. If the second breast does not soften after the infant's feeding, the breast may be emptied with a breast pump. Alternate breasts with each feeding. ☐☐ For breast engorgement, apply cool compresses between feedings and apply warm compresses, or take a warm shower prior to breastfeeding. These actions will increase milk flow and promote the letdown reflex. ☐☐ For flat or inverted nipples, suggest that the client roll the nipples between her fingers just before breastfeeding to help them become more erect and make it easier for the infant to latch on. Use a breast shield between feedings. ☐☐ For sore nipples, the client should apply a small amount of breast milk to her nipple and allow it to air dry after breastfeeding. ☐☐ Have the client apply breast creams as prescribed and wear breast shields in her bra to soften her nipples if they are irritated and cracked. ☐☐ Promote adequate fluid intake to replace fluid lost from breastfeeding as well as to provide an adequate amount of milk for the infant. ■■ Breast care for nonlactating clients ☐☐ Wear a well-fitting, supportive bra continuously for the first 72 hr. ☐☐ Suppression of lactation is necessary for clients who are not breastfeeding. Avoid breast stimulation and running warm water over the breasts for prolonged periods until no longer lactating. ☐☐ For breast engorgement, which may occur on the third or fifth postpartum day, apply cold compresses 15 min on and 45 min off. Fresh, cold cabbage leaves can be placed inside the bra. Mild analgesics may be taken for pain and discomfort of breast engorgement. ◯◯ Rest/sleep ■■ Plan at least one daily rest period; rest when the infant naps. ◯◯ Activity ■■ Do not perform housework requiring heavy lifting for at least 3 weeks. Do not lift anything heavier than the infant. ■■ Avoid sitting for prolonged periods of time with legs crossed (to prevent thrombophlebitis). ■■ Limit stair climbing for the first few weeks postpartum. ■■ Clients who have had a cesarean birth should wait until the 4- to 6-week follow-up visit before performing strenuous exercise, heavy lifting, or excessive stair climbing. ■■ Instruct not to drive for the first 2 weeks postpartum, or while taking opioids for pain control. ◯◯ Nutrition ■■ Teach the importance of eating a nutritious diet including all food groups. Encourage a diet high in protein, which will aid in tissue repair. The client should also consume 2,000 to 3,000 mL (2 to 3 L) of fluid each day from food and beverage sources. ■■ Encourage clients who are lactating to add an additional 330 calories/day to their prepregnancy diet. This includes calcium-enriched foods. ◯◯ Postpartum exercises ■■ Regain pelvic floor muscle control by performing Kegel exercises. The same muscles are used when starting and stopping the flow of urine. Have the client relax and contract the pelvic floor muscles 10 times 8 times a day. ■■ Teach how to perform pelvic tilt exercises to strengthen back muscles and relieve strain on the lower back. These exercises involve alternately arching and straightening the back. ◯◯ Sexual intercourse ■■ Avoid sexual intercourse until the episiotomy/laceration is healed and vaginal discharge has turned white (lochia alba). This usually takes 2 to 4 weeks or until the client is seen by the provider. Over-the-counter lubricants may be needed during the first 6 weeks. ■■ Physiological reactions to sexual activity may be slower and less intense for the first 3 months following birth. ◯◯ Contraception ■■ Advise to begin using contraception upon resumption of sexual activity and that pregnancy can occur while breastfeeding even though menses has not returned. ■■ Clients who are lactating should be advised that oral contraceptives should not begin until milk production is well established (usually 4 weeks). ■■ Menses for nonlactating clients may not resume until around 4 to 10 weeks. ■■ Menses for lactating clients may not resume for 3 months or until cessation of breastfeeding. ●● Provide client education on danger signs to report to the provider. ◯◯ Chills or fever greater than 38° C (100.4° F) for 2 or more days. ◯◯ Change in vaginal discharge with increased amount, large clots, change to a previous lochia color, such as bright red bleeding, and a foul odor. ■■ Normal lochial flow patterns ☐☐ Bright red vaginal drainage for 2 to 3 days. ☐☐ Blood-tinged serous vaginal drainage from days 4 to 10. ☐☐ White vaginal discharge from day 11 to 6 weeks. ◯◯ Episiotomy, laceration, or incision pain, that does not resolve with analgesics, foul-smelling drainage, redness, and/or edema. ◯◯ Pain or tenderness in the abdominal or pelvic areas that does not resolve with analgesics. ◯◯ Breast(s) with localized areas of pain and tenderness with redness and swelling, and/or nipples with cracks or fissures. ◯◯ Calves with localized pain and tenderness, redness, and swelling. A lower extremity with either areas of redness and warmth or coolness and paleness. ◯◯ Urination with burning, pain, frequency, urgency; urine that is cloudy or has blood. ●● Postpartum depression is when the client feels apathy toward the infant, cannot provide self- or infant-care, or has feelings that she might hurt herself or her infant. ●● The client should be discharged with an appointment set for a postpartum follow-up visit or a number to call and schedule an appointment. Following a vaginal delivery, the follow-up visit should take place in 4 to 6 weeks; following a cesarean birth, the visit should take place in 2 weeks. ●● Date and time of the follow-up appointment should be written and discussed in the discharge instructions.

Fetal Assessment During Labor: Monitoring Fetal Heart Rate at 40 Weeks of Gestation

■■ Guidelines for intermittent auscultation or continuous electronic fetal monitoring ☐☐ Low-risk women XX During latent phase, every 60 min XX During active phase, every 30 min XX During second stage, every 15 min ☐☐ High-risk women XX During latent phase, every 30 min XX During active phase, every 15 min XX During second stage, every 5 mi ●● Nursing Actions ◯◯ Preparation of the client ■■ Based on findings obtained using Leopold maneuvers, auscultate at PMI using listening device. ■■ Palpate the uterine fundus to assess uterine activity. ■■ Count FHR for 30 to 60 seconds to determine baseline rate. ■■ Auscultate FHR during a contraction and for 30 seconds following the completion of the contraction. ◯◯ Ongoing care ■■ Identify FHR patterns and characteristics of uterine contractions. ◯◯ Interventions ■■ It is the responsibility of the nurse to assess FHR patterns and characteristics of uterine contractions, implement nursing interventions, and report nonreassuring patterns or abnormal uterine contractions to the provider. ■■ Cultural considerations, as well as the emotional, educational, and comfort needs of the mother and the family, must be incorporated into the plan of care while continuing to assess the FHR pattern's response to uterine contractions during the labor process. ◯◯ The method and frequency of fetal surveillance during labor will vary and depend on maternal‑fetal risk factors as well as the preference of the facility, provider, and client. ●● Description of Procedure ◯◯ Continuous electronic fetal monitoring ■■ Continuous external fetal monitoring is accomplished by securing an ultrasound transducer over the client's abdomen to determine PMI, which records the FHR pattern, and a tocotransducer on the fundus that records the uterine contractions. ■■ Advantages of external fetal monitoring ☐☐ Noninvasive and reduces risk for infection ☐☐ Membranes do not have to be ruptured ☐☐ Cervix does not have to be dilated ☐☐ Placement of transducers can be performed by the nurse ☐☐ Provides permanent record of FHR and uterine contraction tracing ■■ Disadvantages of external fetal monitoring ☐☐ Contraction intensity is not measurable ☐☐ Movement of the client requires frequent repositioning of transducers ☐☐ Quality of recording is affected by client obesity and fetal position ●● Indications for Monitoring ◯◯ Potential diagnoses ■■ Multiple gestations, oxytocin (Pitocin) infusion (augmentation or induction of labor) ■■ Placenta previa ■■ Fetal bradycardia ■■ Maternal complications (diabetes mellitus, gestational hypertension, kidney disease) ■■ Intrauterine growth restriction ■■ Postdate ■■ Active labor ■■ Meconium-stained amniotic fluid ■■ Abruption placenta - suspected or actual ■■ Abnormal nonstress test or contraction stress test ■■ Abnormal uterine contractions ■■ Fetal distress ◯◯ Interpretation of Findings ■■ A normal fetal heart rate baseline at term is 110 to 160/min excluding accelerations, decelerations, and periods of marked variability within a 10 min window. At least 2 min of baseline segments in a 10 min window should be present. A single number should be documented instead of a baseline range. ■■ Fetal heart rate baseline variability is described as fluctuations in the FHR baseline that are irregular in frequency and amplitude. Classification of variability is as follows: ☐☐ Absent or undetectable variability (considered nonreassuring) ☐☐ Minimal variability (greater than undetectable but less than 5/min) ☐☐ Moderate variability (6 to 25/min) ☐☐ Marked variability (greater than 25/min) ■■ Changes in fetal heart rate patterns are categorized as episodic or periodic changes. Episodic changes are not associated with uterine contractions, and periodic changes occur with uterine contractions. These changes include accelerations and decelerations.

Medical Conditions: Priority Finding of Mild Preeclampsia

●● Mild preeclampsia is GH with the addition of proteinuria of greater than 1+. Report of transient headaches may or may not occur along with episodes of irritability. Edema may be present.

Medical Conditions: Provide Care for Client Experiencing Preeclampsia

●● Mild preeclampsia is GH with the addition of proteinuria of greater than 1+. Report of transient headaches may or may not occur along with episodes of irritability. Edema may be present. ●● Severe preeclampsia consists of blood pressure that is 160/100 mm Hg or greater, proteinuria greater than 3+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (headache and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and right upper‑quadrant pain, and thrombocytopenia. ●● Eclampsia is severe preeclampsia symptoms along with the onset of seizure activity or coma. Eclampsia is usually preceded by headache, severe epigastric pain, hyperreflexia, and hemoconcentrations, which are warning signs of probable convulsions. Patient-Centered Care ●● Nursing Care ◯◯ Assess the client's level of consciousness. ◯◯ Obtain pulse oximetry. ◯◯ Monitor the client's urine output and obtain a clean-catch urine sample to assess for proteinuria. ◯◯ Obtain daily weights. ◯◯ Monitor vital signs. ◯◯ Encourage lateral positioning. ◯◯ Perform NST and daily kick counts as prescribed. ◯◯ Instruct the client to monitor I&O. ●● Medications ◯◯ Antihypertensive medications ■■ Methyldopa (Aldomet). ■■ Nifedipine (Adalat, Procardia). ■■ Hydralazine (Apresoline, Neopresol). ■■ Labetalol hydrochloride (Normodyne, Trandate). ■■ Avoid ACE inhibitors and angiotensin II receptor blockers. CHAPTER 9 Medical Conditions 102 RN Maternal Newborn Nursing ◯◯ Anticonvulsant medications ■■ Magnesium sulfate. ■■ Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS. ◯◯ Nursing Considerations ■■ Use an infusion control device to maintain a regular flow rate. ■■ Inform the client that she may initially feel flushed, hot, and sedated with the magnesium sulfate bolus. ■■ Monitor the client's blood pressure, pulse, respiratory rate, deep-tendon reflexes, level of consciousness, urinary output (indwelling urinary catheter for accuracy), presence of headache, visual disturbances, epigastric pain, uterine contractions, and FHR and activity. ■■ Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary output of 30 mL/hr or greater. ■■ Monitor the client for signs of magnesium sulfate toxicity. ☐☐ Absence of patellar deep tendon reflexes ☐☐ Urine output less than 30 mL/hr ☐☐ Respirations less than 12/min ☐☐ Decreased level of consciousness ☐☐ Cardiac dysrhythmias ◯◯ If magnesium toxicity is suspected: ■■ Immediately discontinue infusion. ■■ Administer antidote calcium gluconate. ■■ Prepare for actions to prevent respiratory or cardiac arrest. ●● Health Promotion and Disease Prevention ◯◯ Discharge instructions ■■ Maintain the client on bed rest, and encourage side-lying position. ■■ Promote diversional activities. ■■ Have the client avoid foods that are high in sodium. ■■ Have the client avoid alcohol and limit caffeine. ■■ Instruct the client to increase her fluid intake to 8 glasses/day. ■■ Maintain a dark quiet environment to avoid stimuli that may precipitate a seizure. ■■ Maintain a patent airway in the event of a seizure. ■■ Administer antihypertensive medications as prescribed.

Care of Those Who Are Dying and/or Grieving: Assist Client who is Coping with Fetal Loss

◯◯ Provide client education and emotional support. ◯◯ Provide referral for client and partner to pregnancy loss support groups.

Postpartum Disorders: Caring for a Client who has a Large Amount of Lochia Rubra

Abnormal lochia is evidenced by ■■ Excessive spurting of bright red blood from the vagina, possibly indicating a cervical or vaginal tear. ■■ Numerous large clots and excessive blood loss (saturation of one pad in 15 min or less), which may indicate hemorrhage. ■■ Foul odor, which is suggestive of infection. ■■ Persistent lochia rubra in the early postpartum period beyond day 3, which may indicate retained placental fragments. ■■ Continued flow of lochia serosa or alba beyond the normal length of time may indicate endometritis, especially if it is accompanied by fever, pain, or abdominal tenderness.

Newborn Nutrition: Evaluating Teaching of Bottle Feeding

Bottle feeding ●● Formula feeding can be a successful and adequate source of nutrition if the mother chooses not to breastfeed. The newborn should be fed every 3 to 4 hr. Parents should awaken the newborn to feed at least every 3 hr during the day and at least every 4 hr during the night until the newborn is feeding well and gaining weight adequately. Then, a feed-on-demand schedule may be followed. ●● Nursing Interventions to Promote Successful Bottle Feeding ◯◯ Teach the parents how to prepare formula, bottles, and nipples. Review the importance of handwashing prior to formula preparation. ◯◯ Teach the parents about the different forms of formula (ready-to-feed, concentrated, and powder) and how to prepare each correctly. ◯◯ Bottles can be put in the dishwasher or washed by hand in hot soapy water using a good bottle and nipple brush. CHAPTER 25 Newborn Nutrition RN Maternal Newborn Nursing 295 ◯◯ Teach parents to wash the lid of a can of concentrated formula with hot soapy water before opening it. ◯◯ Instruct parents to use tap water to mix concentrated or powder formula. If the water source is questionable, tap water should be boiled first. ◯◯ Instruct parents that prepared formula can be refrigerated for up to 48 hr. ◯◯ Teach the parents to check the flow of formula from the bottle to ensure it is not coming out too slow or too fast. ◯◯ Show the parents how to cradle the newborn in their arms in a semi-upright position. The newborn should not be placed in the supine position during bottle feeding because of the danger of aspiration. Newborns who bottle feed do best when held close and at a 45˚ angle. ◯◯ Instruct the mother how to place the nipple on top of the newborn's tongue. ◯◯ Keep the nipple filled with formula to prevent the newborn from swallowing air. ◯◯ Always hold the bottle and never prop the bottle for feeding. ◯◯ Newborns should be burped several times during a feeding, usually after each ½ to 1 oz of formula or breast milk. ◯◯ Place the newborn on his back after feedings. ◯◯ Tell the parents to discard any unused formula remaining in the bottle when the newborn is finished feeding due to the possibility of bacterial contamination. ◯◯ Teach the parents how to tell if their newborn is being adequately fed (gaining weight; bowel movements are yellow, soft and formed; infant will stool after every feeding, and after a couple of weeks, movements decrease to 1 to 2 per day; voiding 6 to 8 times per day; and satisfaction between feedings).

Nursing Care During Stages of Labor: Client Care During Fourth Stage of Labor

Fourth Stage ●● Nursing Assessments During the Fourth Stage ◯◯ Maternal vital signs ◯◯ Fundus ◯◯ Lochia ◯◯ Urinary output ◯◯ Baby-friendly activities of the family ●● Nursing Interventions During the Fourth Stage ◯◯ Assess maternal vital signs every 15 min for the first hour and then according to facility protocol. ◯◯ Assess fundus and lochia every 15 min for the first hour and then according to facility protocol. ◯◯ Massage the uterine fundus and/or administer oxytocics as prescribed to maintain uterine tone and to prevent hemorrhage. ◯◯ Encourage voiding to prevent bladder distention. ◯◯ Promote an opportunity for parental-newborn bonding.

Fetal Assessment During Labor: Priority Assessment when Caring for a Client in Labor

Leopold Maneuvers ●● Nursing Actions ◯◯ Preparation of the Client ■■ Ask the client to empty her bladder before beginning the assessment. ■■ Place the client in the supine position with a pillow under her head, and have her flex her knees slightly. ■■ Place a wedge under her right hip to displace the uterus to the left and prevent supine hypotension syndrome. Unit 2 In trapartum nursing care Section: Labor and Delivery Chapter 13 Fetal Assessment During Labor CHAPTER 13 Fetal Assessment During Labor 144 RN Maternal Newborn Nursing ◯◯ Ongoing care ■■ Identify the fetal part occupying the fundus. The head should feel round, firm, and move freely. The breech should feel irregular and soft. This maneuver identifies the fetal lie (longitudinal or transverse) and presenting part (cephalic or breech). ■■ Locate and palpate the smooth contour of the fetal back using the palm of one hand and the irregular small parts of the hands, feet, and elbows using the palm of the other hand. This maneuver validates the presenting part. ■■ Determine the part that is presenting over the true pelvis inlet by gently grasping the lower segment of the uterus between the thumb and fingers. If the head is presenting and not engaged, determine whether the head is flexed or extended. This maneuver assists in identifying the descent of the presenting part into the pelvis. ■■ Face the client's feet and outline the fetal head using the palmar surface of the fingertips on both hands to palpate the cephalic prominence. If the cephalic prominence is on the same side as the small parts, the head is flexed with vertex presentation. If the cephalic prominence is on the same side as the back, the head is extended with a face presentation. This maneuver identifies the fetal attitude. ◯◯ Interventions ■■ Auscultate the FHR postmaneuvers to assess the fetal tolerance to the procedure. ■■ Document the findings from the maneuvers. FHR Pattern and Uterine Contraction Monitoring ●● Nursing Actions ◯◯ Preparation of the client ■■ Based on findings obtained using Leopold maneuvers, auscultate at PMI using listening device. ■■ Palpate the uterine fundus to assess uterine activity. ■■ Count FHR for 30 to 60 seconds to determine baseline rate. ■■ Auscultate FHR during a contraction and for 30 seconds following the completion of the contraction. ◯◯ Ongoing care ■■ Identify FHR patterns and characteristics of uterine contractions. ◯◯ Interventions ■■ It is the responsibility of the nurse to assess FHR patterns and characteristics of uterine contractions, implement nursing interventions, and report nonreassuring patterns or abnormal uterine contractions to the provider. ■■ Cultural considerations, as well as the emotional, educational, and comfort needs of the mother and the family, must be incorporated into the plan of care while continuing to assess the FHR pattern's response to uterine contractions during the labor process. ◯◯ The method and frequency of fetal surveillance during labor will vary and depend on maternal‑fetal risk factors as well as the preference of the facility, provider, and client.

Pain Management: Nonpharmacological Comfort Measures

Nonpharmacological Pain Management ●● Nonpharmacological pain management measures reduce anxiety, fear, and tension, which are major contributing factors to pain in labor. ◯◯ Gate-control theory of pain is based on the concept that the sensory nerve pathways that pain sensations use to travel to the brain will allow only a limited number of sensations to travel at any given time. By sending alternate signals through these pathways, the pain signals can be blocked from ascending the neurological pathway and inhibit the brain's perception and sensation of pain. ◯◯ The gate-control theory of pain assists in the understanding of how nonpharmacological pain techniques can work to relieve pain. ●● Interventions for nonpharmacological pain management ◯◯ Childbirth preparation education, sensory and cutaneous strategies, and frequent maternal position changes ■■ Childbirth preparation methods such as Lamaze and/or patterned breathing exercises are used to promote relaxation and pain management. ☐☐ Nursing implications include assessing for signs of hyperventilation (caused by low blood levels of PCO2 from blowing off too much CO2) such as light-headedness and tingling of the fingers. If this occurs, have the client breathe into a paper bag or her cupped hands. ■■ Sensory stimulation strategies (based on the gate-control theory) to promote relaxation and pain relief ☐☐ Aromatherapy ☐☐ Breathing techniques ☐☐ Imagery ☐☐ Music ☐☐ Use of focal points ☐☐ Subdued lighting ■■ Cutaneous strategies (based on the gate-control theory) to promote relaxation and pain relief ☐☐ Back rubs and massage ☐☐ Effleurage XX Light, gentle circular stroking of the client's abdomen with the fingertips in rhythm with breathing during contractions ☐☐ Sacral counterpressure XX Consistent pressure is applied by the support person using the heel of the hand or fist against the client's sacral area to counteract pain in the lower back ☐☐ Heat or cold therapy ☐☐ Hydrotherapy (whirlpool or shower) increases maternal endorphin levels ☐☐ Acupressure CHAPTER 12 pain management 134 RN Maternal Newborn Nursing ■■ Frequent maternal position changes to promote relaxation and pain relief ☐☐ Semi-sitting ☐☐ Squatting ☐☐ Kneeling ☐☐ Kneeling and rocking back and forth ☐☐ Supine position only with the placement of a wedge under one of the client's hips to tilt the uterus and avoid supine hypotension syndrome ◯◯ Client Education ■■ Teach the client who is in labor about techniques to promote pain management, such as patterned breathing and progressive relaxation exercises.

Therapeutic Procedures to Assist with Labor and Delivery: Caring for a Client whose Fetus has a Posterior Presentation

Persistent occiput posterior presentation is when the fetal occiput is directed toward the posterior maternal pelvis rather than the anterior pelvis. Persistent occiput posterior position prolongs labor and the client reports greater back pain as the fetus presses against the maternal sacrum. ■■ Encourage position changes to aid in fetal descent or to open up the pelvic outlet. ☐☐ Assist client to a position on her hands and knees to help the fetus to rotate from a posterior to anterior position. 1. nurse is caring for a client who is in active labor. The client reports lower back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions is appropriate? Sacral counterpressure to the lower back relieves the pressure exerted on the pelvis and spinal nerves by the fetus. External cephalic version (ECV): attempt to manipulate the abdominal wall to direct a malpositioned fetus into a normal vertex presentation after 37 weeks. contradicted for uterine abnormalities, previous CS, cephalopelvic disproportion, placenta previa, multifetal pregnancy, or oligohydraaminos. risk- prolapse of umbilical cord nursing actions: informed consent, US, nonstress, ensure RhoGam was given at 28 weeks

Newborn Assessment: Assigning Apgar Score

Physical Assessment of Newborn Following Birth ●● Apgar scoring and a brief physical exam is done immediately following birth to rule out abnormalities. An Apgar score is assigned based on a quick review of systems that is completed at 1 and 5 min of life. This allows the nurse to rapidly assess extrauterine adaptation and intervene with appropriate nursing actions. ◯◯ 0 to 3 indicates severe distress ◯◯ 4 to 6 indicates moderate distress ◯◯ 7 to 10 indicates no distress Score 0 1 2 Heart rate ›› Absent ›› Less than 100 ›› Greater than 100 Respiratory rate ›› Absent ›› Slow, weak cry ›› Good cry Muscle tone ›› Flaccid ›› Some flexion ››Well-flexed Reflex irritability ›› None ›› Grimace ›› Cry Color ›› Blue, pale ›› Pink body, cyanotic hands and feet (acrocyanosis) ›› Completely pink

Infections: Teaching About Herpes Genitalis

The herpes simplex virus (HSV) is spread by direct contact with oral or genital lesions. Transmission to the fetus is greatest during vaginal birth if the woman has active lesions. ■■ Herpes simplex virus initially presents with lesions and tender lymph nodes. Fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction. ◯◯ Laboratory Tests ■■ For herpes simplex, obtain cultures from women who have HSV or are at or near term.

Assessment and Management of Newborn Complications: Monitor Newborn Receiving Phototherapy

Treatment ■■ Phototherapy is the primary treatment for hyperbilirubinemia. It is prescribed if a newborn's serum bilirubin is greater than 15 mg/dL prior to 48 hr of age, greater than 18 mg/dL prior to 72 hr of age, and greater than 20 mg/dL at any time. Patient-Centered Care ●● Nursing Care ◯◯ Observe the newborn's skin and mucous membranes for jaundice. ◯◯ Monitor the newborn's vital signs. ◯◯ Set up phototherapy if prescribed. ■■ Maintain an eye mask over the newborn's eyes for protection of corneas and retinas. ■■ Keep the newborn undressed with the exception of a male newborn. A surgical mask should be placed (like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. Be sure to remove the metal strip from the mask to prevent burning. ■■ Avoid applying lotions or ointments to the skin because they absorb heat and can cause burns. ■■ Remove the newborn from phototherapy every 4 hr, and unmask the newborn's eyes, checking for inflammation or injury. ■■ Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. ■■ Check the lamp energy with a photometer per facility protocol. ■■ Turn off the phototherapy lights before drawing blood for testing. ◯◯ Observe the newborn for effects of phototherapy. ■■ Bronze discoloration - not a serious complication ■■ Maculopapular skin rash - not a serious complication ■■ Development of pressure areas ■■ Dehydration (poor skin turgor, dry mucous membranes, decreased urinary output) ■■ Elevated temperature CHAPTER 27 Assessment and Management of Newborn Complications RN Maternal Newborn Nursing 337 ◯◯ Encourage the parents to hold and interact with the newborn when phototherapy lights are off. ◯◯ Monitor elimination and daily weights, watching for evidence of dehydration. ◯◯ Check the newborn's axillary temperature every 4 hr during phototherapy because temperature may become elevated. ◯◯ Feed the newborn early and frequently - every 3 to 4 hr. This will promote bilirubin excretion in the stools. ◯◯ Encourage continued breastfeeding of the newborn. Supplementation with formula may be prescribed. ◯◯ Maintain adequate fluid intake to prevent dehydration. ◯◯ Reassure the parents that most newborns experience some degree of jaundice. ◯◯ Explain hyperbilirubinemia, its causes, diagnostic tests, and treatment to parents. ◯◯ Explain that the newborn's stool contains some bile that will be loose and green. ●● Administer an exchange transfusion for newborns who are at risk for kernicterus. ●● Discharge Instructions ◯◯ Educate the parents regarding the newborn's plan of care.

Bleeding During Pregnancy: Priority Action for a Client who is at 34 Weeks of Gestation and Bleeding

pg 71-74 1. Placenta Previa: placenta implants near or on cervical os instead of to the fundus, causing painless bleeding in 3rd trimester when cervix begins to dilate and efface; complete or total, incomplete or partial, & marginal or low-lying; uterus soft and relaxed, fundal height greater that expected for GA, fetus in breech, oblique, or transverse position. ●● Nursing Actions ◯◯ Assess for bleeding, leakage, or contractions. ◯◯ Assess fundal height. ◯◯ Perform Leopold maneuvers (fetal position and presentation). ◯◯ Refrain from performing vaginal exams (may exacerbate bleeding). ◯◯ Administer IV fluids, blood products, and medications as prescribed. ■■ Corticosteroids, such as betamethasone (Celestone), promote fetal lung maturation if delivery is anticipated (cesarean birth). ◯◯ Have oxygen equipment available in case of fetal distress. ●● Health Promotion and Disease Prevention ◯◯ Discharge instructions ■■ Bed rest ■■ Nothing inserted vaginally 2. Abruptio Placenta: premature separation of placenta from the uterus, complete or partial, in 3rd trimester, leading cause of maternal morbidity; hypertension, trauma, cocaine use, previous incidents, cig. smoking, PROM, multifetal; intense pain, hypertonic contraction Patient-Centered Care ●● Nursing Actions ◯◯ Palpate the uterus for tenderness and tone. ◯◯ Assess FHR pattern. ◯◯ Administer IV fluids, blood products, and medications as prescribed. ■■ Corticosteroids to promote fetal lung maturity ◯◯ Administer oxygen 8 to 10 L/min via face mask. ◯◯ Assess urinary output and monitor fluid balance. ●● Client Education ◯◯ Provide emotional support for the client and family.

Pain Management: Morphine PCA Pump

■■ An epidural block consists of a local anesthetic, bupivacaine (Marcaine), along with an analgesic, morphine (Duramorph) or fentanyl (Sublimaze), injected into the epidural space at the level of the fourth or fifth vertebrae. This eliminates all sensation from the level of the umbilicus to the thighs, relieving the discomfort of uterine contractions, fetal descent, and pressure and stretching of the perineum. It is administered when the client is in active labor and dilated to at least 4 cm. Continuous infusion or intermittent injections may be administered through an indwelling epidural catheter. Patient-controlled epidural analgesia is a technique for labor analgesia and is a favored method of pain management for labor and birth. ☐☐ Adverse effects of an epidural block XX Maternal hypotension XX Fetal bradycardia XX Inability to feel the urge to void XX Loss of the bearing down reflex

Pain Management: Complications of an Epidural Infusion

■■ Epidural and spinal regional analgesia consists of using analgesics such as fentanyl (Sublimaze) and sufentanil (Sufenta), which are short-acting opioids that are administered as a motor block into the epidural or intrathecal space without anesthesia. These opioids produce regional analgesia providing rapid pain relief while still allowing the client to sense contractions and maintain the ability to bear down. ☐☐ Adverse effects of epidural and spinal analgesia XX Decreased gastric emptying resulting in nausea and vomiting XX Inhibition of bowel and bladder elimination sensations XX Bradycardia or tachycardia XX Hypotension CHAPTER 12 pain management 136 RN Maternal Newborn Nursing XX Respiratory depression XX Allergic reaction and pruritus XX Elevated temperature ☐☐ Client Education XX Provide the client with ongoing education related to expectations for procedure. ☐☐ Nursing Actions XX Institute safety precautions, such as putting side rails up on the client's bed. The client may experience dizziness and sedation, which increases maternal risk for injury. XX Assess the client for nausea and emesis, and administer antiemetics as prescribed. XX Monitor maternal vital signs per facility protocol. XX Monitor for allergic reaction. XX Continue FHR pattern monitoring.

Assessment and Management of Newborn Complications: Maternal Opiate Use

■■ Opiate withdrawal ☐☐ Can last for 2 to 3 weeks ☐☐ Manifestations of neonatal abstinence syndrome - rapid changes in mood, hypersensitivity to noise and external stimuli, dehydration, and poor weight gain

Pain Management: Evaluation of Client's Understanding of Nonpharmacological Comfort Management

■■ Teach the client who is in labor about techniques to promote pain management, such as patterned breathing and progressive relaxation exercises.

Newborn Assessment: Obtaining Infant's Measurements

●● A gestational age assessment is performed within 2 to 12 hr of birth. Neonatal morbidity and mortality are related to gestational age and birth weight. This assessment involves taking measurements of the newborn and the use of the New Ballard Scale. This scale provides an estimation of gestational age and a baseline to assess growth and development. ◯◯ Expected reference ranges of physical measurements ■■ Weight - 2,500 to 4,000 g ■■ Length - 45 to 55 cm (18 to 22 in) ■■ Head circumference - 32 to 36.8 cm (12.6 to 14.5 in) ■■ Chest circumference - 30 to 33 cm (12 to 13 in)

Assessment of Fetal Well-Being: Educating a Client About an Amniocentesis

●● Amniocentesis - the aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client's uterus and amniotic sac under direct ultrasound guidance locating the placenta and determining the position of the fetus. It may be performed after 14 weeks of gestation. ●● Indications for the use of an amniocentesis during pregnancy ◯◯ Potential diagnoses ■■ Previous birth with a chromosomal anomaly ■■ A parent who is a carrier of a chromosomal anomaly ■■ A family history of neural tube defects ■■ Prenatal diagnosis of a genetic disorder or congenital anomaly of the fetus ■■ Alpha fetoprotein level for fetal abnormalities ■■ Lung maturity assessment ■■ Fetal hemolytic disease ■■ Meconium in the amniotic fluid ●● Interpretation of findings ◯◯ Alpha-fetoprotein (AFP) can be measured from the amniotic fluid between 16 and 18 weeks of gestation and may be used to assess for neural tube defects in the fetus or chromosomal disorders. May be evaluated to follow up a high level of AFP in maternal serum. ■■ High levels of AFP are associated with neural tube defects, such as anencephaly (incomplete development of fetal skull and brain), spina bifida (open spine), or omphalocele (abdominal wall defect). High AFP levels also may be present with normal multifetal pregnancies. ■■ Low levels of AFP are associated with chromosomal disorders (Down syndrome) or gestational trophoblastic disease (hydatidiform mole). ◯◯ Tests for fetal lung maturity may be performed if gestation is less than 37 weeks, in the event of a rupture of membranes, for preterm labor, or for a complication indicating a cesarean birth. Amniotic fluid is tested to determine whether the fetal lungs are mature enough to adapt to extrauterine life, or if the fetus will likely have respiratory distress. Determination is made whether the fetus should be removed immediately or if the fetus requires more time in utero with the administration of glucocorticoids to promote fetal lung maturity. ■■ Fetal lung tests ☐☐ Lecithin/sphingomyelin (L/S) ratio - a 2:1 ratio indicating fetal lung maturity (2.5:1 or 3:1 for a client who has diabetes mellitus). ☐☐ Presence of phosphatidylglycerol (PG) - absence of PG is associated with respiratory distress ●● Preprocedure for an amniocentesis ◯◯ Nursing actions ■■ Explain the procedure to the client, and obtain informed consent. ◯◯ Client education ■■ Instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture.

Newborn Assessment: Prioritize the Delivery of Newborn Care

●● Apgar scoring and a brief physical exam is done immediately following birth to rule out abnormalities. An Apgar score is assigned based on a quick review of systems that is completed at 1 and 5 min of life. This allows the nurse to rapidly assess extrauterine adaptation and intervene with appropriate nursing actions. ◯◯ 0 to 3 indicates severe distress ◯◯ 4 to 6 indicates moderate distress ◯◯ 7 to 10 indicates no distress The nurse performs a quick initial assessment to review the newborn's systems and to observe for any abnormalities. ●●A gestational age assessment is performed within 2 to 12 hr of birth. Neonatal morbidity and mortality are related to gestational age and birth weight. This assessment involves taking measurements of the newborn and the use of the New Ballard Scale. This scale provides an estimation of gestational age and a baseline to assess growth and development. Vital signs are checked in the following sequence: respirations, heart rate, blood pressure, and temperature. The nurse observes the respiratory rate first before the newborn becomes active or agitated by use of the stethoscope, thermometer, and/or the blood pressure cuff.

Pain Management: Evaluating a Client's Understanding of Pain Management

●● Assess the beliefs and expectations related to discomfort, pain relief, and birth plans regarding pain relief methods of the client who is in labor. ●● Assess the client's level, quality, frequency, duration, intensity, and location of pain through verbal and nonverbal cues. Use an appropriate pain scale allowing the client to indicate the severity of her pain on a scale of 0 to 10, with 10 representing the most severe pain. ☐ Client Education XX Explain to the client that the medication will cause drowsiness. XX Instruct the client to request assistance with ambulation. ☐☐ Client Education XX Instruct the client about the method. XX Instruct the client to bear down for expulsion of the fetus because during a vaginal birth, the mother will not feel her contractions.

Assessment of Fetal Well-Being: Indications of a Biophysical Profile

●● Biophysical profile (BPP) - uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. ●● BPP assesses fetal well-being by measuring the following five variables with a score of 2 for each normal finding, and 0 for each abnormal finding for each variable. ◯◯ Reactive FHR (reactive nonstress test) = 2; nonreactive = 0. ◯◯ Fetal breathing movements (at least 1 episode of greater than 30 seconds duration in 30 min) = 2; absent or less than 30 seconds duration = 0. ◯◯ Gross body movements (at least 3 body or limb extensions with return to flexion in 30 min) = 2; less than 3 episodes = 0. ◯◯ Fetal tone (at least 1 episode of extension with return to flexion) = 2; slow extension and flexion, lack of flexion, or absent movement = 0. ◯◯ Qualitative amniotic fluid volume (at least 1 pocket of fluid that measures at least 2 cm in 2 perpendicular planes) = 2; pockets absent or less than 2 cm = 0. ●● Interpretation of findings ◯◯ Total score of 8 to 10 is normal; low risk of chronic fetal asphyxia ◯◯ 4 to 6 is abnormal; suspect chronic fetal asphyxia ◯◯ < 4 is abnormal; strongly suspect chronic fetal asphyxia ●● Potential diagnoses ◯◯ Nonreactive stress test ◯◯ Suspected oligohydramnios or polyhydramnios ◯◯ Suspected fetal hypoxemia and/or hypoxia ●● Client presentation ◯◯ Premature rupture of membranes ◯◯ Maternal infection ◯◯ Decreased fetal movement ◯◯ Intrauterine growth restriction ●● Nursing Actions ◯◯ Prepare the client following the same nursing management principles as those used for an ultrasound.

Nursing Care and Discharge Teaching: Car Seat Safety

●● Car Seat Safety ◯◯ Use an approved rear-facing car seat in the back seat, preferably in the middle, (away from air bags and side impact) to transport the newborn. Keep infants in rear-facing car seats until age 2 or until the child reaches the maximum height and weight for the seat. Do not use a used or secondhand car seat.

Nursing Care and Discharge Teaching: Antimicrobial Agents and the Umbilical Cord

●● Cord Care ◯◯ Before discharge, the cord clamp is removed. ◯◯ Prevent cord infection by keeping the cord dry, and keep the top of the diaper folded underneath it. ◯◯ Sponge baths are given until the cord falls off, which occurs around 10 to 14 days after birth. Tub bathing and submersion can follow. ◯◯ Cord infection (complication of improper cord care) can result if the cord is not kept clean and dry. ■■ Monitor for symptoms of a cord that is moist and red, has a foul odor, or has purulent drainage. ■■ Notify the provider immediately if findings of cord infection are present.

Therapeutic Procedures to Assist with Labor and Delivery: Vacuum-Assisted Delivery

●● Description of Procedure ◯◯ A vacuum-assisted birth involves the use of a cuplike suction device that is attached to the fetal head. Traction is applied during contractions to assist in the descent and birth of the head, after which, the vacuum cup is released and removed preceding delivery of the fetal body. ◯◯ Recommendations by the manufacturer should be followed for product use to ensure safety. ◯◯ Conditions for use of a vacuum-assisted birth ■■ Vertex presentation ■■ Absence of cephalopelvic disproportion ■■ Ruptured membranes ◯◯ Risks associated with vacuum-assisted births ■■ Scalp lacerations ■■ Subdural hematoma of the neonate ■■ Cephalohematoma ■■ Maternal lacerations to the cervix, vagina, or perineum ●● Indications ◯◯ Maternal exhaustion and ineffective pushing efforts ◯◯ Fetal distress during second stage of labor CHAPTER 15 Therapeutic Procedures to Assist with Labor and Delivery RN Maternal Newborn Nursing 173 ●● Nursing Actions ◯◯ Preparation of the client ■■ Provide the client and her partner with support and education regarding the procedure. ■■ Assist the client into the lithotomy position to allow for sufficient traction of the vacuum cup when it is applied to the fetal head. ■■ Assess and record FHR before and during vacuum assistance. ■■ Assess for bladder distention, and catheterize if necessary. ◯◯ Ongoing care ■■ Prepare for a forceps-assisted birth if a vacuum-assisted birth is not successful. ◯◯ Interventions ■■ Alert postpartum care providers that vacuum assistance was used. ■■ Observe the neonate for lacerations, cephalohematomas, or subdural hematomas after delivery. ■■ Check the neonate for caput succedaneum. Caput succedaneum is a normal occurrence and should resolve within 24 hr.

Nursing Care and Discharge Teaching: Evaluating Teaching About Home Care

●● Discharge teaching and newborn care including bathing, umbilical cord care, circumcision, car seat safety, environmental safety, newborn behaviors, feeding, elimination and signs of illness to report to the provider will be discussed in this chapter. ●● Prior to discharge, a nurse should provide anticipatory guidance to prepare new parents to care for their newborn at home. Mothers and newborns are normally discharged once the newborn is 6 to 48 hr old. Serious complications can result if improper discharge instructions are given to the parents prior to taking the newborn home. ●● A nurse should inquire about the family's current experience and knowledge regarding newborn care, anticipate the learning needs of the parents, and assess their readiness for learning to provide education about newborn care. ●● Parents should be made aware of general guidelines about newborn behavior and care. These guidelines include causes of crying in the newborn, quieting techniques, sleeping patterns, hunger cues, and feeding, bathing, and clothing the newborn. ●● Parents need to be aware of the importance of well-newborn checkups, immunization schedules, and when to call the provider for signs of illness. ●● Providing a safe protective environment at home should be stressed to new parents and should include instruction about proper car seat usage, which is a very important part of the discharge instruction process. ●● Assessment of the family's readiness to care for the newborn at home ◯◯ Previous newborn experience and knowledge ◯◯ Parent-newborn attachment ◯◯ Adjustment to the parental role ◯◯ Social support ◯◯ Educational needs ◯◯ Sibling rivalry issues ◯◯ Readiness of the parents to have their home and lifestyle altered to accommodate their newborn ◯◯ Parents' ability to verbalize and demonstrate newborn care following teaching Complications Related to Newborn Home Care ●● Complications stemming from improper understanding of discharge instructions may include: ◯◯ An infected cord or circumcision from improper care or tub bathing too soon. ◯◯ Falls; suffocation; strangulation; burns resulting in injuries, fractures, aspiration; or even death due to improper safety precautions. ◯◯ Respiratory infections due to passive smoke or inhaled powders. ◯◯ Improper or no use of a car seat resulting in injuries or death. ◯◯ Serious infections due to lack of noncompliance with immunization schedule.

Nursing Care of Newborns: Evaluating Client Understanding of Newborn Safety

●● Home Safety ◯◯ Never leave the newborn unattended with pets or other small children. ◯◯ Keep small objects (coins) out of the reach of newborns due to choking hazard. ◯◯ Never leave the newborn alone on a bed, couch, or table. Newborns move enough to reach the edge and fall off. ◯◯ Never place the newborn on his stomach to sleep during the first few months of life. The backlying position is the position of choice. The newborn can be placed on his abdomen when awake and being supervised. ◯◯ Never provide a newborn with a soft surface to sleep on (pillows and waterbed). The newborn's mattress should be firm. Never put pillows, toys, bumper pads, or loose blankets in a crib. Crib linens should be tight-fitting. ◯◯ Do not tie anything around the newborn's neck. ◯◯ Monitor the safety of the newborn's crib. The space between the mattress and sides of the crib should be less than 2 fingerbreadths. The slats on the crib should be no more than 5.1 cm (2.25 in) apart. ◯◯ The newborn's crib or playpen should be away from window blinds and drapery cords. Newborns can become strangled in them. ◯◯ The bassinet or crib should be placed on an inner wall, not next to a window, to prevent cold stress by radiation. ◯◯ If an infant carrier is placed on a high place, such as a table, always be within arm's reach. ◯◯ Smoke detectors should be on every floor of a home and should be checked monthly to ensure that they are working. Batteries should be changed twice a year. (Change batteries when daylight savings time occurs or on a child's birthday.) CHAPTER 26 Nursing Care and Discharge Teaching RN Maternal Newborn Nursing 309 ◯◯ Eliminate potential fire hazards. Keep a crib and playpen away from heaters, radiators, and heat vents. Linens could catch fire if they come into contact with heat sources. ◯◯ Control the temperature and humidity of the newborn's environment by providing adequate ventilation. ◯◯ Avoid exposing the newborn to cigarette smoke in a home or elsewhere. Secondhand exposure increases the newborn's risk of developing respiratory illnesses. ◯◯ All visitors should wash their hands before touching the newborn. Any individual who has an infection should be kept away from the newborn. ◯◯ Carefully handle the newborn. Do not toss the newborn up in the air or swing him by his extremities. ◯◯ Provide community resources to clients who may need additional and ongoing assessment and instruction on newborn care (adolescent parents).

Assessment and Management of Newborn Complications: Assess Client for Clinical Manifestations of Hypoglycemia

●● Hypoglycemia is a serum glucose level of less than 40 mg/dL. Routine assessment of all newborns, especially newborns who are LGA and SGA, should include monitoring for hypoglycemia. ●● Hypoglycemia - differs for a newborn who is preterm or term. Hypoglycemia occurring in the first 3 days of life in the term newborn is defined as a blood glucose level of less than 40 mg/dL. In the preterm newborn, hypoglycemia is defined as a blood glucose level of less than 25 mg/dL. ●● Untreated hypoglycemia can result in seizures, brain damage, and/or death. Assessment ●● Objective Data ◯◯ Physical assessment findings ■■ Poor feeding ■■ Jitteriness/tremors ■■ Hypothermia ■■ Diaphoresis ■■ Weak shrill cry ■■ Lethargy ■■ Flaccid muscle tone ■■ Seizures/coma ■■ Irregular respirations ■■ Cyanosis ■■ Apnea ◯◯ Laboratory tests and diagnostic procedures ■■ Two consecutive plasma glucose levels less than 40 mg/dL in a newborn who is term, and less than 25 mg/dL in a newborn who is preterm Patient-Centered Care ●● Nursing Care ◯◯ Obtain blood by heel stick for glucose monitoring. ◯◯ Provide frequent oral and/or gavage feedings, or continuous parenteral nutrition early after birth to treat hypoglycemia. ◯◯ Monitor the neonate's blood glucose level closely per facility protocol. ◯◯ Monitor IV if the neonate is unable to feed orally.

Nutrition During Pregnancy: Provide Prenatal Education

●● Instruct the client to adhere to and maintain the following during pregnancy. ◯◯ An increase of 340 calories/day is recommended during the second trimester. An increase of 452 calories/day is recommended during the third trimester. ◯◯ If the client is breastfeeding during the postpartum period, an additional intake of 330 calories/day is recommended during the first 6 months, and an additional intake of 400 calories/day is recommended during the second 6 months. ◯◯ Increasing protein intake is essential to basic growth. Also, the intake of foods high in folic acid is crucial for neurological development and the prevention of fetal neural tube defects. Foods high in folic acid include leafy vegetables, dried peas and beans, seeds, and orange juice. Breads, cereals, and other grains are fortified with folic acid. Increased intake of folic acid is encouraged for clients who wish to become pregnant and clients of childbearing age. It is recommended that 600 mcg of folic acid should be taken during pregnancy. Current recommendations for clients who are lactating include consuming 500 mcg of folic acid. ◯◯ Iron supplements are often added to the prenatal plan to facilitate an increase of the maternal RBC mass. Iron is best absorbed between meals and when given with a source of vitamin C. Milk and caffeine interfere with the absorption of iron supplements. Food sources of iron include beef liver, red meats, fish, poultry, dried peas and beans, and fortified cereals and breads. A stool softener may need to be added to decrease constipation experienced with iron supplements. ◯◯ Calcium, which is important to a developing fetus, is involved in bone and teeth formation. ■■ Sources of calcium include milk, calcium-fortified soy milk, fortified orange juice, nuts, legumes, and dark green leafy vegetables. Daily recommendation is 1,000 mg/day for pregnant and nonpregnant women over the age of 19, and 1,300 mg/day for those under 19 years of age. ◯◯ 2 to 3 L of fluids is recommended daily. Preferred fluids are water, fruit juice, and milk. ◯◯ Caffeine intake should be limited to 300 mg/day. The equivalent of 500 to 750 mL/day of coffee may increase the risk of a spontaneous abortion or fetal intrauterine growth restriction. ◯◯ It is recommended that women abstain from alcohol consumption during pregnancy. Risk Factors

Assessment of Fetal Well-Being: Perform Fetal Heart Monitoring

●● Nonstress test (NST) - most widely used technique for antepartum evaluation of fetal well-being performed during the third trimester. It is a noninvasive procedure that monitors response of the FHR to fetal movement. A Doppler transducer, used to monitor the FHR, and a tocotransducer, used to monitor uterine contractions, are attached externally to a client's abdomen to obtain tracing strips. The client pushes a button attached to the monitor whenever she feels a fetal movement, which is then noted on the tracing. This allows a nurse to assess the FHR in relationship to the fetal movement. ●● Indications for the use of an NST during pregnancy ◯◯ Potential diagnoses for: ■■ Assessing for an intact fetal CNS during the third trimester. ■■ Ruling out the risk for fetal death in clients who have diabetes mellitus. Used twice a week or until after 28 weeks of gestation. ◯◯ Client presentation ■■ Decreased fetal movement ■■ Intrauterine growth restriction ■■ Postmaturity ■■ Gestational diabetes mellitus ■■ Gestational hypertension ■■ Maternal chronic hypertension ■■ History of previous fetal demise ■■ Advanced maternal age ■■ Sickle cell disease ■■ Isoimmunization ●● Interpretation of findings ◯◯ The NST is interpreted as reactive if the FHR is a normal baseline rate with moderate variability, accelerates to 15 beats/min for at least 15 seconds and occurs two or more times during a 20-min period. View Image: Reactive NST ◯◯ Nonreactive NST indicates that the fetal heart rate does not accelerate adequately with fetal movement. It does not meet the above criteria after 40 min. If this is so, a further assessment, such as a contraction stress test (CST) or biophysical profile (BPP), is indicated. ●● Nursing actions ◯◯ Preparation of client ■■ Seat the client in a reclining chair, or place in a semi-Fowler's or left-lateral position. ■■ Apply conduction gel to the client's abdomen. ■■ Apply two belts to the client's abdomen, and attach the FHR and uterine contraction monitors. CHAPTER 6 Assessment of Fetal Well-Being 54 RN Maternal Newborn Nursing ◯◯ Ongoing care ■■ Instruct the client to press the button on the handheld event marker each time she feels the fetus move. ■■ If there are no fetal movements (fetus sleeping), vibroacoustic stimulation (sound source, usually laryngeal stimulator) may be activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus. ●● Miscellaneous ◯◯ Disadvantages of a NST include a high rate of false nonreactive results with the fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications, and chronic smoking.

Complications Related to the Labor Process: Priority Action for a Client who has a Prolapsed Umbilical Cord

●● Nursing Care ◯◯ Call for assistance immediately. ◯◯ Notify the provider. ◯◯ Use a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. ◯◯ Reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the client's right or left hip to relieve pressure on the cord. ◯◯ Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow. ◯◯ Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia. ◯◯ Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation. ◯◯ Initiate IV access, and administer IV fluid bolus. ◯◯ Prepare for a cesarean birth if other measures fail. ◯◯ Inform and educate the client and her partner about the interventions.

Medical Conditions: Caring for a Client who has Hyperemesis Gravidarum

●● Nursing Care ◯◯ Monitor the client's I&O. ◯◯ Assess the client's skin turgor and mucous membranes. ◯◯ Monitor the client's vital signs. ◯◯ Monitor the client's weight. ◯◯ Have the client remain NPO for 24 to 48 hr. ●● Medications ◯◯ Give the client IV fluids of lactated Ringer's for hydration. ◯◯ Give pyridoxine (Vitamin B6) and other vitamin supplements as tolerated. ◯◯ Use antiemetic medications cautiously for uncontrollable nausea and vomiting (ondansetron [Zofran], metoclopramide [Reglan]). ◯◯ Use corticosteroids to treat refractory hyperemesis gravidarum. ●● Health Promotion and Disease Prevention ◯◯ Discharge instructions ■■ Advance the client to clear liquids after 24 hr if no vomiting. ■■ Advance the client's diet, as tolerated, with frequent, small meals. Start with dry toast, crackers, or cereal; then move to a soft diet; and finally to a normal diet as tolerated. ■■ In severe cases, or if vomiting returns, enteral nutrition per feeding tube or total parental nutrition (TPN) may be considered.

Baby Friendly Care: Facilitate Sibling Adaptation to Newborn

●● Nursing interventions to facilitate sibling acceptance of the infant ◯◯ Take the sibling on a tour of the obstetric unit. ◯◯ Encourage the parents to: ■■ Let the sibling be one of the first to see the infant. ■■ Provide a gift from the infant to give the sibling. ■■ Arrange for one parent to spend time with the sibling while the other parent is caring for the infant. ■■ Allow older siblings to help in providing care for the infant. ■■ Provide the preschooler with a doll to care for.

Bleeding During Pregnancy: Characteristics of Placentae Previa

●● Placenta previa occurs when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. The abnormal implantation results in bleeding during the third trimester of pregnancy as the cervix begins to dilate and efface.

Medical Conditions: Priority Intervention for a Client who is Having a Seizure

◯◯ Anticonvulsant medications ■■ Magnesium sulfate. ■■ Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS. ■■ Maintain a dark quiet environment to avoid stimuli that may precipitate a seizure. ■■ Maintain a patent airway in the event of a seizure. Maintain the client on bed rest, and encourage side-lying position.

Nutrition During Pregnancy: Educating a Client who has Heartburn

◯◯ Heartburn may occur during the second and third trimesters due to the stomach being displaced by the enlarging uterus and a slowing of gastrointestinal tract motility and digestion brought about by increased progesterone levels. The client should eat small frequent meals, not allow the stomach to get too empty or too full, sit up for 30 min after meals, and check with her provider prior to using any over-the-counter antacids.

Nursing Care of Newborns: Hepatitis B Immunization

◯◯ Hepatitis B Immunization ■■ Provides protection against hepatitis B. ■■ Nursing Considerations and Client Education ☐☐ Recommended to be given to all newborns; informed consent must be obtained. ☐☐ For newborns born to healthy women, recommended dosage schedule is at birth, 1 month, and 6 months. ☐☐ For women infected with hepatitis B, hepatitis B immunoglobulin (HBIG) and the hepatitis B vaccine is given within 12 hr of birth. The hepatitis B vaccine is given alone at 1 month, 2 months, and 12 months. ☐☐ It is important NOT to give the vitamin K and the hepatitis B injections in the same thigh. Sites should be alternated.

Nursing Care of Newborns: Newborn Safety

◯◯ Identification (using two identifiers) is applied to the newborn immediately after birth by the nurse. It is an important safety measure to prevent the newborn from being given to the wrong parents, switched, or abducted. ■■ The newborn, mother, and mother's partner are identified by plastic identification wristbands with permanent locks that must be cut to be removed. Identification bands should include the newborn's name, sex, date, time of birth, and mother's health record number. The newborn should have one band placed on the ankle and one on the wrist. In addition, the newborn's footprints and mother's thumbprints are taken. The above information is also included with the footprint sheet. ■■ Each time the newborn is taken to the parents, the identification band should be verified against the mother's identification band. ■■ All facility staff who assist in caring for the newborn are required to wear photo identification badges. ■■ The newborn is not to be given to anyone who does not have a photo identification badge that distinguishes that person as a staff member of the facility maternal-newborn unit. ■■ Many facilities have locked maternal-newborn units that require staff to permit entrance or exit. Some facilities have a sensor device on the ID band or umbilical cord clamp that sounds an alarm if the newborn is removed from the facility.

Postpartum Physiological Adaptations: Assessing Fundal Height Postpartum

◯◯ Immediately after delivery, the fundus should be firm, midline with the umbilicus, and approximately at the level of the umbilicus. At 12 hr postpartum, the fundus may be palpated at 1 cm above the umbilicus. ◯◯ Every 24 hr, the fundus should descend approximately 1 to 2 cm. It should be halfway between the symphysis pubis and the umbilicus by the sixth postpartum day. ◯◯ By day 10, the uterus should lie within the true pelvis and should not be palpable. ●● The nurse should assess the fundal height, uterine placement, and uterine consistency at least every 8 hr after the recovery period has ended. ◯◯ Explain the procedure to the client. ◯◯ Apply clean gloves, a lower perineal pad, and observe lochia flow as the fundus is palpated. ◯◯ Cup one hand just above the symphysis pubis to support the lower segment of the uterus, and with the other hand, palpate the client's abdomen to locate the fundus. ◯◯ Document the fundal height, location, and uterine consistency. ■■ Determine the fundal height by placing fingers on the abdomen and measuring how many fingerbreadths (centimeters) fit between the fundus and the umbilicus above, below, or at the umbilical level. ■■ Determine whether the fundus is midline in the pelvis or displaced laterally (caused by a full bladder). ■■ Determine whether the fundus is firm or boggy. If the fundus is boggy (not firm), lightly massage the fundus in a circular motion.

Nursing Care of Newborns: Umbilical Cord Care

◯◯ Inspect the newborn's umbilical cord. Observe for any bleeding from the cord, and ensure that the cord is clamped securely to prevent hemorrhage. ◯◯ Topical Antimicrobial Therapy ■■ May be used for prevention of infection and to promote drying of the umbilical cord stump. ■■ Nursing Considerations ☐☐ Assess stump and base of cord for edema, erythema, and drainage with each diaper change. ☐☐ Care for the cord as prescribed by the provider. This may include applying triple dye or cleansing with neutral pH cleanser and sterile water. The cord should be kept clean and dry to prevent infection. ☐☐ Bathing infant by submerging in water should not occur until the cord has fallen off.

Nutrition During Pregnancy: Foods that Support Iron Absorption

◯◯ Iron supplements are often added to the prenatal plan to facilitate an increase of the maternal RBC mass. Iron is best absorbed between meals and when given with a source of vitamin C. Milk and caffeine interfere with the absorption of iron supplements. Food sources of iron include beef liver, red meats, fish, poultry, dried peas and beans, and fortified cereals and breads. A stool softener may need to be added to decrease constipation experienced with iron supplements.

Early Onset of Labor: Magnesium Sulfate Toxicity

◯◯ Magnesium sulfate ■■ Classification and Therapeutic Intent ☐☐ Magnesium sulfate is a commonly used tocolytic that relaxes the smooth muscle of the uterus and thus inhibits uterine activity by suppressing contractions. ■■ Nursing Considerations ☐☐ Monitor the client closely. Tocolytic therapy should be discontinued immediately if the client exhibits manifestations of pulmonary edema, which includes chest pain, shortness of breath, respiratory distress, audible wheezing and crackles, and/or a productive cough containing blood-tinged sputum. ☐☐ Monitor for adverse effects. CHAPTER 10 Early onset of labor 110 RN Maternal Newborn Nursing ☐☐ Monitor for magnesium sulfate toxicity, and discontinue for any of the following adverse effects: loss of deep tendon reflexes, urinary output less than 30 mL/hr, respiratory depression less than 12/min, pulmonary edema, and/or chest pain. ☐☐ Administer calcium gluconate as an antidote for magnesium sulfate toxicity. ☐☐ Contraindications for tocolysis include active vaginal bleeding, dilation of the cervix greater than 6 cm, chorioamnionitis, greater than 34 weeks of gestation, and acute fetal distress. ■■ Client Education ☐☐ Instruct the client to notify the nurse of blurred vision, headache, nausea, vomiting, or difficulty breathing.

Labor and Delivery Process: Identifying a Concern During Labor

◯◯ Nursing Actions ■■ Leopold maneuvers - abdominal palpation of the number of fetuses, the fetal presenting part, lie, attitude, descent, and the probable location where fetal heart tones may be best auscultated on the woman's abdomen. ■■ External electronic monitoring (tocotransducer) - separate transducer applied to the maternal abdomen over the fundus that measures uterine activity. ☐☐ Displays uterine contraction patterns ☐☐ Easily applied by the nurse but must be repositioned with maternal movement to ensure proper placement ■■ External fetal monitoring (EFM) - transducer applied to the abdomen of the client to assess FHR patterns during labor and birth. ◯◯ Laboratory Analysis ■■ Group B streptococcus - culture is obtained if results are not available from screening at 36 to 37 weeks. ☐☐ If positive, intravenous prophylactic antibiotic is prescribed (exceptions are planned cesarean birth and membranes intact). ■■ Urinalysis - clean-catch urine sample obtained to ascertain maternal: ☐☐ Hydration status via specific gravity ☐☐ Nutritional status via ketones ☐☐ Proteinuria, which is indicative of gestational hypertension ☐☐ Urinary tract infection via bacterial count ■■ Blood Tests ☐☐ Hct level ☐☐ ABO typing and Rh-factor if not previously done ◯◯ Client Education ■■ Provide the client and the client's partner with ongoing education regarding the labor and delivery process and procedures. ●● Intraprocedure for Labor and Birth Process ◯◯ Nursing Actions ■■ Assess maternal vital signs per agency protocol. ☐☐ Check maternal temperature every 1 to 2 hr if membranes are ruptured. ■■ Assess FHR to determine fetal well-being. This may be performed by use of EFM or spiral electrode that is applied to the fetal scalp. ☐☐ Prior to electrode placement, cervical dilation and rupture of membranes must occur. ■■ Assess uterine labor contraction characteristics by palpation (placing a hand over the fundus to assess contraction frequency, duration, and intensity) or by the use of external or internal monitoring. ☐☐ Frequency - established from the beginning of one contraction to the beginning of the next. ☐☐ Duration - the time between the beginning of a contraction to the end of that same contraction. ☐☐ Intensity - strength of the contraction at its peak described as mild, moderate, or strong. ☐☐ Resting tone of uterine contractions - tone of the uterine muscle in between contractions. XX A prolonged contraction duration (greater than 90 seconds) or too frequent contractions (more than five in a 10-min period) without sufficient time for uterine relaxation (less than 30 seconds) in between can reduce blood flow to the placenta. This can result in fetal hypoxia and decreased FHR.

Nursing Care and Discharge Teaching: Evaluate Client Ability to Care for the Newborn's Circumcision

◯◯ Nursing interventions ■■ Preprocedure - Parent teaching ☐☐ Signed informed consent form from parents is needed. ☐☐ Explain to the parents that the newborn will not be able to be bottle feed for up to 4 hr prior to the procedure to prevent vomiting and aspiration based on the preferences of the provider. Newborns who are breastfed may nurse up until the procedure. ☐☐ Explain that the newborn is restrained on a special board during the procedure. ■■ Gather and prepare supplies. ■■ Administer medication to newborn as prescribed. ■■ Assist with procedure ☐☐ Place the newborn on the restraining board, and provide a radiant heat source to prevent cold stress. Do not leave the newborn unattended. Have bulb syringe readily available. ☐☐ Comfort the newborn as needed. ☐☐ Document time and type of circumcision, excessive bleeding, and newborn voiding following procedure. ◯◯ Postprocedure care ■■ Remove the newborn from the restraining board and swaddle to provide comfort. ■■ Monitor for bleeding and voiding per facility protocol. Apply gauze lightly to penis if bleeding or oozing is observed. ■■ Fan fold diapers to prevent pressure on the circumcised area. ◯◯ Postprocedure parent teaching ■■ Teach the parents to keep the area clean. Change the newborn's diaper at least every 4 hr, and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. ■■ Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. ■■ A tub bath should not be given until the circumcision is healed. Until then, warm water should be trickled gently over the penis. ■■ Notify the provider if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the newborn. ■■ Tell the parents that a film of yellowish mucus may form over the glans by day 2 and it is important not to wash it off. ■■ Teach the parents to avoid using premoistened towelettes to clean the penis because they contain alcohol. ■■ Inform the parents that the newborn may be fussy or may sleep for several hours after the circumcision. Provide comfort measures for 24 to 48 hr, to include acetaminophen (Tylenol) as prescribed. ■■ Inform the parents that the circumcision will heal completely within a couple of weeks. CHAPTER 26 Nursing Care and Discharge Teaching 308 RN Maternal Newborn Nursing ◯◯ Complications and nursing management ■■ Hemorrhage ☐☐ Monitor the newborn for bleeding. ☐☐ Provide gentle pressure on the penis using a small gauze square. Gelfoam powder or a sponge may be applied to stop bleeding. If bleeding persists, notify the provider that a blood vessel may need to be ligated. Have a nurse continue to hold pressure until the provider arrives while another nurse prepares the circumcision tray and suture material. ■■ Cold stress/hypoglycemia ☐☐ Monitor the newborn for excessive loss of heat resulting in increased respirations and lowered body temperature. ☐☐ Swaddle and feed the newborn as soon as the procedure is over. ■■ Other complications ☐☐ Report any frank bleeding, foul-smelling drainage, or lack of voiding to the provider. ☐☐ Provide discharge instructions to the parents about manifestations of infection, comfort measures, medications, and when to notify the provider.

Postpartum Infections: Preventing Mastitis

◯◯ Nursing interventions for mastitis ■■ Provide the client with education regarding breast hygiene to prevent and manage mastitis. ☐☐ Instruct to thoroughly wash hands prior to breastfeeding. ☐☐ Instruct to maintain cleanliness of breasts with frequent changes of breast pads. ☐☐ Encourage allowing nipples to air-dry. ☐☐ Teach proper infant positioning and latching-on techniques, including both the nipple and the areola. The client should release the infant's grasp on the nipple prior to removing the infant from the breast. ☐☐ Instruct the client about completely emptying her breasts with each feeding to prevent milk stasis, which provides a medium for bacterial growth. ☐☐ Encourage using ice packs or warm packs on affected breasts for discomfort. ☐☐ Instruct the client to continue breastfeeding frequently (at least every 2 to 4 hr), especially on the affected side. Instruct the client to manually express breast milk or use a breast pump if breastfeeding is too painful. ☐☐ Instruct the client to begin breastfeeding from the unaffected breast first to initiate the letdown reflex in the affected breast that is distended or tender. ☐☐ Encourage rest, analgesics, and fluid intake of at least 3,000 mL per day. ☐☐ Encourage the client to wear a well-fitting bra for support. ☐☐ Tell the client to report redness and fever. ☐☐ Administer antibiotics, and teach the client the importance of completing the entire course of antibiotics as prescribed.

Prenatal Care: Assessing Fetal Heart Rate During Routine Prenatal Exams

☐☐ FHR can be heard by Doppler at 10 to 12 weeks of gestation or heard with an ultrasound stethoscope at 16 to 20 weeks of gestation. Listen at the midline, right above the symphysis pubis, by holding the stethoscope firmly on the abdomen.