Postpartum and Care of the Normal Newborn

What is colostrum and what it looks like?

Colostrum is the first substance produced, it is thin, watery and slightly yellow. It is rich in protein and calories in addition to antibodies and lymphocytes. It also contains high levels of immunoglobulins, which transfer some immunity to the newborn. The mother begins producing colostrum in the last trimester of pregnancy and continues for 2 to 3 days after delivery.

What he nurse should do if the uterus appeared boggy on palpation?

Gently massage the fundus to increase contractlility. A boggy and soft fundus will be difficult to locate and may be atonic, which can result in hemorrhage. If the fundal massage does not help, oxytocic agents may be prescribed to increase contractlility.

What is uterine involution?

Gradual return of the uterus to it's pre-pregnancy size and the return into the pelvis which takes about 6 weeks. The normal uterus weighs approximately 2 ounces.

What is Lochia and the different types?

Lochia is the fluid waist discharged from the vagina after delivery and it consists of blood, mucus and tissue. Lochia has a fleshy odor similar to that of menstrual discharge. Lochia Rubra-For the first day to day 3 after delivery the lochia is made out mostly of blood, resulting in a bright red discharge called Lochia Rubra. Lochia serosa-pink to brown discharge as the placental site starts to heal-from day 4 to day 10 Lochia Alba-after day 11 to 14th day- the discharge is yellow/white and continues for another 10 days to 2 weeks. The Lochia decreases daily in amount and increases with ambulation. To most accurately determine the amount of discharge, the perineal pads should be weight before and after use. There should be no more than 8 pads per day used.

How is the fundus assessed after delivery, hand placement?

Palpate the uterus by placing one hand over the lower segment of the uterus near the pubic bone. use the side of the other hand to feel the location and consistency of the uterus.

Perinatal Loss

associated with miscarriage, neonatal death, stillbirth and therapeutic abortion

Breast milk production

decrease in estrogen and progesterone levels after delivery stimulate increased prolactin which promote breast milk production

Palmer/Plantar grasp

examiners finger placed in newborns hand and fingers curl around it examiner's finger placed at the base of newborns toes and toes curl downward -Palmer lessens in 3-4 months -Plantar lessens in 8 months

Subinvolution

failure of the uterus to return to its normal size & condition -uterine pain on palpation -uterus larger than expected -more vaginal bleeding than normal -Methergine may be given to sustain contractions

Uncircumsized newborn

foreskin and glans are 2 similar layers of cells that separate from each other. separation process is normally complete by age 3 but can remain until puberty. mom should not pull back foreskin, but allow for normal separation.

Preterm newborn

neonate before 37 weeks gestation

What is Moro reflex?

new born held in a semi sitting position then allowed to fall backward to a 30 degree angle. newborn assumes sharp extension and abduction of arms with thumbs and forefingers in a "C" position followed by flexion and adduction to an embrace position -present at birth and gone by 6 months if neurological maturation is not delayed

Pull to sit response

newborn is pulled up from the wrist from prone position head will lag until in upright position then will be level with chest momentarily before falling forward head will then lift for a few min

Startle reflex

newborn should be at least 24 hours old -examiner makes a loud noise and newborn responds with adducted arms and flexed elbows -disappears in 4 months

What is swallowing reflex?

occurs spontaneously after sucking without gagging or coughing

Respiratory distress syndrome

serios lung disorder caused by immaturity and inability to produce surfactant causing hypoxia and acidosis -tachypnea, flaring nares, retractions, expiratory grunting, seesaw respirations -decreased breath sounds -apnea -pallor and cyanosis -hypothermia -poor muscle tone

A baby is having difficulty latching on the the breast, what interventions/teachings would help?

-Correct position of the baby against the nipple and the areola in the babies mouth

Mom has delivered in the past 10-12 hours, what is done to help them have a bowel movement?

-Encourage fluid intake -Encourage a diet high in fiber -Encourage ambulation -Administer stool softener, laxative, enema or suppository if needed -Sitz baths may also help with normal elimination -Inspect the perineum and reassure the client that no harm will come from normal elimination

What would be considered normal within the first hour after delivery when it comes to the fundus and vaginal discharge?

-Fundus decreases one cm per day, at first day postpartum is approximately at the level of the umbilicus -it should feel firm, like a softball, contracted and midline -may have cramps and contractions Lochia will be present, which will be dark red in the first 3 days postpartum

What ways the baby looses heat?

-Radiation-keep away from cold objest -Evaporation-keep dry and warm -Conduction-perform all treatment on a warm, padded surface -Convection-shield the newborn from drafts

What interventions would make a patient with an episiotomy more comfortable?

-Sitz baths -Clense front to back -Use perineal spray water bottle -change pad frequently -Do not douche or use tampons -Continue using Tucks pads -Ice pack to the area -Dry heat application -Topical anesthetic creams and sprays -Episiotomy heals in approximately 3 weeks

Normal Postpartum VS

-Temp: may rise to 110.4 F r/t dehydrating effects of labor. any higher could be infection -Pulse: may decrease to 50bpm -BP: should be normal -Resp: rarely changes

Physiological maternal changes

-Uterus decreases from 2lb to 2oz in 6 wks -endometrium regenerates -fundus descends into pelvis by 1 cm per day -10 days postpartum uterus can't be palpated -flaccid fundus indicates atony & should be massaged until firm -tender fundus indicates infection -cervical involution occurs. in 1 wk muscle begins to regenerate -vaginal distention decreases but muscle tone is never completely restored -menstrual flow resumes within 1-2 months (non-breastfeeding) -period resumes in 3-6months (breastfeeding) -breastfeeding moms may have amenorrhea but will still ovulate.

Urinary tract

-may have urinary retention r/t loss of elasticity, tone & sensation in bladder from trauma, meds, anesthesia or lack of privacy -Diuresis usually begins within first 12 hrs

GI Tract

-very hungry after delivery -constipation can occur -hemorrhoids are common

Breast feeding procedure

-wash hands and assume comfortable pos. -start with breast that ended last feeding -brush baby's lower lip with nipple -tickle lips to make baby open its mouth -guide nipple and areola into mouth -listen for sucking and swallowing -after baby has nursed release suction by depressing baby's chin or inserting finger in its mouth -burp after first breast -repeat on 2nd breast until baby is finished -burp again

N/I for mastitis

-wear a supportive non-underwire bra -rest during acute phase -maintain fluid intake of at least 3000 mL per day -Continue to Breastfeed if breasts aren't too sore -Antibiotics may be prescribed & must take full course -moist heat or ice packs -continued decompression of breasts by breast feeding or pump

What nursing interventions would help promote father-infant bonding?

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When forceps is used for delivery, how would you explain the results of the procedure to the parent?

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Initial assessment of the newborn, what finding would be considered abnormal? Select all that apply

-Airway (grunting, hypoxia, nasal flaring, retractions, cyanosis) -Skin color -Heart rate -Presence of meconium in lungs -Diminished or absent reflexes -Weak muscle tone (hyper and hypotonicity is an indication of CNS damage) -High-pitched cry -Jaundice present at birth -Hypoglycemia (tremors)

If a mother chooses not to breastfeed, what would help her to suppress the milk supply?

-Apply breast bonding by wearing a supportive bra within 4 to 6 hours after delivery -Avoid exposure of the breasts to heat and warm/hot water -Avoid any breast stimulation -Ice to the breasts -Do not restrict fluid intake

What care is given to a newly circumcised male baby?

-Apply petroleum jelly to the penis, except when a PlastiBell is used. -Remove the gauze after the first voiding following the circumcision. -Observe for swelling, infection and bleeding. Clean the penis after each void by squeezing warm water over it. -A milky covering over the glans penis is normal and should not be disrupted. -Monitor for urinary retention. -Do not allow pressure over circumcised area and use loose diaper if needed.

Immediately after the baby is delivered, what is the nursing priority? Select all that apply

-Assess and ensure airway -Suction the baby -Cover mom and baby with warm blanket -dry the baby -Keep baby with mom to facilitate bonding -Place baby on mother's brests or abdomen -Place proper identification on both mom and baby -Place baby in preheated warmer -Footprint the newborn

Umbilical cord care for the newborn?

-Check the cord for bleeding or oozing in the first hours after birth -The cord clamp must be securely fastened with no skin caught in it -Keep the cord clean and dry -Fold the diaper so it does not cover the cord and to prevent moisture retention -Use alcohol on cord stump daily to facilitated drying and prevent infection -Sponge bathe for 7 to 10 days until the cord comes off. -Report any redness, drainage or foul odor.

What would be the first nursing intervention, if the new mom is saturating pads right after birth?

-Check the fundus and the amount and quality of the lochia -Assess for signs and symptoms of hypovolemic shock

What metabolic disorders are tested with newborn screening?

-PKU-phenylketonuria

What is Babinski reflex?

1. fanning and then curling toes when bottom of foot is stroked along side of sole beginning at heel and then moving across ball of foot to big toe. Toes will fan out with dorsiflexion of big toe. Disappears at 1 year of age. Absence laterally indicates CNS damage.

Postpartum interventions

1.monitor VS 2.monitor pain level 3.monitor height, consistency & location of funds 4.Monitor color, amount, odor of lochia 5.check breasts for engorgement 6.monitor perineum for swelling or discoloration 7.check for episiotomy healing 8.check incisions/dressing of cesarean 9.monitor I&Os 10.monitor bowel status 11.encourage voiding 12.encourage ambulation 13.check extremities for thrombophlebitis 14.RhoGAM administered within 72 hrs to Rh- mom 15.monitor parent/newborn bonding 16.monitor mom's emotional status

What is the normal respiratory rate for the newborn?

30 to 60

What is a gomco clamp?

A clamp used for circumcision and petroleum jelly needs to be applied to glans penis after.

What are the signs and symptoms of hemorrhaging shock postpartum?

A hemorrhage postpartum is considered when the blood loss is 500 ml or more. It is an emergency. Early hemoarrhage: occurs during the first 24 hours after delivery. Early signs include restlessness and increased pulse rate. Late: occurs more than 24 hours after delivery. A decrease in BP is a late sign of hemorrhage. Foundations: Signs and Symptoms: -Persistent significant bleeding-perineal pad soaked within 15 minutes and may not be accompanied by change in vital signs or maternal color and behavior. -Feels weak, lightheaded, sick to stomach, sees stars -anxiety and air hunger -skin turns ashen or gray, feels cool and clammy -pulse rate increases -blood pressure declines Interventions: -notify HCP -if atonic uterus, massage gently to expel clots and to cause uterine contractions, compress uterus manually as needed by using two hands -administer Oxytocic agents to IV as prescribed. -Give oxygen by face mask at 8/10 lpm -Tilt the woman to her side or elevate the right hip, elevate legs to at least 30 degree angle. -Provide additional or maintain existing IV infusion of NS or Lactated Ringer's to restore circulatory volume -Administer blood or blood products as ordered -Monitor Vital Signs -Insert indwelling catheter -Administer emergency drugs as ordered -Prepare for possible surgery -Document events and care provided

What is APGAR score and what is considered normal the first minute after birth?

APGAR score is given to the baby to rate well-being at birth. It is done at 1 minutes and 5 minutes postpartum. The number ranges from 0-10. There are 5 vital indicators that are measured-Heart rate, respiratory rate, muscle tone, reflex irritability, skin color. Score of 8-10 requires no interventions, score of 4-7 requires gentle stimulation by rubbing the infant's back and administration of oxygen. )-3 score requires infant resuscitation.

What are afterpains?

Afterbirth pains are cramping sensations resulting from the contraction of the uterus. they are more common and may be more severe in multiparas, breastfeeding mothers, patients treated with Oxytocin and patients who had over-distended uterus during pregnancy. Analgesics may be prescribed.

What is Grasping?

Also called Palmar reflex. When fingers are placed in the infant's hand, the fingers of the baby curl around examiner's fingers. This response lessens within 3 to 4 months.

What is the apical rate of a newborn? Other VS

Apical rate of 100 to 160 bpm Axillary temp: 96.8 - 99 F BP: 73/55 mm Hg

Where the fundus should be within the first 12 hours?

At the level of the umbilicus

What is acrocyanosis?

Bluish color of hands and feet of the newborn which is caused by poor peripheral circulation. It can last for 7 to 10 days. It is mostly observed when the infant is cold. Because of acrocyanosis, the infant is never given an APGAR score of 10 in the 1 minute after birth.

Postpartum hemorrhage

Causes: -uterine atony -laceration of vagina -cervix, perineum, labia hematoma development -retained placental fragments Predisposing factors: -High parity -Dystocia -Prolonged labor -Operative delivery -Overdistention of the uterus -Abruptio placentae -Previous Hx of postpartum hemorrhage -Infection -Placenta Previa

When palpating the uterus of a postpartum patient, what should it feel like if it is normal?

Contracted, firm and mid-line-like softball.

During the first 12 hours postpartum, up to what amount is considered normal for voiding?

Daily urinary output of up to 3 liters is common.

When checking the fundus and it is displaced to the side, what is the most likely cause?

Distended bladder

What is engorgement?

Engorgement is an uncomfortable fullness of the breasts that occurs when the milk supply initially comes in. It is a result of venous and lymphatic stasis that occurs during lactation. Usually observed about on the 4th day postpartum and resolves in about 48 hours. Breast feeding relieves engorgement

What are epstein's pearls?

Epstein's pearls are small white nodules seen on the hard palate of the newborn. These are a result of epithelial cells and disappear spontaneously within a few weeks.

What is startle reflex?

Flexing of the newborn's thighs and knees accompanied by fingers that fan, then clench, as the arms are simultaneously thrown out and then brought together, as though embracing something. This reflex can be elicited by startling the newborn with a sudden noise or movement.

What is called if the newborn exhibits jaundice at 48hours post-delivery?

Icterus neonatorum, which is caused by high bilirubin levels. It is abnormal if present less than 24 hours after birth.

What are the nutritional requirements for a breast-feeding mother?

Increase fluid intake Increase calorie intake by 200 to 500 calories per day. Continue taking prenatal vitamins as prescribed. Avoid spicy, gas forming foods and caffeine, and alcohol.

If a patient is given Oxytocin, how is effectiveness determined?

Increase in uterine contractions Strong afterbirth pains

What is engrossment?

Intense interest in how the infant looks and responds and a desire to touch and hold the baby. The father's developing bond with the newborn is seen with engrossment., Paternal analogue of maternal emotional bonding; term used to describe fathers' fascination with their neonates, including their desire to touch, hold, caress, and talk to the newborn baby.

Large or small for gestational age

Large = at or above 90th percentile small = at or below 10th percentile

LATCH

Latch achieved by infant Audible swallowing Type of nipple Comfort of mother Help given to mother with nursing

Body measurements

Length: 18 - 22 inches Weight: 5.5 - 9.5 lbs Head circumference: 13.2 - 14 inches Head is 1/4 of the body length

What is considered a normal stool for a neonate (first few stools)

Meconium- it is odorless, black-greenish, sticky stool made or vernix, lanugo, mucus and other substances of the amniotic fluid. The first stool should appear within the first 24 to 48 hours after birth.

What are the signs and symptoms of postpartum depression?

NCLEX: -Anxiety -Appetite changes -Crying, sadness -Difficulty concentrating or making decision -Fatigue and inability to sleep -Feeling of guilt -Irritability and aggitation -Lack of energy -Less responsive to the infant -Loss of pleasure in normal activities -Suicide thoughts All patients should be assessed for depression during pregnancy and the postpartum period.

Why is Vitamin K given to the newborn and how soon after birth?

Newborns have low prothrombin levels at birth and are at risk for hemorrhage. Because they are not able to synthesize vitamin K in the colon, an initial dose is given via injection in the vastus lateralis. It is administered during the early newborn period.

What is the appropriate way to bathe a newborn 1-2 days post-delivery?

Sponge bath only until the umbilical cord drys off and falls out. Wash the head last, dry and wrap with blanket immediately after bath to prevent heat loss.

Breast milk and formula

Sufficient diet for first 4-6 months

When bathing the newborn and noticed a bluish marking across the lower back, is this normal and which ethic groups are more likely to have that?

The bluish-black pigmentation which is seen in the lumbar dorsal area and the buttocks are called Mongolian spots. These are more common among Asian and dark-skinned individuals. The spots will gradually fade during the first and second year of life.

What is the taking in-phase of maternal adjustment?

The time immediately after birth when the client needs sleep, depends on others to meet her needs, and relives the events of the birth process.

Why is Homan's sign test done in a postpartum patient?

To assess the patient for thrombophlebitis, which they are at a greater risk for due to prolonged bed rest and elevated platelet count.

What % of weight is normal for the baby to loose in 24-48 hours after delivery?

Up to 10% of total body weight loss is considered normal.

What muscle is preferred when administering Vitamin K injection to a newborn?

Vastus lateralis-in the lateral aspect of the middle third.

What is the term for the white cream-cheese like covering on the babies body?

Vernix caseosa-it protect's the infant's skin from the amniotic fluid.

What is Tonic Neck Reflex?

When the infant's head is quickly turned to one side, arm and leg will extend to that side and opposite arm and leg will flex. Posture resembles a fencing position.This reflex disappears by 3 to 4 months of age and is replaced by symmetric positioning of both sides of body.

Is it normal for the newborn's eyes to cross?

Yes-Eyes cross because of weak extraoccular muscle and immature nervous system. It is called Strabismus.

High pitched shrill cry in newborns

can indicate increased intracranial pressure

What is Sucking and rooting reflex?

when newborn turns head toward nipple opens mouth, takes hold of nipple and sucks

Tonic neck or fencing position

while newborn is falling asleep head is turned to one side. Ex. if head is turned to left side the left arm and leg extend while the right arm and leg are flexed. Reverse for other side. -Disappears within 3-4 months