Exam 3

newborn heart rate

120-160

PP Hemorrhage-failure to clot

DIC

types of puerperal infections

Endometritis Mastitis wound infection respiratory tract infection Urinary tract

neutral thermal environment

Environment in which body temperature is maintained without an increase in oxygen or glucose comsumption.

baby blues

characterized by mood swings, feelings of sadness and anxiety, crying, difficulty sleeping, and loss of appetite. These symptoms usually go aways within a few days, TX is not needed.

major cause of death over 1 yr/teens

injuries (page 695)

immature respiratory control

irregular respirations with periodic breathing; risk for apnea; inability to rapidly alter depth of respirations

SGA (small for gestational age)

less than 10th percentile the lower the birth weight the higher the mortality (same true for gest. age: the lower the gest. age, the higher the mortality.)

PP Hemorrhage-dark red blood

likely of venous origin varices, superficial lacerations of the cervix

unintentional injuries-pediatrics

page 691

therapeutic management of ROP

prevent preterm birth provide early screening in infants that are born at <30 weeks of gestation and weight <1500 g and those with a birth weight between 1500-2000 g with an unstable clinical course. decrease exposure to bright direct lighting use supplemental oxygen judiciously and monitor oxygen blood levels (hyperoxia and hypoxia) arrest vascular proliferation process-cryotherapy or laser photocoagulation; surgical repair of detached retina

when is the greatest risk for early PP hemorrhage?

1 hour after delivery

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn? Select all that apply. 1. lethargy 2. sleepiness 3. irritability 4. constant crying 5. difficult to comfort 6. cuddles when being held

3, 4, 5

respiratory rate for newborns

30-60

kangaroo care

Treatment for preterm infants that involves skin-to-skin contact.

rooting reflex

a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple

acrocyanosis

a bluish discoloration of hands and feet a normal finding in the first 24 hours after birth.

PP Hemorrhage-Bright red blood

arterial deep lacerations of the cervix

decreased elastic lung tissue and recoil

decreased lung compliance requiring higher pressures and more work to expand, increased risk for atelectasis

tendency to nose breathe; altered position of larynx and epiglotttis

enhanced ability to synchronize swallowing and breathing; risk for airway obstruction; possibly more difficult to intubate

thermoregulation-radiation

the loss of heat from the body surface to cooler solid surface not in direct contact but in relative proximity. (place bassinet away from window)

Physiologic Jaundice of the Newborn

unconjugated hyperbilirubinemia occurs in 60% of term newborns disappears without treatment

risk factors and causes of Postpartum Hemorrhage

uterine atony overdistended uterus large fetus/multiple fetuses hydramnios distension with clots anesthesia and analgesia PMHX of uterine atony high parity obesity prolonged labor/pitocin induced labor trauma during labor and birth (forceps, vacuum, csection) unrepaired lacerations of birth canal retained placental fragments ruptured uterus inversion of the uterus placenta accreta, increta, percreta coagulation disorders placental abruption placenta previa manual removal of retained placenta mag sulfate administration during labor or PP period chorioamnionitis uterine subinvolution

what are the three stages of newborn transition?

1. The period of reactivity: HR increases and then decreases to baseline within 30 min, RR are irregular and 60-80. crackles, grunting, crying, nasal flaring, and retractions may be present but then go away after an hour. 2. The period of decreased responsiveness: sleep, decreased motor activity, lasts 60-100 min. Infant is pink, RR are rapidd (up to 60), shallow, and unlabored. Bowel sounds may be present. 3. The second period of reactivity: occurs between 2-8 hours after birth, and lasts from 10 mins to several hours. Brief periods of tachycardia/penia, increased muscle tone, skin color changes, mucous production, meconium is passed. Most healthy newborns regardless of type of birth and gestational age experience this except very preterm babies.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position.

3 If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast- feeding." 4. "I should wash my nipples daily with soap and water."

4 Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand-washing and that she should breast-feed every 2 to 3 hours.

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1."I will place my baby's crib close to the door." 2."Some health care personnel won't have name badges." 3."It's OK to allow the unlicensed assistive personnel to carry my newborn to the nursery." 4."I will ask the nurse to attend to my infant if I am napping and my husband is not here."

4 Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking the nurse to attend to the newborn if the mother is napping and no family member is available to watch the newborn (the newborn is never left unattended). If the mother states that she will ask the nurse to watch the newborn while she is sleeping, she has understood the teaching. Options 1, 2, and 3 are incorrect and would indicate that the mother needs further teaching.

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

4 The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than the other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 3 that present the risk for hemorrhage.

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1.Avoid stimulation. 2.Decrease fluid intake. 3.Expose all of the newborn's skin. 4.Monitor skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with eye shields or patches.

4, 5, 6 Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.

postpartum infection (puerperal infection)

any clinical infection of the genital tract that occurs within 28 days of miscarriage, induced AB, or birth. DX criteria: fever of 100.4 F or more on 2 successive days of the first 10 pp days (not counting first 24 hours after birth)

thicker alveolar wall; decreased alveolar surface area

less efficient gas transport and exchange

immature alveoli

risk for respiratory insufficiency and pulmonary problems

thermoregulation-evaporation

the loss of heat that occurs when a liquid is converted into a vapor. In the newborn, heat loss by evaporation occurs as a result of moisture evaporation from the skin. This heat loss is intensified by failing to complete dry the newborn after birth or with bathing. Evaporative heat loss, as a component of insensible water loss, is the most significant cause of heat loss in the first few days of life

Hypothermia

from excessive heat loss is a common and potentially serious problem

LGA (large for gestational age)

more than the 90th percentile for weight

normal blood glucose newborn

40-80 mg/dL ??

macrosomia

>4000 grams

what is considered postpartum hemorrhage?

vaginal birth: >500 ml C-section: >1000 ml 10% change in hematocrit from the time of admission to the birthing facility for labor until postpartum, or the need for erythrocyte infusion S/S may no show, but tachycardia is a sign

jaunice

visible yellow color of the skin and sclera, is likely to appear when the total serum bilirubin (TSB) exceeds 6-7 mg/dL.

nursing assessments and interventions for excessive postpartum bleeding

(page 509)

initiation of breathing

(watch a video or something-or page 529) - fetus practices breathing movements in utero - fetal lungs actively secrete fetal lung fluid, which decreases as it gets closer to term - reabsorption begins before birth and speeds up during labor - "physiologic squeeze" of vaginal birth aids in removal of fluid stimuli: temp, noise, pain, hypoxemia, hypercarbia, acidosis, chest compression VIP = cutting of umbilical cord = air inflates lungs w/first breath - *newborns are obligate nose breathers until 3 weeks so must clear airway* INITIAL breath - high than norm insp pressure = air enters lungs and overcomes resistance = airways and alveoli opened = fluid to interstitial space - increased alveolar pao2 = decrease pulm vasc resistance = gas exchange

benefits of bottle feeding

-allows a flexible schedule -no risk of passing on illness such as HIV -unwanted chemicals from mom -anyone can feed the baby -publicly acceptable -know how much baby is getting with feeding

suctioning with a bulb syringe

-the bulb syringe should always be kept in the infant's crib -the mouth is suctioned first to prevent the infant from inhaling pharyngeal secretions when gasping as the nares are touched -nasal passages are suctioned one nostril at a time -the bulb is compressed and the tip is inserted into one side of the mouth. The center of the mouth is avoided because the gag reflex can be stimulated -when the infant's cry does not sound as though it is through mucus or a bubble , suctioning can be stopped -the parents should be given demonstrations on how to use the bulb syringe and asked to perform a return demonstration

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1 Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1.Bring the infant to the clinic. 2.This is a normal occurrence. 3.Increase the number of times that the cord is cleaned per day. 4.Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

1 Symptoms of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the client should be instructed to notify a health care provider (HCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are inappropriate nursing interventions for the description given in the question.

kcal/kg needed in the first 3 months

110 kcal/kg/day (6-8 voiding per day)

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43 week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. turn on the apnea and cardiorespiratory monitors. 2. connect the resuscitation bag to the oxygen outlet 3. set up the intravenous line with 5% dextrose in water 4. set the radiant warmer control temperature at 36.5 C (97.6F)

2 (ABCs)

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings.

3 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 4 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1.Protects the newborn's eyes from possible infections acquired while hospitalized. 2.Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3.Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4.Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.

4 Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes for administering this medication to a newborn infant.

maternal breastfeeding reflexes

A= milk production B= milk ejection (let down)

treatment for mastitis

ABX for 10-14 days analgesic/antipyretics rest breastfeed/pump often warm compress before feeding or pumping fluid, adequate nutrition

methylergonovine

Action: contraction of the uterus Side effects: HTN, hypotension, nausea, vomiting, headache Contraindications: HTN, preeclampsia, cardiac disease Dosage and Route: 0.2mg IM q2-4h up to 5 doses, may be given intrauterine or orally. Nursing: check BP (don't give >140/90, continue monitoring vaginal bleeding and uterine tone)

Misoprostol (Cytotec)

Action: contraction of uterus Side Effects: headache, n/v/d, fever, chills Contraindications: none Dosage and Route: 600-1000 mcg rectally once or 400 mcg sublingually or PO once Nursing: continue to monitor vaginal bleeding and uterine tone.

Dinoprostone (Prostin E2)

Action: contraction of uterus Side Effects: headache, n/v/d, fever, chills Contraindications: use with caution with history of asthma, hyper/hypotension Dosage and Route: 20 mg vaginal or rectal suppository q2h Nursing: continue to monitor vaginal bleeding and uterine tone

Transient Tachypnea of the Newborn (TTN)

Characterized by Tachypnea greater than 60 bpm May also include - Chest retractions using accessory muscles and stomach - Grunting - Mild cyanosis - nasal flaring Often referred to as respiratory distress syndrome, type II Typically resolves suddenly after 3 days - May be caused by slow absorption of fluid in lungs after birth supplemental oxygen may be needed. Usually resolves in 24-48 hours

Moro reflex

Infant reflex where a baby will startle in response to a loud sound or sudden movement.

postpartum depression

can be biologic, physiologic, situational, or multifactorial. the change from high levels of estrogen and progesterone at the end of pregnancy to the much lower levels of both hormones that are present after birth are important etiologic factors in the development of PPD. poor nutrition may also be a factor risk factors include: PMHX of depression/anxiety, unintended pregnancy, social HX, lack of support, substance abuse, lower education, low self-esteem, stress, intimate partner violence.

latching

defined as placement of the infant's mouth over the nipple, areola, and breast, making a seal between the mouth and breast to create adequate suction for milk removal.

Subinvolution of the uterus

delayed return of the enlarged uterus to normal size and function. causes: retained placental fragments and pelvic infection. S/S: prolonged lochial discharge, irregular excessive bleeding, and sometimes hemorrhage. A pelvic exam reveals a larger than normal uterus that can be boggy. TX: methergine, dilation and curettage, ABX (tx depends on cause)

increased intrapulmonary right-left shunting

increased risk for atelectasis with wasted ventilation; lower PCO2

immaturity of pulmoary surfactant system in immature infants

increased risk of atelectasis and respiratory distress syndrome; increased work of breathing

mastitis

inflammation of the breast, often from infection. flu-like symptoms, localized breast pain, tenderness, warm reddened area on the breast. most often occurs in the upper outer quadrant of the breast one or both breasts can be affected most cases occur between 2 and 4 weeks PP

reduced diaphragm movement and maximal force potential

less effective respiratory movement, difficulty generating negative intrathoracic pressures, risk for atelectasis

Rh Incompatibility

mom Rh neg baby Rh pos first baby is not a problem, second baby is Rhogam

signs of respiratory distress in newborn

nasal flaring, intercostal or subcostal retractions, grunting with respirations, acrocyanosis, central cyanosis

PP Hemorrhage-spurts of blood

placental separation

clinical manifestations of ROP

progressive vascular growth of retina eventual blindness if not treated diagnosed by ophthalmologic examination

Retinopathy of Prematurity (ROP)

severe vascular constriction in immature retinal vasculature followed by hypoxemia in retina, which in turn stimulates abdominal vascular proliferation of retinal capillaries into hypoxic area; as retinal veins dilate and multiply in direction of lens, retinal detachment may occur if untreated. multifactorial etiology-preterm birth major risk factor

facilitation of latch

support breast with one hand with the thumb o ntp and four fingers underneath the back edge of the areola. the breast is compressed slightly with the fingers parallel to the infant's lips. Expressing some milk on nipple might entice the infant to feed.

thermoregulation-conduction

the loss of heat from the body surface to cooler surfaces in direct contact. During the initial assessment, the newborn is placed on a prewarmed bed under a radiant warmer to minimize heat loss. The scales used for weight the newborn should have a protective cover to minimize conductive heat loss.

retained placenta

when the placenta does not deliver within 30 minutes after the infant despite gentle traction on the umbilical cord and uterine massage. common in preterm deliveries.

increased oxygen consumption

increased respiratory rate and work of breathing, risk for hypoxia

assessment and screening for hyperbilirubinemia of the newborn

most cases are physiologic jaundice caused by increased levels of unconjugated bilirubin. in some cases phototherapy is used to lower bili levels

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2 Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

the nurse is monitoring a client in immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 ° F 2. An increase in the pulse rate from 88 to 102 beats/ minute 3. A blood pressure change from 130/ 88 to 124/ 80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/ minute

2 During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1.Apply gentle pressure. 2.Reinforce the dressing. 3.Document the findings. 4.Contact the health care provider (HCP).

3 The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the health care provider. Because the findings identified in the question are normal, the nurse would document the assessment findings.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3 Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/ minute, by face mask.

4 If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/ minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1."Your newborn needs vitamin K to develop immunity." 2."The vitamin K will protect your newborn from being jaundiced." 3."Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel." 4."Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

4 Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn to prevent bleeding disorders. Vitamin K promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K-deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.

fragments of placenta left behind

boggy uterus (due to uterine atony) excessive bleeding manually removed (uterine curettage/suction)

complications of mastitis

breast abscess chronic mastitis fungal infections of the breast

AAP recommendations for breastfeeding

ideal and sufficient for 1st 6 months, should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child.

AGA (appropriate for gestational age)

between 10th and 90th percentile

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

1, 2, 3, 4 Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/ day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? Select all that apply. 1. cyanosis 2. tachypnea 3. Hypotension 4. retractions 5. audible grunts 6. presence of a barrel chest

1, 2, 4, 5

The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? 1.Monitoring the newborn's vital signs routinely 2.Maintaining standard precautions at all times while caring for the newborn 3.Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4.Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

2 An infant born to a mother infected with human immunodeficiency virus (HIV) must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Mothers infected with HIV should not breast-feed. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn.

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?1.Warming the crib pad 2.Closing the doors to the room 3.Drying the infant with a warm blanket 4.Turning on the overhead radiant warmer

3 Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).

pitocin

Action: contraction of uterus; decreases bleeding Side effects: infrequent: water intoxication; nausea and vomiting Contraindications: None Dosage and Route: 10 to 40 units/L diluted in lactated Ringer's' solution or normal saline at 125 to 200 mU/min IV or 10 to 20 units IM Nursing Considerations continue to monitor vaginal bleeding and uterine tone.

Pathologic Jaundice of the Newborn

Hyperbilirubinemia is considered pathological when: It appears on the 1st day of life Bilirubin rises more than 5 per day Bilirubin rises above 19.5 in term child Direct bilirubin rises above 2 at any time Hyperbilirubinemia persists after the 2nd week of Life

clinical manifestations of NEC

distended (often shiny) abdomen blood in stools or gastric contents gastric retention (undigested formula) localized abdominal wall erythema or induration bilious vomitus poor feeding decreased urinary output unstable body temp jaundice

Where is the PMI on a newborn?

fourth intercostal space the the left of the midclavicular line. heart sounds during the neonatal period are of higher pitch, shorter duration, and greater intensity than during adult life

what is uterine atony associated with?

high parity, polyhydramnios, fetal macrosomia, obesity, and multiple gestation.

TORCH

Toxoplasmosis Other (HBV, parvovirus, HIV, West Nile Virus) Rubella CMV Infection (cytomegalovirus) Herpes Simplex

Necrotizing Enterocolitis (NEC)

an acute inflammatory disease of the bowel with increased incidence in preterm infants. cause is unknown, but they think it has to do with infants having vascular compromise of the GI tract ischemia of unknown etiology, immature host defenses, bacterial proliferation, and feeding substrate are now believed to have a multifactorial role in the etiology of NEC.

Idiopathic or immune thrombocytopenic purpura (ITP)

an autoimmune disorder in which antiplatelet antibodies decrease the lifespan of the platelets. diagnostic findings include thrombocytopenia, capillary fragility, and increased bleeding prophylaxis: corticosteroids or immunoglobulins TX: platelets, splenectomy

Nursing care for NEC

breast feeding is preferred and enteral feedings should be minimized if the infant is believed to have experienced birth asphyxia treatment: d/c of all oral feeding, institution of abdominal decompression via NG suction, IV ABX, correction of extravascular volume depletion, lyte abnormalities, acid-base imbalances, and hypoxia, possibly an ileostomy, jejunostomy, or colostomy. check for abdomen distension monitor vs, do not use rectal thermometer listen to BS strict hand hygiene

nursing for macrosomia

historically, maternal hyperglycemia was believed to contribute to fetal macrosomia. However, maternal hyperlipidemia and increased lipid transfer to the fetus are more likely responsible for excessive weight gain and fat deposition seen in such infants. because macrosomic infants are at risk for problems associated with a difficult birth, they are monitored for birth injuries such as brachial plexus injury and palsy, fractured clavicle, and phrenic nerve palsy, polycythemia, hypocalcemia, poor feeding, and hyperbilirubinemia

hypoglycemia in newborn

hypoglycemia in a term infant during the early newborn period is defined as a blood glucose concentration inadequate to support neurologic, organ, and tissue dysfunction.

risk factors for mastitis

inadequate emptying of the breasts plugged ducts sudden decrease in feedings abrupt weaning wearing underwire bras sore/cracked nipples stress maternal illness/family illness breast trauma poor maternal nutrition

kernicterus

irreversible, long-term consequences of bilirubin toxicity such as hypotonia, delayed motor skills, hearing loss, cerebral palsy, and gaze abnormalities

NIPS

neonatal infant pain scale

signs of neonatal abstinence syndrome

neurologic -irritability -seizures -hyperactivity -high-pitched cry -tremors -exaggerated moro reflex -hypertonicity of the muscles Gastrointestinal -poor feeding -d/v -frantic, uncoordinated sucking -gastric residuals Autonomic -diaphoresis -fever -mottled skin Respiratory -tachypnea (<60 breaths/min) -nasal flaring/stuffiness Miscellaneous -disturbed sleep patterns -excoriations on knees and face -temp instability

care management of ROP

preventative care=monitor blood oxygen levels carefully, responding promptly to saturation alarms, and preventing fluctuations in blood oxygen levels provide postop pain management if surgery is performed provide parental education and support provide nursing care using principles pf individualized developmental care

oxytocin-breastfeeding

promotes let down reflex -brings milk to the front of nipple -ejects milk

prolactin-breastfeeding

stimulates milk production anterior pituitary

Neonatal Abstinence syndrome (NAS)

the term used to describe the set of behaviors exhibited by infants exposed to opioids in utero.

thermoregulation

the maintenance of balance between heat loss and heat production. Newborns attempt to stabilize their core body temp within a narrow range

Uterine Atony

the leading cause of early PP hemorrhage

15-Methylprostaglandin F2α (Carboprost, Hemabate)

Action: contraction of uterus Side Effects: headache, n/v/d, fever, chills, tachycardia, HTN Contraindications: avoid with asthma and HTN Dosage and Route: 250 mcg IM or intrauterine injection q15-90 min up to 8 doses Nursing: continue to monitor vaginal bleeding and uterine tone.

medical management of PP hemorrhage order

oxytocin (pitocin) misoprostol (cytotec) methylergonovine Hemabate Dinoprostone

continued development of alveoli until childhood

possible opportunity to reduce effects of discrete lung injury

surfactant

protein manufactured in type II lung cells lowers surface tension which reduces the pressure required to keep the alveoli open during inspiration and prevents total alveolar collapse on exhalation.

phototherapy for hyperbilirubinemia in newborns

purpose is to reduce the level of circulating unconjugated bili or keep it from increasing. changes the shape and structure of unconjugated bili, converting it to a conjugated form that can be excreted through urine and stool. lotions and ointments should not be put on the baby (Burn)

small complaint airway passages with higher airway resistance; immature reflexes

risk for airway obstruction and apnea

hypoglycemia-high risk newborn

-The aap recommends that symptomatic infants receive treatment if the BG is less than 40 -due to hypertrophy and hyperplasia of the pancreatic islet cells and the transient state of hyperinsulinism. -high maternal BG during pregnancy provides a continuous stimulus to islet cells for insulin production. (glucose easily passes placental barrier, insulin does not) -when baby is in uterus, it is use to high levels of glucose and produces enough insulin to take care of it, when the infant is independent, it continues to produce the extra insulin

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1.Length of 19 inches 2.Abnormal palmar creases 3.Birth weight of 6 lb, 14 oz 4.Head circumference appropriate for gestational age

2 Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother?1.Feed the newborn less frequently. 2.Continue to breast-feed every 2 to 4 hours. 3.Switch to bottle-feeding the infant for 2 weeks. 4.Stop breast-feeding and switch to bottle-feeding permanently.

2 Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?1.Developmental delays because of excessive size 2.Maintaining safety because of low blood glucose levels 3.Choking because of impaired suck and swallow reflexes 4.Elevated body temperature because of excess fat and glycogen

2 The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problems.

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Elevate the client's legs. 2. Document the findings. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots.

3 If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs would not assist in managing uterine atony. Documenting the findings is an appropriate action but is not the initial action. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

increased pulmonary vascular resistance with sensitive pulmonary arterioles

risk for ductal shunting and hypoxemia with events such as hypoxia, acidosis, hypothermia, hypoglycemia, and hypercarbia

nonpharmacologic pain management for newborns

swadling pacifier oral sucrose kangaroo care breast feeding distraction with visual, oral, auditory, or tactile stimulation talking to them

Mastitis

symptoms: fever, malaise, FLS (flu like symptoms), sore area on breast prevention: hand washing, lanolin cream, air dry nipples after feedings

thermoregulation-convection

the flow of heat from the body surface to cooler ambient air. (put a hat on baby's head, and wrap them up)

conjugation of bilirubin

the liver is responsible for it results from the breakdown of RBCs When RBCs reach the end of their life span, their membranes rupture, and hemoglobin is released. The hemoglobin is phagocytosed by macrophages then splits into heme and globin. The heme is broken down by the reticuloendothelial cells, converted to bilirubin, and released in unconjugated form. The unconjugated (indirect) bilirubin is relatively insoluble and almost entirely bound to circulating albumin (a plasma protein). Bilirubin that is not bound to albumin, or free bilirubin, can easily cross the BBB and cause neurotoxicity. conjugated bilirubin is excreted in stool, so if there is a build up of it in the blood, they need to feed baby more often so they can excrete it in stool. premature babies are more at risk for jaundice