exam 3 --- Postpartum (unit 7) and Newborn (unit 8)

Mottling

Discoloration of the skin due to poor perfusion

6. What cultural practices related to childbirth do you see in your clinical setting? Does the nursing staff support these? Discuss specific cultural practices with new parents of a different culture from your own.

6.

The Carson baby's head is molded from the vaginal delivery. Upon seeing the baby, Ms. Carson says, "Oh, she is so beautiful, but something is wrong with her head."How should the nurse respond?

"Her head has been molded from delivery through the birth canal, which is normal." Rationale: Molding commonly occurs in babies delivered vaginally, and the head will become more symmetrical over time.

How many kilo calories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? a. 50 to 75 b. 85 to 100 c. 100 to 110 d. 150 to 200

ANS: B

Describe postpartum blues. What is the best response to them?

"Postpartum blues" describes a mild, transient depression that affects more than 70% of American women. It has an onset within the first week after birth and is characterized by fatigue, weeping, mood instability, and anxiety. The mother may not be able to define why she is upset. The primary nursing care is to give the woman empathy and support and let her know that the condition is usually self-limiting.

Ortolani and Barlow

Name the two tests used to assess the hips These 2 tests are used to assess for hip dislocation

During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? a. Anticipatory b. Formal c. Informal d. Personal

ANS: B

involution

*The process in which the uterus returns to a non-pregnant state after birth is known as *Return of the uterus to its nonpregnant state- *Retrogressive changes that return the reproductive organs to their prepregnancy states

Current disorders included in newborn screening

1) congenital Adrenal Hyperplasia (CAH) 2) Congenital Hypothyroidism (CH) 3) Biotinidase deficiency (BD) 4)Galactosemia (GAL) 5) Homocystinuria (HCU) 6) Maple syrup urine disease (MSUD) 7) Phenylketonuria (PKU) 8) Sickle cell anemia (SCA)

Repeat screening is required when

1) the specimen is collected before 24 hours of protein feedings 2) The specimen is collected before the infant is 48hours of age 3) both 1 and 2 4)Abnormal result occurs 5) Presumptive positive result occurs 6) There is an unqualified specimen collection (i.e. quantity not sufficient)

Colostrum

1-2 day- Colostrum- a thick, yellow fluid high in protein and contains immunobodies

1. You may note that some postpartum women have a urine output that is greater than their oral fluid intake. Should you be concerned? Why or why not?

1.

5. During clinical practice, observe the reactions of siblings to a new infant. What steps do you see parents take to reassure the older child that he or she is still loved?

5.

3. At 1 minute the infant has a heart rate of 142, has a slow weak cry, is grimacing, and has sluggish movements with acrocyanosis. What Apgar score should the nurse assign?

6 one point each is deducted for acrocyanosis, sluggish movement, a slow weak cry and grimacing

10. The answers to this exercise should be in your own words and should fit the women you care for in your clinical setting.

10.

10. Write out in simple terms how you would teach a woman about each of the following postpartum comfort measures: a. Cold packs b. Perineal care c. Topical medications d. How to sit e. Sitz baths

10.

What documentation on a woman's chart on postpartum day 14 indicates a normal involution process? a. Moderate bright red lochia flow b. Breasts firm and tender c. Fundus below the symphysis and not palpable d. Episiotomy slightly red and puffy

15.

2. Ask a nurse on the gynecology surgery unit what the usual time is for a woman to first urinate after surgery (if a catheter is not used). How does this time interval compare with when a postpartum woman is expected to first uinate?

2.

A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. Which statement is true? Bottle-feeding using commercially prepared infant formulas a. Increases the risk that the infant will develop allergies b. Helps the infant sleep through the night c. Ensures that the infant is getting iron in a form that is easily absorbed d. Requires that multivitamin supplements be given to the infant

2.

3. Write a narrative nurse's note to document the expected findings for a postpartum woman 12 hours after birth.

3.

Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? a. Varicosities of the legs b. Carpal tunnel syndrome c. Periodic numbness and tingling of the fingers d. Headaches

34.

The apical pulse can best be heard at this intercostal space

3rd - 4th

4. If you are a parent, did you or your partner experience separation grief because of the demands of employment? How did you deal with it?

4.

If my glucose level falls below this number, I can have problems

40, 40mg/dl

8. Describe the proper techniques to massage a soft fundus. How should the nurse expel any clots?

8.

8. Refer to text, "Procedure: Assessing the Uterine Fundus. to complete this exercise.

8.

9. Complete the following chart for postpartum assessments. What to Assess and Expected Deviations from Normal, Cause, Assessment Findings and Nursing Actions Fundus

9.

9. Complete the following chart for postpartum assessments. What to Assess and Expected Deviations from Normal, Cause, Assessment Findings and Nursing Actions Lochia

9.

9. Refer to text, "Focused Assessments After Vaginal Birth," to complete this exercise.

9.

Phenylketonuria

A common metabolic disease caused by inability to metabolize phenylalanine

Explain how a full bladder at birth can lead to postpartum hemorhage.

A full bladder interferes with the ability of the uterus to firmly contract and can occlude open vessels at the placental site. This allows them to freely bleed.

Physiologic jaundice

A harmless condition caused by increased RBC's and immaturity of the liver

Ortolani's maneuver

A manual procedure performed to rule out hip dysplasia

The infant has a reddish popular rash across his face. How should the nurse respond when Mrs. Iv asks about the rash?

A newborn rash is very common, but it will disappear soon. Erythema toxicum, very common and usually disappears by the third day of life.

Vernix caseosa

A protective cheese-like whitish substance A thick white substance that protects my skin in utero

Brown fat

A special tissue found in mature newborns to conserve or produce body heat Oxidation of this tissue is used to produce heat

Nipples

Note whether nipple is normally erect and not inverted Assess the niple for cracks, fissures, bleeding, bruising, blisters

Gestational age

Number of weeks of fetal development

When teaching the postpartum woman about peripads, the nurse shoukd tell her that: a. she can change to tampons when the initial perineal soreness goes away. b. pads having cold packs within them usually hold more lochia than regular pads. c. blood-soaked pads must be returned in a plastic bag to the hospital after discharge. d. the pads should be applied and removed in a front- to-back direction.

ANS d

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is a. Uterine atony b. Uterine inversion c. Vaginal hematoma d. Vaginal laceration

ANS: A

A young mother is excited about her first baby. Choose the best teaching to help her obtain adequate rest after discharge. a. Plan to sleep or rest any time the infant sleeps b. Do all housecleaning while the infant sleeps. c. Cook several meals at once and freeze for later use. d. Tell family and friends not to visit for the first month.

ANS a

Twelve hours after birth, a mother lies in bed resting. Although she will be discharged in another 12 hours, she does not ask about her baby or provide any care. What is the probable reason for her behavior? a. She is still in the taking-in phase of maternal adaptation. b. She shows behaviors that may lead to postpartum depression. c. She is still affected by medications given during labor. d. She may be dissatistied with some aspect of the newbom.

ANS a

When checking a woman's fundus 24 hours after a cesarean birth of her third baby, the nurse finds her fundus at the level of her umbilicus, firm, and in the midline. The appropriate nursing action related to this assessment is to: a. document the normal assessment. b. determine when she last urinated. c. limit her intake of oral fluids. d. vigorously massage her fundus.

ANS a

A woman who is 18 hours postpartum says she is having "hot flashes" and "sweats all the time." The appropriate nursing response is to: a. report her signs and symptoms of hypovolemic shock. b. tell her that her body is getting rid of unneeded fluid. c. notify her nurse-midwife that she may have an infection. d. limit her intake of caffeine-containing fluids.

ANS b

Choose the best independent nursing action to aid episiotomy healing in a woman who is 24 hours postpartum. a. Antibiotic cream application to the area b. Warm sitz baths taken four times per day c. Maintaining cold packs to the area at all times d. Checking the leukocyte level

ANS b

A woman who is 3 hours postpartum has had difficulty urinating. She finally urinates 100 ml. The initial nurs- ing action is to: a. insert an indwelling catheter. b. have her drink additional fluids. c. assess the height of her fundus. d. chart the urination amount.

ANS c

The best nursing encouragement for parents to care for their infant is to: a. stay out of the room for as long as possible. b. have the grandmother nearby as a backup. c. give positive feedback when they provide care. d. cotke. their performance whenever they make a

ANS c

To help the postpartum woman avoid constipation, the nurse should teach her to: a. avoid the intake of foods such as milk, cheese, or yogurt. b. take a laxative for the first 3 postpartum days. c. drink at least 2500 ml. of non-caffeinated fluids daily. d. limit her walking until the episiotomy is fully healed.

ANS c

A new father is reluctant to "spoil" his newborn when she cries by picking her up. The best nursing response is to: : a. teach him that she will eventually stop crying if he waits. b. take the baby to the nursery to allow the parents to c. rest. pick the baby up and rock her until she sleeps again. d. tell the father that the baby cries to communicate a need.

ANS d

Choose symptom that a new mother should be the sign or taught to report. a. Occasional uterine cramping when the infant nurses b. Oral temperature that is 37.2°C (99 F) in the moming c. Descent of the fundus one fingerbreadth each day d. Reappearance of red lochia after it changes to se- rous

ANS d

To prevent breast engorgement, the nurse should teach the non-breastfeeding postpartum woman to: a. maintain loose-fitting clothing ower her breasts. b pump the breasts briefly if they become painful. c. limit fluid intake to suppress milk production. d. constantly wear a well-fitting bra or breast binder.

ANS d

A newborn is rooming in with his teenage mother, who is watching TV. The nurse notes that the baby is awake and quiet. The best nursing action is to: a. pick the baby up and point out his alert behaviors to the mother, b. tell the mother to pick up her baby and talk with him while he is awake. c. focus care on the mother, rather than the infant, so she can recuperate. d. encourage the mother to feed the infant before he begins crying.

ANS.a

A newborn weight loss of % in a breastfeeding infant during the first 3 days of life should be investigated. Most often, the excessive weight loss is associated with poor breastfeeding techniques.

ANS: 7-8

A breastfeeding mother who was discharged yesterday calls to ask about a tender, hard area on her right breast. The nurses first response should be a. Try massaging the area and apply heat, as this is probably plugged duct. b. Stop breastfeeding because you probably have an infection. c. Notify your doctor so he can start you on antibiotics. d. This is a normal response in breastfeeding mothers.

ANS: A

A new mother asks if she should feed her newborn colostrum, because it is not real milk. The nurses best answer is that a. Colostrum is high in antibodies, protein, vitamins, and minerals. b. Colostrum is lower in calories than milk and should be supplemented by formula. c. Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. d. Colostrum is unnecessary for newborns.

ANS: A

According to Becks studies, what risk factor for postpartum depression (PPD) is likely to have the greatest effect on the womans condition? a. Prenatal depression b. Single-mother status c. Low socioeconomic status d. Unplanned or unwanted pregnancy

ANS: A

According to the recommendations of the American Academy of Pediatrics (AAP) on infant nutrition a. Infants should be given only human milk for the first 6 months of life. b. Infants fed on formula should be started on solid food sooner than breastfed infants. c. If infants are weaned from breast milk before 12 months, they should receive cows milk, not formula. d. After 6 months, mothers should shift from breast milk to cows milk.

ANS: A

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting go b. Taking hold c. Taking in d. Taking on

ANS: A

Early postpartum hemorrhage is defined as a blood loss greater than a. 500 mL in the first 24 hours after vaginal delivery b. 750 mL in the first 24 hours after vaginal delivery c. 1000 mL in the first 48 hours after cesarean delivery d. 1500 mL in the first 48 hours after cesarean delivery

ANS: A

In providing support to a new mother who must return to full-time employment 6 weeks after a vaginal delivery, the nurse should a. Allow her to express her positive and negative feelings freely. b. Reassure her that shell get used to leaving her baby. c. Discuss child care arrangements with her. d. Allow her to solve the problem on her own.

ANS: A

Late preterm infants need closer monitoring during her hospital stay than term infants. In order to prevent unrecognized cold-stress the nurse should perform all except a. Wean the infant to an open crib. b. Check temperature every 3 to 4 hours. c. Encourage kangaroo care. d. Place infant on a radiant warmer.

ANS: A

Many types of breast pumps are available, varying in price and effectiveness. Before either renting or purchasing a pump, the new mother would benefit from counseling by a nurse or lactation consultant to determine the most appropriate pump to suit her needs. The mother who is pumping for an occasional bottle would be most suited for which type of pump? a. Manual or hand pump b. Hospital grade pump c. Electric self-cycling double pumps d. Smaller electric or battery operated pump

ANS: A

Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. What statement is valid? a. A premature infant more easily digests breast milk than formula. b. A glass of wine just before pumping will help reduce stress and anxiety. c. The mother should only pump as much as the infant can drink. d. The mother should pump every 2 to 3 hours, including during the night.

ANS: A

Rh, immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh, baby Rh+ b. Mother Rh, baby Rh c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh

ANS: A

The best reason for recommending formula over breastfeeding is that a. The mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. b. The mother lacks confidence in her ability to breastfeed. c. Other family members or care providers also need to feed the baby. d. The mother sees bottle-feeding as more convenient.

ANS: A

The mother-baby nurse is able to recognize reciprocal attachment behavior. This refers to a. The positive feedback an infant exhibits toward parents during the attachment process b. Behavior during the sensitive period when the infant is in the quiet alert stage c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of falling in love from the parents

ANS: A

The nurse providing couplet care should understand that nipple confusion results when a. Breastfeeding babies receive supplementary bottle feedings. b. The baby is weaned too abruptly. c. Pacifiers are used before breastfeeding is established. d. Twins are breastfed together.

ANS: A

The nurse should expect medical intervention for subinvolution to include a. Oral methylergonovine maleate (Methergine) for 48 hours b. Oxytocin intravenous infusion for 8 hours c. Oral fluids to 3000 mL/day d. Intravenous fluid and blood replacement

ANS: A

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by a. Subinvolution of the uterus b. Defective vascularity of the decidua c. Cervical lacerations d. Coagulation disorders

ANS: A

Which data should alert the nurse that the neonate is postmature? a. Cracked, peeling skin b. Short, chubby arms and legs c. Presence of vernix caseosa d. Presence of lanugo

ANS: A

Which finding 12 hours after birth requires further assessment? a. The fundus is palpable two fingerbreadths above the umbilicus. b. The fundus is palpable at the level of the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: A

Which measure may prevent mastitis in the breastfeeding mother? a. Initiating early and frequent feedings b. Nursing the infant for 5 minutes on each breast c. Wearing a tight-fitting bra d. Applying ice packs before feeding

ANS: A

Which woman is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child C. Primipara who delivered a 7-lb boy d. Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

ANS: A

While caring for the postterm infant, the nurse recognizes that the fetus may have passed meconium prior to birth as a result of a. Нурохіа in uterо b. NEC c. Placental insufficiency d. Rapid use of glycogen stores

ANS: A

Examples of appropriate techniques to wake a sleepy infant for breastfeeding include (select all that apply) a. Unwrap the infant. b. Change the diaper. c. Talk to the infant. d. Slap the infants hands and feet. e. Apply a cold towel to the infants abdomen.

ANS: A, B, C

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? Select all that apply. a. Breast tenderness b. Warmth in the breast c. An area of redness on the breast often resembling the shape of a pie wedge d. A small white blister on the tip of the nipple e. Fever and flulike symptoms

ANS: A, B, C, E

Medications used to manage postpartum hemorrhage include (select all that apply) a. Pitocin b. Methergine c. Terbutaline d. Hemabate e. Magnesium sulfate

ANS: A, B, D

Many women given up smoking during pregnancy to protect the health of the fetus. The majority of women resumed smoking within the first 6 months postpartum. Factors that increase the likelihood of relapse include (select all that apply) a. Living with a smoker b. Returning to work c. Weight concerns d. Successful breastfeeding e. Failure to breastfeed

ANS: A, C, E

A man calls the nurses station stating that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, She was never like this before the baby was born. The nurses initial response should be to a. Tell him to ignore the mood swings, as they will go away. b. Reassure him that this behavior is normal. c. Advise him to get immediate psychological help for her. d. Instruct him in the signs, symptoms, and duration of postpartum blues.

ANS: B

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000 g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. The nurse should a. Continue to massage the fundus. b. Notify the physician. c. Recheck vital signs. d. Insert a Foley catheter.

ANS: B

A new mother is concerned because her 1-day-old newborn is taking only 1 ounce at each feeding. The nurse should explain that the a Infant does not require as much formula in the first few days of life. b. Infants stomach capacity is small at birth but will expand within a few days. C. Infant tires easily during the first few days but will gradually take more formula. d. Infant is probably having difficulty adjusting to the formula.

ANS: B

A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. Based on this information, this woman should feed her infant about every 2.5 to 3 hours when she a. Waves her arms in the air b. Makes sucking motions c. Has hiccups d. Stretches out her legs straight

ANS: B

A postpartum patient is at increased risk for postpartum hemorrhage if she delivers a(n) a. 5-lb, 2-oz infant with outlet forceps b. 6.5-lb infant after a 2-hour labor c. 7-lb infant after an 8-hour labor d. 8-lb infant after a 12-hour labor

ANS: B

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and cries inconsolably until held. The correct nursing diagnosis is ineffective coping related to a. Severe immaturity b. Environmental stress c. Physiologic distress d. Behavioral responses

ANS: B

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests a. Uterine atony b. Lacerations of the genital tract c. Perineal hematoma d. Infection of the uterus

ANS: B

A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she feels all wet underneath. You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. b. Assess the fundus for firmness. c. Take her blood pressure. d. Check the perineum for lacerations.

ANS: B

If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the patient has a. Been lying on her right side too long b. A distended bladder c. Stretched ligaments that are unable to support the uterus d. A normal involution

ANS: B

If the nurse suspects a uterine infection in the postpartum patient, she should assess the a. Pulse and blood pressure b. Odor of the lochia c. Episiotomy site d. Abdomen for distention

ANS: B

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Bronchopulmonary dysplasia (BPD) d. Intraventricular hemorrhage (IVH)

ANS: B

In order to prevent nipple trauma, the nurse should teach the new mother to a. Limit the feeding time to less than 5 minutes. b. Position the infant so the ople is far back in the mouth. c. Assess the nipples before each feeding. d. Wash the nipples daily with mild soap and water.

ANS: B

The breastfeeding mother should be taught a safe method to remove the breast from the babys mouth. Which suggestion by the nurse most appropriate? a. Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed. b. Break the suction by inserting your finger into the corner of the infants mouth. c. A popping sound occurs when the breast is correctly removed from the infants mouth. d. Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.

ANS: B

The nurse knows that a measure for preventing late postpartum hemorrhage is to a. Administer broad-spectrum antibiotics. b. Inspect the placenta after delivery. c. Manually remove the placenta. d. Pull on the umbilical cord to hasten the delivery of the placenta.

ANS: B

The nurse should explain to new parents that the most serious consequence of propping an infants bottle is a. Dental caries b. Aspiration c. Ear infections d. Colic

ANS: B

The patient who is being treated for endometritis is placed in Fowlers position because it a. Promotes comfort and rest b. Facilitates drainage of lochia c. Prevents spread of infection to the urinary tract d. Decreases tension on the reproductive organs

ANS: B

The postpartum woman who continually repeats the story of her labor, delivery, and recovery experiences is a. Providing others with her knowledge of events b. Making the birth experience real c. Taking hold of the events leading to her labor and delivery d. Accepting her response to labor and delivery

ANS: B

The preterm infant who should receive gavage feedings instead of a bottle is the one who a. Sometimes gags when a feeding tube is inserted b. Is unable to coordinate sucking and swallowing c. Sucks on a pacifier during gavage feedings d. Has an axillary temperature of 98.4 F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

ANS: B

To assess fundal contraction 6 hours after cesarean delivery, the nurse should a. Palpate forcefully through the abdominal dressing. b. Gently palpate, applying the same technique used for vaginal deliveries. c. Place hands on both sides of the abdomen and press downward. d. Rely on assessment of lochial flow rather than palpating the fundus.

ANS: B

To prevent breast engorgement, the new breastfeeding mother should be instructed to a. Apply cold packs to the breast before feeding. b. Breastfeed frequently and for adequate lengths of time. c. Limit her intake of fluids for the first few days. d. Feed her infant no more than every 4 hours.

ANS: B

To promote bonding and attachment immediately after delivery, the nurse should a. Allow the mother quiet time with her infant. b. Assist the mother in assuming an en face position with her newborn. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in feeding her baby.

ANS: B

What information about iron supplementation should the nurse teach a new mother? a. Start iron supplementation shortly after birth if the infant is breastfeeding exclusively. b. Iron-fortified formula will meet the infants iron requirements. c. Iron supplements must be given when the infant begins teething. d. Infants need a multivitamin with iron every day.

ANS: B

What instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia, d. The passage of clots as large as an orange can be expected.

ANS: B

What is most helpful in preventing premature birth? a. High sociocconomic status b. Adequate prenatal care c. Transitional Assistance to Needy Families d. Women, Infants, and Children nutritional program

ANS: B

When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is a. Rectal suppositories b. Early and frequent ambulation c. Tightening and relaxing abdominal muscles d. Carbonated beverages

ANS: B

Which nursing measure is appropriate to prevent thrombophlebitis in the recovery period after a cesarean birth? a. Roll a bath blanket and place it firmly behind the knees. b. Limit oral intake of fluids for the first 24 hours. c. Assist the patient in performing gentle leg exercises. d. Ambulate the patient as soon as her vital signs are stable.

ANS: B

Which woman is at greatest risk for early postpartum hemorrhage? a. A primiparous woman (G 2 P100 1) being prepared for an emergency cesarean birth for fetal distress b. A woman with severe preeclampsia on magnesium sulfate whose labor is being induced c. A multiparous woman (G 3 P 200 2) with an 8-hour labor d. A primigravida in spontaneous labor with preterm twins

ANS: B

The nurse caring for the postpartum woman understands that breast engorgement is caused by a. Overproduction of colostrum b. Accumulation of milk in the lactiferous ducts and glands c. Hyperplasia of mammary tissue d. Congestion of veins and lymphatics

ANS: D

Late in pregnancy, the womans breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Some nipple conditions make it necessary to provide intervention before birth. These include (select all that apply) a. Everted nipples b. Flat nipples c. Inverted nipples d. Nipples that contract when compressed e. Cracked nipples

ANS: B, C, D

Nurses must be aware of the conditions that increase the risk of hemorrhage, one of the most common complications of the puerperium. What are the conditions? Select all that apply. a. Primipara b. Rapid or prolonged labor c. Overdistention of the uterus d. Uterine fibroids e. Preeclampsia

ANS: B, C, D, E

A mother with mastitis concerned about breastfeeding while she has an active infection. The nurse should explain that a. The infant is protected from infection by immunoglobulins in the breast milk. b. The infant not susceptible to the organisms that cause mastitis. c. The organisms that cause mastitis are not passed to the milk. d. The organisms will be inactivated by gastric acid.

ANS: C

A new mother wants to be sure that she is meeting her daughters needs while feeding her commercially prepared infant formula. The nurse should evaluate the mothers knowledge about appropriate infant care. The mother meets her child's needs when she a. Adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition b. Warms the bottles using a microwave oven c. Burps her infant during and after the feeding as needed d. Refrigerates any leftover formula for the next feeding

ANS: C

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurses best response is a. You have pitting edema in your ankles. b. You have deep tendon reflexes rated 2+. c. You have calf pain when the nurse flexes your foot. d. You have a fleshy odor to your vaginal drainage.

ANS: C

A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after delivery because of a. Increased estrogen b. Increased progesterone c. Decreased melanocyte-stimulating hormone d. Decreased human placental lactogen

ANS: C

An infant girl is preterm and on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. It is important for the nurse to a. Suggest that the parents visit for only a short time to reduce their anxieties. b. Reassure the parents that the baby is progressing well. c. Encourage the parents to touch her. d. Discuss the care they will give her when she goes home.

ANS: C

Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is A phobia b. Panic disorder c. Posttraumatic stress disorder (PTSD) d. Obsessive-compulsive disorder (OCD)

ANS: C

As the nurse assists a new mother with breastfeeding, she asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? The nurses best response is that it contains a. More calories b. Essential amino acids c. Important immunoglobulins d. More calcium

ANS: C

Decreased surfactant production in the preterm lung is a problem because surfactant a. Causes increased permeability of the alveoli b. Provides transportation for oxygen to enter the blood supply c. Keeps the alveoli open during expiration d. Dilates the bronchioles, decreasing airway resistance

ANS: C

How many ounces will a formula fed infant who is on a 4-hour feeding schedule need to consume at each feeding to meet daily caloric needs? a. 0.5 to 1 b. 1 to 2 c. 2 to 3 d. 4

ANS: C

If the patients white blood cell (WBC) count is 25,000/mm on her second postpartum day, the nurse should a. Tell the physician immediately. b. Have the laboratory draw blood for reanalysis. c. Recognize that this is an acceptable range at this point postpartum. d. Begin antibiotic therapy immediately.

ANS: C

Nursing measures that help prevent postpartum urinary tract infection include a. Promoting bed rest for 12 hours after delivery b. Discouraging voiding until the sensation of a full bladder is present c. Forcing fluids to at least 3000 mL/dav d. Encouraging the intake of orange, grapefruit, or apple juice

ANS: C

Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome? a. Pulse more than 160 beats/min b. Circumoral cyanosis c. Grunting d. Substernal retractions

ANS: C

On observing a woman on her first postpartum day sitting in bed while her newborn lies awake in the bassinet, the nurse should a. Realize that this situation is perfectly acceptable. b. Offer to hand the baby to the woman. c. Hand the baby to the woman. d. Explain taking in to the woman.

ANS: C

What nursing action is especially important for the SGA newborn? a. Observe for respiratory distress syndrome. b. Observe for and prevent dehydration. c. Promote bonding. d. Prevent hypoglycemia by early and frequent feedings.

ANS: D

Over stimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem? a. Group all care activities together to provide long periods of rest. b. While giving your report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation. c. Teach the parents signs of over stimulation, such as turning the face away or stiffening and extending the extremities and fingers. d. Keep charts on top of the incubator so the nurses can write on them there.

ANS: C

Postpartal over distention of the bladder and urinary retention can lead to which complication? a. Postpartum hemorrhage and eclampsia b. Fever and increased blood pressure c. Postpartum hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture

ANS: C

The best way for the nurse to promote and support the maternal-infant bonding process is to a. Help the mother identify her positive feelings toward the newborn. b. Encourage the mother to provide all newborn care. c. Assist the family with rooming-in. d. Return the newborn to the nursery during sleep periods.

ANS: C

The mother-baby nurse must be able to recognize what sign of thrombophlebitis? a. Visible varicose veins b. Positive Homans sign c. Local tenderness, heat, and swelling d. Pedal edema in the affected leg

ANS: C

To initiate the milk ejection reflex, the mother should a. Wear a firm-fitting bra. b. Drink plenty of fluids. c. Place the infant to the breast d. Apply cool packs to her breast.

ANS: C

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) a. Is the baby blues plus the woman has a visit with a counselor or psychologist b. Is more common among older, Caucasian women because they have higher expectations c. Is distinguished by pervasive sadness that lasts at least 2 weeks d. Will disappear on its own without outside help

ANS: C

Two days ago, a woman gave birth to a full-term infant. Last night, she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is a. Elevated temperature caused by postpartum infection b. Increased basal metabolic rate after giving birth c. Loss of increased blood volume associated with pregnancy d. Increased venous pressure in the lower extremities

ANS: C

What is the first step in assisting the breastfeeding mother? a. Provide instruction on the composition of breast milk. b. Discuss the hormonal changes that trigger the milk ejection reflex. c. Assess the woman's knowledge of breastfeeding. d. Help her obtain a comfortable position and place the infant to the breast.

ANS: C

What will the nurse note when assessing an SGA infant with asymmetric intrauterine growth restriction? a. One side of the body appears slightly smaller than the other. b. All body parts appear proportionate. c. The head seems large compared with the rest of the body. d. The extremities are disproportionate to the trunk.

ANS: C

When a woman is diagnosed with postpartum psychosis, one of the main concerns is that she may a. Have outbursts of anger b. Neglect her hygiene c. Harm her infant d. Lose interest in her husband

ANS: C

Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? a. Estrogen b. Progesterone c. Prolactin d. Human placental lactogen

ANS: C

Which statement is true about large for gestational age (LGA) infants? a. They weigh more than 3500 g. b. They are above the 80th percentile on gestational growth charts. c. They are prone to hypoglycemia, polycythemia, and birth injuries. d. Postmaturity syndrome and fractured clavicles are the most common complications.

ANS: C

Which type of formula is not diluted before being administered to an infant? a. Powdered b. Concentrated c. Ready-to-use d. Modified cows milk

ANS: C

With regard to eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that a. Infants will stay in the NICU until they are ready to go home. b. Once discharged to home, the high risk infant should be treated like any healthy term newborn. c. Parents of high risk infants need special support and detailed contact information. d. If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

ANS: C

a. Roll a bath blanket and place it firmly behind the knees. b. Limit oral intake of fluids for the first 24 hours. c. Assist the patient in performing gentle leg exercises. d. Ambulate the patient as soon as her vital signs are stable.

ANS: C

A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to a. Assess her for pain. b. Point out how lucky she is to have a healthy baby. c. Explain that she is experiencing postpartum blues. d. Allow her time to express her feelings.

ANS: D

When caring for a postpartum woman experiencing hypovolemic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is a. Absence of cyanosis in the buccal mucosa b. Cool, dry skin c. Diminished restlessness d. Decreased urinary output

ANS: D

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurses most appropriate response is to ask the woman a. Didnt you like your lunch? b. Does your doctor know that you are planning to eat that? c. What is that anyway? d. Ill warm the soup in the microwave for you.

ANS: D

A new father states, I know nothing about babies, but he seems to be interested in learning. The nurse should a. Continue to observe his interaction with the newborn. b. Tell him when he does something wrong. c. Show no concern, as he will learn on his own. d. Include him in teaching sessions.

ANS: D

A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. The nurse should a. Report the incident to the social services department. b. Advise the parents that the toddler needs to be reprimanded. c. Report to oncoming staff that the mother is probably not a good disciplinarian. d. Realize that this is a normal family adjusting to family change.

ANS: D

A postpartum patient asks, Will these stretch marks go away? The nurses best response is They will fade to silvery lines but wont disappear completely.

ANS: D

A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who a. Sleeps for 6 hours at a time between feedings b. Has at least one breast milk stool every 24 hours c. Gains 1 to 2 ounces per week d. Has at least six to eight wet diapers per day

ANS: D

A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infants correct latch-on by helping the woman hold the infant a. With his arms folded together over his chest b. Curled up in a fetal position c. With his head cupped in her hand d. With his head and body in alignment

ANS: D

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information most closely correlated with these orders? a. The woman is a gravida 2, para 2. b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy.

ANS: D

All parents are entitled to a birthing environment in which breastfeeding is promoted and supported. The Baby Friendly Hospital Initiative endorsed by WHO and Unicef was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which is not one of the Ten Steps to Successful Breastfeeding for Hospitals? a. Give newborns no food or drink other than breast milk. b. Have a written breastfeeding policy that is communicated to all staff. c. Help mothers initiate breastfeeding within one half hour of birth. d. Give artificial teats or pacifiers as necessary.

ANS: D

An important aspect about storage of breast milk is that it a. Can be frozen for up to 2 months b. Should be stored only in glass bottles c. Can be thawed and refrozen d. Can be kept refrigerated for 48 hours

ANS: D

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse might try is a. Pouring water from a squeeze bottle over the woman's perineum b. Providing hot tea c. Asking the physician to prescribe analgesics d. Inserting a sterile catheter

ANS: D

Because of the premature infants decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a. Delayed growth and development b. Ineffective thermoregulation c. Ineffective infant feeding pattern d. Risk for infection

ANS: D

Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the patient understands the correct process for completing these conditioning exercises when she reports a. I contract my thighs, buttocks, and abdomen. b. I do 10 of these exercises every day. c. I stand while practicing this new exercise routine. d. I pretend that I am trying to stop the flow of urine midstream.

ANS: D

Compared to the term infant, the preterm infant has a. Few blood vessels visible though the skin b. More subcutaneous fat c. Well-developed flexor muscles d. Greater surface area in proportion to weight

ANS: D

How can the nurse help the mother who is breastfeeding and has engorged breasts? a. Suggest that she switch to bottled formula just for today. b. Assist her into removing her bra, making her more comfortable. c. Apply heat to her breasts between feeding and cold to the breasts just before feedings. d. Instruct and assist the mother to massage her breasts.

ANS: D

If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. D&C

ANS: D

If rubella vaccin icated for a postpartum patient, uctions the patient should lude a. Drinking plenty of fluids to prevent fever b. No specific instructions c. Recommending that she stop breastfeeding for 24 hours after injection d. Explaining the risks of becoming pregnant within month after injection

ANS: D

One of the first symptoms of puerperal infection to assess for in the postpartum woman is a. Fatigue continuing for longer than 1 week b. Pain with voiding c. Profuse vaginal bleeding with ambulation d. Temperature of 38 C (100.4 F) or higher on 2 successive days starting 24 hours after birth

ANS: D

The difference between the aseptic and terminal methods of sterilization that the a. Aseptic method does not require boiling of the bottles. b. Terminal method requires boiling water to be added to the formula. c. Aseptic method requires a longer preparation time. d. Terminal method sterilizes the prepared formula at the same time it sterilizes the equipment.

ANS: D

When responding to the question Will I produce enough milk for my baby as she grows and needs more milk at each feeding? the nurse should explain that a. The breast milk will gradually become richer to supply additional calories. b. As the infant requires more milk, feedings can be supplemented with cows milk. c. Early addition of baby food will meet the infants needs. d. The mothers milk supply will increase as the infant demands more at each feeding.

ANS: D

Which combination of expressing pain could be demonstrated in a neonate? a. Low-pitched crying, tachycardia, eyelids open wide b. Cry face, flacid limbs, closed mouth c. High-pitched, shrill cry, withdrawal, change in heart rate d. Cry face, eye squeeze, increase in blood pressure

ANS: D

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? a. Postpartum depression b. Postpartum psychosis c. Postpartum bipolar disorder d. Postpartum blues

ANS: D

Which is true about newborns classified as small for gestational age (SGA)? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. Placental malfunction is the only recognized cause of this condition. d. They are below the 10th percentile on gestational growth charts.

ANS: D

Which maternal event is abnormal in the early postpartum period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.

ANS: D

Which statement by a postpartum woman indicates that further teaching is not needed regarding thrombus formation? a. Ill stay in bed for the first 3 days after my baby born. b. Ill keep my legs elevated with pillows. c. Ill sit in my rocking chair most of the time. d. Ill put my support stockings on every morning before rising.

ANS: D

With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to a. Stay home and avoid outside activities to ensure adequate rest. b. Be certain that you are the only caregiver for your baby in order to facilitate infant attachment. c. Keep feelings of sadness and adjustment to your new role to yourself. d. Realize that this is a common occurrence that affects many women.

ANS: D

Of all pregnant women being treated for depression, approximately one-third have a first occurrence during pregnancy. All pregnant and postpartum women should be screened for perinatal mood disorders by using the Postnatal Depression Scale.

ANS: Edinburgh

___________ is the most common postpartum infection.

ANS: Endometritis

Clotting factors and fibrinogen levels normally are decreased during pregnancy and remain low in the immediate puerperium. This hypocoagulable state increases the risk of thromboembolism, especially after cesarean birth. Is this statement true or false?

ANS: F

Should a postpartum complication such as hemorrhage occur, the nursing staff will spring into action to ensure that patient safety needs are met. This level of activity is very reassuring to both the new mother and hei family members as they can see that the patient is receiving the best care. Is this statement true or false?

ANS: F

The cultural group in the United States that is most likely to breastfeed are non-Hispanic black women. Is this statement true or false?

ANS: F

At some hospitals in the United States, new mothers are given formula gift packs at discharge. Having been given the gift pack by hospital staff leads parents to believe that formula will be necessary even for breastfeeding mothers. Is this statement true or false?

ANS: T

Pulmonary embolism (PE) is a serious complication of deep vein thrombosis (DVT) and the leading cause of maternal mortality. As many as 15% to 25% of all DVTS lead to PEs if not recognized and treated. Is this statement true or false?

ANS: T

The nurse evaluating the amount of lochia on a newly delivered patient knows that amoderate amount of flow constitutes a 4- to 6-inch stain on the peripad. Is this statement true or false?

ANS: T

A woman who is 4 hours postpartum ambulates to the bathroom and suddenly has a large gush of lochia rubra. The nurse's first action should be to: a. determine whether the bleeding slows to normal or remains heavy. b. observe the vital signs for signs of hypovolemic shock. c. check to see what her previous lochia flow has been. d. identify the type of pain relief that was given when she was in labor.

ANS: a

The nurse is in the process of assessing the comfort level of her postpartum patient. Excess bleeding is not obvious; however, the new mother complains of deep, severe pelvic pain. The registered nurse (RN) has noted both skin and vital sign changes. This patient may have formed a(n)_______________

ANS: hematoma

Milk that gradually changes from colostrum to mature milk, appears over about 10 days after delivery. This is known as milk.

ANS: transitional

Atony

Absence of muscle tone-

REEDA

Acronym that helps assess wound healing (e.g., redness, edema, ecchymosis, discharge, approximation) Acronym for assessing wounds - Redness Edema Ecchymosis Discharge Approximation

Erythema Toxicum

Also known as "newborn rash" - it is very common

Physioloy of lactation

Alveolar growth is regulated by estrogen, progesterone, human placental lactogen, prolactin, cortisol and insulin Initiation of lactation triggered by decrease in estrogen and progesterone ---> prolactin produces milk Oxytocin released by suckling at breast Oxytocin stimulates release of milk Montgomenry tubercles lubricate and protect nipple area.

Dehydration

An elevated temperature during the first 24 hours after delivery is generally due to this

Kernicterus

An encephalopathy caused by deposition of unconjugated biliubin in brain cells

Hemorrhoids

Anal Varicosities

breast assessment

Assess 1.Symmetry 2.Shape 3.Firmness 4.Tenderness

New parents may not recognize signals from the infant that he or she has had enough stimulation and now needs to rest. What signals should the nurse teach parents to recognize?

Avoidance include looking away splaying the fingers arching the back, and fussiness. These are clues that the infant needs some quiet time.

22. Ms. Myers is told that a neonatal screening test needs to be done before they are discharged.When asked the reason for including the PKU test in the screening, which information should the nurse provide?

B) A problem converting the protein, phenylalanine, may be present, which can lead to mental retardation if not found and treated early. CORRECT: PKU testing is done to detect the level of phenylalanine in the baby's blood.

14. The nurse is preparing to give the baby her first bath. Which assessment data indicates that it is safe for the baby to be given her bath at this time?

B) Axillary temperature of 98° F. CORRECT A bath may potentially lower the temperature, which will not be harmful because the core temperature is near 99° F.

10. Which physical finding, if present, should the nurse report to the healthcare provider?

B) Loose natal teeth that are not covered by the gums. CORRECT: Natal teeth present at birth is an unusual occurrence that should be reported to the healthcare provider. Loose natal teeth are frequently removed to prevent aspiration.

15. At 2400 hours the infant is crying, her skin is mottled, and her hands are shaking. Which action should the nurse take first?

B) Monitor the blood glucose level. CORRECT: Since it has been 2 hours since delivery, the infant may be experiencing hypoglycemia.

18. The nurse checks on Ms. Myers and her baby every 2 hours throughout the night. The baby is breastfed at 0300 and 0600 hours without difficulty. After the change of shift report at 0700 hours, the day nurse assesses the mother and baby. Ms. Myers states that the baby had a bowel movement after breastfeeding. She tells the nurse that she attempted to change the diaper, but had difficulty doing so. What action should the nurse implement?

B) Observe Ms. Myers as she performs a diaper change. E) Advise Ms. Myers that classes to teach infant care, such as diapering, are available on the unit. CORRECT: B) This approach helps the nurse evaluate the problems Ms. Myers is experiencing so the most effective teaching can be provided. E) It is appropriate to address the need for teaching at this time.

12. Which findings are consistent with an infant born at 38 weeks' gestation? (Select all that apply.)

B) Plantar creases covering 2/3 of the sole of foot. C) Well defined nipples, with raised areola CORRECT B) This finding is consistent with a baby born at 28 weeks' gestation. C) The infant of 38 weeks should have well defined nipples with raised areola.

23. How should the nurse collect the blood needed for PKU screening?

B) Puncture the lateral heel after warming and collect blood samples on the designated lab form. CORRECT: The heel should be warmed, cleaned with alcohol, and dried with gauze. After puncturing the heel with a microlancet, blood is collected on a special neonatal screening form.

Increased intercranial pressure, increased ICP

Bulging of the anterior fontanel in a quiet baby may indicate this

Biotinidase Deficiency (BD)

BD is caused by diminished activity of the enzyme biotinidase that recycles and conserves biotin, an important B vitamin. BD may cause serious complications such as seizures , developmental delay, mental retardation and hearing loss. Untreated, the deficiency can lead to coma and death. Infants with BD appear normal at birth but then develop symptoms after the first few weeks of life. These symptoms include hypotonia, ataxia, alopecia, seborrheic dermatitis, and optic nerve atrophy Incidence: 1 in 65,000 live births

Galactosemia

Babies with classic GAL have diminished activity of galactose-1 -phosphate uridyl transferase, a liver enzyme needed to convert galactose, most commonly found in milk products into glucose. Galactose then accumulates in the body and causes damage in the vital organs leading to blindness, severe mental retardation, infection , and death. Incidence: 1 in 40,000 live births.

cephalohematoma

Blood from ruptured vessels between skull bone and the periosteum Bleeding between the periosteum and skull that does not cross the suture line

Vital signs

Blood pressure- remember to watch for hypotension Pulse- Initial bradycardia may occur Repirations Temperature- A low grade temp (up to 100.4 ) is common during 1st 24 hours d/t dehydration

Circumoral cyanosis

Bluish appearance around the mouth

Describe the processes of bonding and attachment. Note the similarities and differences in these processes.

Bonding describes the initial, rapid attraction felt by parents toward their newborn infant. It is a one-way process, from the parent to the infant. Attachment describes a longer-term, two-way process that binds the parents and infant. Attachment is facilitated by positive feedback from the infant and by mutually satisfying experiences.

A nursing student is assisting the RN in caring for the infants in the nursery. The RN questions the student about vitamin K (Aqua MEPHYTON) as preparations are made for administration. 13. Which response by the student indicates an understanding of the purpose for administering this drug?

C) "This drug is given to the newborn to prevent and/or treat hemorrhagic disease." CORRECT: Because this vitamin does not cross the placenta and there is very little in breast milk, supplemental vitamin K should be given to newborns at birth to help clot the blood. Therefore, this is an accurate response by the student and no further client teaching is needed.

20. While changing the infant's clothing, Ms. Myers notices the baby startles easily. Ms. Myers asks the nurse what is causing this reaction. Which explanation should the nurse provide?

C) "This reflex is a normal response, swaddling the infant should help." CORRECT: The moro reflex is a startling response by the infant as a reaction to a loud noise, sudden touch, or a change in position.

The nurse notes a skin tag on the side of the infants hand. 9. What should the nurse do in response to this finding?

C) Document the findings and notify the pediatrician. Rational: Skin tags are a common finding on a newborn assessment. They can be harmless, but the pediatrician should be informed.

17. When returning the baby to the crib, the nurse notices that the blanket covering the baby is loose, and the cap is off her head. The nurse takes the baby's temperature, which is 97.6° F. Which should the nurse do next?

C) Show Ms. Meyers how to wrap the baby for warmth and apply the cap to her head. CORRECT: This action not only protects the baby, but also involves and teaches the mother

Congenital adrenal Hyperplasia (CAH)

CAH is most often caused by diminished activity of an enzyme, 21 hydroxylase, that results in failure of the formation of cortisol, a hormone needed for stress and normal blood glucose levels. Mild forms result in severe acne, excess facial and / or body hair, early development of pubic hair , and infertility in both males and females. More severe forms of CAH can result in ambiguous genitalia in a newborn girl. Males however usually have normal genitalia and are less likely to be diagnosed early. If not treated cause heart failure withing a few days of Incidence: 1 in 13,000 live births

Congenital Hypothyroidism (CH)

CH is a disorder caused by the under development or under activity of the thyroid gland. Decreased production of thyroid hormones prevents proper body growth and psychomotor development. Physical signs of CH may not be recognised until the infant is 3-4 months of age, at which time irreversible brain damage may have already occurred. Many times, early diagnosis of CH relies almost solely on the results of the newborn screening tests IncidenceL 1 in 4,000 live births, which makes CH one of the most common metabolic disorders.

Homans sign

Calf pain that occurs when the foot is dorsiflexed-

Chapter 28: The Woman with a Postpartum Complication

Chapter 28: The Woman with a Postpartum Complication

Chapter 29: The High-Risk Newborn: Problems Related to Gestational Age and Development

Chapter 29: The High-Risk Newborn: Problems Related to Gestational Age and Development

Ductus arteriosus

Closes due to increased oxygenation, decreased prostaglandins, and regurgitation of blood flow

Hyperbilirubinemia

Cold stress, breastfeeding and prematurity are risk factors for this serious complication

Harlequin sign

Color change that occurs between the longitudinal halves of the newborn's body

The nurse places the infant under a radiant warmer and starts to dry him quickly 1) what is the rationale for these actions?

Convective heat loss from evaporation is reduced.

Catabolism

Conversion of living cellular substances to simpler compounds

The nurse next prepares to administer the erythromycin ointment (llotycin ophthalmic ointment). Which approach should the nurse use to administer the ointment?

Cover entire lower conjunctiva with ointment after gently retracting the lid. Thumb and forefinger used to open the eye. Applied in the lower conjunctiva from the inner to the outer canthus.

Afterpains

Cramping pain following childbirth caused by alternating relation and contraction of the uterine muscle is called

Lochia Alba

Creamy white vaginal discharge

Acrocyanosis

Cyanosis of hands and feet This term describes the bluish discoloration of my hands and feet

21. At two days post birth, Ms. Myers and her baby are doing well and preparing for discharge. The baby's weight at birth was 7 lb 15 oz (3600 gms), and today she weighs 7 lb 3 oz (3300 gms). Ms. Myers expresses her concern to the nurse when she realizes that her baby has lost almost a pound since birth. How should the nurse respond?

D) "Don't be concerned. Your baby's weight loss is in the typical range for all babies." CORRECT: Babies may lose up to approximately 10% of their birth weight.

19. When Ms. Myers removes the diaper, the nurse notices that the baby has caked powder in the inguinal leg folds and vulva areas. What action should the nurse take?

D) Instruct Ms. Myers to use plain water instead of powder. CORRECT: Until the baby is 4 days old, only plain warm water is recommended (after the initial bath) because soaps, ointments, powders, lotions, and baby wipes can disrupt the acid mantle on the skin and provide a medium for bacterial growth. Ointments are prescribed only if a rash develops in the first few days of life. Use of powder also places the infant at risk for fine particle aspiration.

11. When examining the baby's extremities, which finding would warrant additional assessment by the nurse?

D) No bowl movements in the first 72 hours. CORRECT: The first meconium stool should pass within 48 hours. Obstruction may be suspected if no bowel movement in the first 72 hours.

The baby's vital signs have stabilized by 0100 hours. Upon completion of assessment and documentation, the nurse takes the baby to Ms. Myers who wants to breastfeed and 'room-in' with the baby. After checking the ID bands, the infant is positioned for breastfeeding. The nurse checks on Ms. Myers and the baby ar 0200 hours. Both are asleep in the bed, with the baby lying beside Ms. Myers.16. What should the nurse do next?

D) Remind Ms. Myers about infant safety and assist her to place the infant in the crib. CORRECT: This action protects the baby while reinforcing teaching to the mother.

Meconium

Dark green or black material present in the large intestine First stool usually passed within the 1st 24 hours of birth is called this

Mongolian spots

Dark, flat pigmentation of the lower back and buttocks

Mongolian spot

Dark, flat pigmented areas of lower back and buttocks These look like bruises on my back, but they're not

Ballard tool

Device used to measure gestational age

Anterior Fontanel

Diamond Shaped

Upon examining the infant's extremities, which findings should the nurse report to the HCP?

Diminished movement in one arm. May indicate nerve damage.

While examining the infant's head, the nurse notes soft swelling of the scalp that extends across the suture lines of the fetal skull. What action should the nurse take in response to this finding?

Document the finding in the record. Rationale: This finding indicates caput succedaneum, which commonly occurs after a vaginal birth.

While the infant receives phototherapy, his stools become loose and green. What action should the nurse take?

Document the findings in the EMR. The loose green stools are a typical response to phototherapy, so stools should continue to be monitored and results documented.

The nurse measures the infants head and chest What action should the nurse take when finding that the head measures 36 cm and the chest circumference measures 35 cm ?

Document the findings in the EMR. Within normal limits.

The infants vital signs include the following T 96.8 F (36 C) axillary Heart rate 136 beats/min irregular with soft murmur respiratory rate 42 breaths/min Which action should the nurse take?

Document the findings in the electronic medical record

1) which action should the nursery nurse take first in caring for the infant?

Dry the infant quickly with warm blanketsPrevent evaporative heat loss Dry the infant quicklyUse a scale to immediatelyApply a servomechanismCover the infant's leg

Charateristics of disorders currently included in newborn screening

Early detection and treatment significantly improve the outcome All disorders require treatment for the life of the individual Mild forms of the disorders may not be detected by newborn screening

Thrombosis, DVT, Thrombophlebitis

Elevation of blood clotting factors during pregnancy and the initial postpartum period can lead to this

Sucking Reflex

Elicited by inserting a finger or nipple in newborn's mouth

Grasp reflex

Elicited by placing an object in the newborn's hand

Palmar reflex

Elicited by stimulating the palm with a finger or object

Thermal Neutral Zone

Environmental temperature that provides for minimal heat loss

Describe the influence of these hormones lactation. Estrogen Progesterone Prolactin Oxytocin

Estrogen and progesterone prepare the breasts for lactation. Prolactin initiates milk production in the alveoli. Oxytocin causes milk ejection from the alveoli into the lactiferous ducts.

Puerperal Infections

Etiology: tissue trauma, prolonged rupture of membranes Types Metritis, wound infections, urinary tract, mastitis

LGA

Excessive growth of the fetus in relation to gestational age

Cold stress

Excessive heat loss resulting in increased respirations and non-shivering thermogenesis in order to maintain core body temperature

Polydactyly

Extra fingers and toes is called this

Brown Adipose Tissue

Fat deposits in neonates that provide greater heat-generating activity than ordinary fat

IUGR

Fetal undergrowth due to infection, malnutrition, congenital malformation

List the signs and symptoms that the postpartum woman should report to her physician or nurse-midwife.

Fever localized area of redness swelling pain in the breasts that is unrelieved by support or analgesics persistent abdominal tenderness or feelings of pelvic fullness or pelvic pressure; persistent perineal pain frequency urgency burning when urinating change in the lochia character (increased amount return to red color, passage of clots, or foul odor) localized tenderness, redness, or warmth of the legs

Lanugo

Fine downy hair found on all body parts of the fetus except palms and soles I may still have some of this fine hair at birth

Lanugo

Fine, downy hair found on body parts of fetus

Neonate

First 30 days of life

Taking-in

First phase of materal adaptation

Meconium

First stool of the newborn; dark green or black in color

Moro reflex

Flexion of newborn's thighs and knees accompanied by fingers that fan and arms which form a c-curve

Convection

Flow of heat from body surface to cooler surounding air

To promote family bonding, which part of infant care should the nurse delay?

Giving eye prophylaxis Giving VItamin K Securing ID Bands Cord Care Eye Prophylaxis

Hypoglycemia

Glucose less than 40 mg/dl

Postpartum Interventions

Goalds of care are to 1) maintain physiologic safety through assessments 2)Provide comfort 3) Provide health education 4)Empower client: self care

Homocystinuria (HCU)

HCU is caused by diminished activity of the enzyme cystathionine synthase, which is responsible for converting the amino acid homocysteine into cystathionine. This enzyme is needed by the brain for normal development If undetected and untreated, HCU can lead to seizures delays in reaching developmental milestones, mental retardation, and skeletal abnormalities. Incidence: 1 in 275,000 live births.

The nurse instructs the family about feeding the infant. The mother asks how often the infant should be burped.

He needs burping at the start of the feeding and after each ounce (30 mL) of formula. This gives specific guidelines to the parents.

Bradycardia

Heart rate less than 110

Evaporation

Heat loss incurred when water on the skin surface is converted to vapor

Most common complications

Hemorrhage Thrombosis Infection Depression

Subconjunctival hemorrhages

Hemorrhage on the sclera of a newborn

Which instructions should the nurse include in the discharge planning?

Holding the infant does not interrupt the phototherapy process. The phototherapy blanket allows the infact to be held while the process is continued.

Newborn Screening Law

If the infant is discharged from the hospital before forty eight (48) hours after birth or before being on a protein diet for twenty-four (24) hours, a blood specimen shall be collected regardless.

Immunoglobins

IgG, IgA, IgM are examples of these substances to protect me from infection

Mastitis

Inflammation of breast tissue Infection of the lactating breast Etiology- Staphylococcus aureus, enters through injured area of nipple. Proceded by engorgement and stasis of milk Common causes Skipped or sudden stop to feeding Constriction of the breasts Fatigue/ stress Signs and Symptoms Initial flu- like with fatigue and body aches, fever, malaise, headache Characterized by localized area of redness and inflammation Management of Mastitis Antibiotics, breast support , emptying of breat (feed and / or pump), heat or cold for comfor, analgesics, fluids

endometritis

Inflammation of the inner uterine lining

Bonding

Initial attraction felt by parents for their infants

Endometrium

Inner lining of the uterus

Erythema neonatorum toxicum

Innocuous pink macular rash of unknown origin with superimposed vesicles

2) Which action should the nurse take prior to drying the infants back?

Inspect the back for possible neurological defects. rationale: To prevent harm while drying the newborn, the back should always be inspected for possible neurological defects, like spinal bifida.

Engrossment

Intense fascination between the father and newborn

A valid screen

Is one in which blood is drawn after the baby is 48 hours of age and has been on protein feedings for 24 hours Repeat screening is requested when an invalid screening occurs

Bleeding Hemorrhage

Lack of Vitamin K puts me at risk for this problem

LGA stands for this?

Large for gestational age

Nevus flammeus

Large port-wine stain

Puerperium

Last six weeks following delivery The 6 week interval between the birth of the newborn and the return of the uterus and other organs to a pre-pregnant state Period from childbirth until the return of the reproductive organs to their pre-pregnancy states

NEW BORN UNIT 8

NEW BORN UNIT 8: •This unit covers nursing assessment and care for the neonate including appearance of the normal newborn, transition to extrauterine life, and nutritional needs. 1.Circulatory changes 2Cardiovascular changes 3.Thermoregulation

Lochia serosa

Light pink vaginal discharge

Describe the changes in lochia and when the aforementioned changes occur.

Lochia rubra contains blood, mucus, and bits of de- cidua; is red in color; and has a duration of approxi- mately 3 days. Lochia serosa contains serous exudate, erythrocytes, leukocytes, and cervical mucus; it is a pinkish color, and its duration is from the 4th to the 10th day. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria; it is white or colorless; its duration varies from the 11th day until the 3rd to 6th week.

Convection

Loss of heat from a warm body surface to a cooler air current

Evaporation

Loss of heat through conversion from liquid to a vapor

Conduction

Loss of heat to a cooler surface by direct skin contact

Radiation

Loss of heat to a distant cold object Method of heat loss in which heat is transferred to cool objects not in contact with skin

After receiving the labor and delivery report, which information should direct the nurse to further assessment of the infant's head? fourteen hours of laborlow forcepsunusual cord lengthvaginal delivery

Low forceps delivery fourteen hours of laborlow forcepsunusual cord lengthvaginal delivery

Cry

Lusty and strong are two good words used to describe this

Maple Syrup Urine Disease (MSUD)

MSUD affects the way the body metabolizes certain small compounds of protein, the three branch chain amino acids- leucine, isoleucine, and valine. These amino acids accumulate in the blood and cause a toxic effect that interferes with brain function. The odor of maple syrup may be noted in body fluids, hence the name for the disorder. Incidence: 1 in 250,000 live births

Startle

Make a loud noise and I will show you this reflex

Describe the progression of maternal touch.

Maternal touch progression is from fingertipping to palm touch to enfolding the infant and bringing him or her close to the body.

Kegel exercises

Method to increase the tone of muscles in the vaginal and urinary meatal area Method to increase urinary muscle tone-

Entrainment

Movement of the newborn in rhythm with the parent's voice

Myometrium

Muscular layer of the uterus-

Palmer grasp

My hand closes in a tight fist with this reflex

What is newborn screening?

Newborn screening is a public health activity that is performed on all newborns. Testing is done by heel-stick shortly after birth for early identification of those babies affected by certain genetic, metabolic, hormonal and/ or functional conditions for which there is effective treatment with early intervention.

Nita is a multipara who vaginally delivered twin boys 4 hours ago. One weighed 6 pounds and the other weighed 5 pounds 6 ounces, She is admitted to the mother-baby unit after an uneventful recovery. Your initial assessment reveals the following data: temperature 37.6°C (97.9°F), pulse 60 beats per minute (bpm), respirations 20 breaths/min, blood pressure 11070 mm Hg: fundus slightly soft and located to the right of the umbilicus: lochia moderate: midline episi- otomy intact with slight edema. What is your interpretation of these data? What is your first intervention? Why? What should you immediately teach Nita?

Nita's fundus is not well contracted probably be- cause of a full bladder as it is positioned to the right of the umbilicus. Her multifetal birth and multiparity increase the risk for postpartum hemorrhage. Massage the uterus to cause it to firmly contract and control bleeding. The next intervention should be to assist Nita to empty her bladder or catheterize her if she is unable to void. Otherwise, the uterus will relax again. You should immediately teach Nita how to assess her uterus for fimness and the relationship between a full bladder, her multiparity, and her multifetal birth to uterine contraction.

On a home visit 2 days postpartum, the nurse assesses Nita's fundus as firm, midline, and -1. Are these assessments normal? Why or why not? If they are not nomal, is there an explanation? What should the nurse expect to find in the lochia flow?

Nita's fundus is slightly higher than usual, but this is explained by her multiparity and delivery of twins. Lochia flow should be rubra (possibly changing to serosa), scant, and free of foul odor or clots.

Nita's vital signs 8 hours after birth are blood pressure 112/80 mm Hg, temperature 37.2°C (99°F). pulse 52 bpm. respirations 18 breaths/min. Are any nursing interventions needed based on these vital signs? What is the rationale for your judgment?

No interventions are needed. Bradycardia and a slight elevation in temperature are common at this time.

The nurse observes that the infant is jaundiced on his face, head and chest. What action should the nurse take next?

Obtain blood for laboratory analysis. Blood drawn for serum bilirubin provides additional data and the basis for treatment of hyperbilirubinemia, which may be physiologic or nonphysiologic.

Upon inspection of the umbilical cord, which finding should the nurse report to the healthcare provider (HCP)?

One artery and one vein are present. Rationale: two arteries and one vein should be present

Phenylketonuria (PKU)

PKU is a hereditary disease that results from diminished activity of phenylalanine (phe) hydroxylase, an enzyme that normally converts the amino acid phenylalanine to tyrosine. This amino acid can then accumulate and cause damage to the brain, resulting in severe mental retardation. Other findings include decreased pigmentation, behavior problems, seizures and an unusual body odor. Incidence: 1 in 12,000 live births.

POSTPARTUM UNIT 7

POSTPARTUM UNIT 7

Fundus

Part of the uterus above the openings of the fallopian tubes

When the nurse conducts a gestational age assessment, which findings may indicate postmaturity? (Select all that apply.)

Peeling, parchment-like skin. Thin with loose skin and little subcutaneous fat. Deep creases at the base of the toes extending to the heels.

Acrocyanosis

Peripheral cyanosis; blue color of hands and feet

Port wine stain, Nevus flammeus

Permanent, flat dark red or purple birth mark is called this

4. Which action should the nurse take prior to weighing the infant?

Place a cover on the scale provide a pacifier Diaper Cover Keep the cap

Upon admission to the transition care nursery, the Carson baby's axillary temperature is 97.4° F (36.3 C) What action should the nurse take?

Place the infant in a radiant warmer and monitor her temperature. Rationale: The baby's temperature is not within normal range (97.5°-99° F). The infant should remain in the radiant heat warmer until her temperature has stabilized.

Suck Reflex Suck Sucking

Placing a nipple or gloved finger in the mouth will elicit this reflex

Positive Babinski Reflex

The great toe dorsiflexes and toes fan

Scarf Sign

Position of the elbow when the hand of the supine infant is drawn over the other shoulder until it meets resistance

En face

Position that facilitates. to-eye contact between the parent and newbom

Chapter 20 Postpartum Adaptations

Postpartum Adaptations Chapter 20

Periods of reactivity

Predictable patterns of newborn behavior during the first hours after birth

Axillary

Preferred method for taking a temperature?

What makes any pregnant and postpartum woman at risk for venous thrombosis? What factors increase this risk?

Pregnant and postpartum women have higher fibrinogen levels, which increase the ability to form clots however, factors that lyse clots are decreased. Some women have another risk in addition to this baseline risk: those who have varicose veins, a history of thrombophlebitis, or a cesarean birth.

2. After cleaning the airway and drying the infant, the nurse assesses that the infant is breathing and has a heart rate of 100 but remains cyanotic

Prepare to give oxygen Apply temp Prepare to give oxygen Wrap the infant warmly Secure a suction cath

Attachment

Process by which an enduring bond between a parent and child is developed through pleasurable, satisfying interactions

What teaching should you provide the postpartum woman to prevent constipation?

Progressively increase activity drink adequate fluids (at least eight glasses of water daily), add dietary fiber (found in fruits and vegetables and whole-grain cereals, bread, and pasta) to prevent constipation. Prunes are a natural laxative.

The acronym is used as a reminder that the site of an episiotomy or perineal laceration should be assessed for five physical signs.

REEDA The acronym REEDA indicates redness, edema, ecchymosis or bruising, discharge, and approximation (the edges of the wound should be close). If redness accompanied by pain or tenderness, this may indicate infection. Edema may illustrate soft tissue damage and delay wound healing. There should be no discharge. The edges of the wound should be closely approximated as if held together by glue.

The nurse checks the identification bands for both the baby and the mother upon admission to the nursery. One ID number is incorrect. Which action should the nurse take to solve this problem?

Redo the identification bands with another nurse witnessing the process Rationale: Identification bands must be correct to ensure the safety and security of all hospitalized clients, especially newborns.

Neurological

Reflexes give us clues about what system assessment

What action should the nurse take?

Remove the bottle from the infant's mouth. Propping a bottle places the infant at risk for choking as well as ear infections.

The bilirubin serum level comes back at 8 mg/dL. The infant is diagnosed with pathologic hyperbilirubinemia. The nurse prepares the infant for placement under a bilirubin light. Which actions should the nurse implement? (Select all that apply.)

Remove the infant' clothing. Place eye patches on the infant. Turn off the lights and allow parents to hold infant for feedings.

Cardio respiratory assessment

Respirations •Normal: ▫Irregular ▫30-60/minute ▫Synchronous chest and abdomen movements ▫Increase with activity ▫May be moist in C-sec babies •Abnormal: ▫Grunting ▫Nasal flaring ▫Cyanosis ▫Asynchronous chest/abdomen ▫Retractions ▫Mouth breathing

Involution

Retrogressive changes that return the reproductive organs to their prepregnancy states

involution

Return of the uterus to its nonpregnant state

Discuss which postpartum mothers would be appropriate candidates for Rho(D) immune globulin and rubella vaccine.

Rho(D)-mother is Rh-, newborn is Rh+; rubella vaccine-if her prenatal rubella antibody screening shows she is nonimmune.

Nita will receive the Rh immune gkobulin (RhoGAM) and rubella vaccine before discharge. Under what circumstances are these drugs given? What precautions should the nurse teach Nita?

RhoGAM is administered to the Rh-negative mother if her infant is Rh positive and if she has not previ- ously built up anti-Rh antibodies. The rubella vac- cine is administered to the nonimmune postpartum woman because it is highly unlikely that she will pregnant soon. Nita should be cautioned to avoid another pregnancy for at least 3 months.

Hematocrit (HCT.)

Rises by day 7 as blood volume decreases --water in the form of urine (diuresis) and diaphoresis is lost thereby making the blood more concentrated.

How can the nurse help the new father adapt to his role?

The nurse should involve the father in infant care teaching and decisions. Fathers may not know what to expect from newborns and benefit from information about growth and development. A review of any prenatal teaching is helpful as well.

Maternal adjustment

Rubin's taking-in, taking-hold, and letting-go describe phases of what assessment

Lactation

Secretion of milk from the breast

Colostrum

Secretions from the breast which contain IgA antibodies and provides a laxative effect

While administering the vitamin K to the infant, which action should the nurse take?

Select the middle part of the vastus lateralis for use. Preferred site, in infants for administration of injections.

Diastasis recti

Separation of the rectus abdominis muscle-

Mrs. Iv asks how she will know the phototherapy is working. How should the nurse respond?

Serum bilirubin level decreases. Decreasing bilirubin levels are the best indicator of phototherapy effectiveness.

Molding

Shaping of the fetal head by overlapping of the cranial bones Reshaping of the skull bones during the birth process results in this

Peeling

Shedding of epithelial cells of the epidermis

Sickle cell anemia

Sickle cell anemia is caused by decreased oxygenation of red blood cells that causes the cells to change shape from round and healthy to rigid, sickle shape rods. This change in shape causes blockage of small blood vessels, which results in severe pain, damage to vital organs, stroke, and sometimes death in childhood . Young affected children are especially prone to severe bacterial infections that can lead to septicemia , pneumonia, and meningitis. Incidence: 1 in 400 african- americans 1 in 1,000 to 30,000 hispanics 1 in 2,700 native americans.

Respiratory Distress

Signs of this include nasal flaring and grunting

Neurologic

•Newborn brain is still growing, and development of nerve fibers is incomplete. ▫Uncoordinated movements ▫Easily startled ▫Tremors of extremities; quivering chin

Nita's episiotomy is slightly reddened along the suture line, the edges are closely approximated, and there is no edema, bruising, or drainage. Do these data support the supposition that the episiotomy is healing properly? Why or why not? What nursing actions are appropriate?

Slight reddening is typical of normal healing at this early stage. Close approximation of the edges and lack of drainage confirm that the healing seems to normally occur. Proper perineal cleansing and pad application should be reinforced. The nurse should also review the signs and symptoms of infection to герort.

The nurse performs a newborn assessment and evaluates the infant's reflexes. How does the nurse perform the Moro reflex?

Slightly raise the infants's head and trunk and allow the infant to drop back 30 degrees. This would elicit the infant's arms and legs to extend and abduct, with fingers fanning open.

Teleangiectatic nevi

Small clusters of flat red-pink spots on the nape of the neck and around eyes

Epstein's pearls

Small white specks on the gumlines of newborns These small white specks on the gum ridges are called this

Epstein's pearls

Small, white blebs found along the gum margins and at the junction of the hard and soft palates

Foramen ovale

Special opening between the atria which closes when lungs become inflated In fetal circulation, this shunt connects the right and left atrium

How newborn screening is performed

Specimen collection Using dried filter paper, blood samples are taken from the heel of the newborn prior to discharge from the hospital The sample is submitted to the designated state newborn screening lab that runs the tests and reports back to the indicated primary care physician / pediatrician. Invalid, abnormal, and positive screens are also reported to the state newborn screening program for additional follow-up

Periodic breathing

Sporadic episodes of apnea, not associated with cyanosis, that last up to 15 seconds

Oxytocin

Stimulates contractions/ milk let down reflex- Involution of the uterus is aided by this hormone

Prolactin

Stimulates production of milk

Describe postpartum changes in the: uterine muscle uterine muscle cells uterine lining

Stretched uterine muscle fibers contract and grad- ually regain their former size and contour. The number of uterine muscle cells remains the same, but each cell decreases in size through ca- tabolism. The outer area of the endometrium (decidua) is expelled with the placenta. The remaining de- cidua separates into two layers: The superficial layer is shed in the lochia and the basal layer re- generates new endothelium.

Cephalohematoma

Subcutaneous swelling containing blood found on the head of an infant which disappears in weeks to months

Episiotomy

Surgical Perineum incision-

Circumcision

Surgical removal of the foreskin

Caput Succadaneum

Swelling or edema occurring in or under the fetal scalp

Nita is worried about constipation because she had this problem after her previous births and has been constipated during the last months of this pregnancy. What interventions and teaching can help Nita avoid constipation?

Teach Nita to gradually increase her ambulation, drink additional fluids (at least eight glasses of water daily). and increase dietary fiber. Prunes are a natural laxa- tive, and she can consult her birth attendant for recom- mended laxatives if natural remedies do not work.

Stork Bite

Telangiectatic nervus is better known as this These flat red marks on the eyelids, back of neck and forehead called Telangiectatic nevi are better known as this

Hemorrhage and Infection, Infection and Hemorrhage

The 2 major risk factors during the initial postpartum period are

Gestational age

The Ballard score helps determine this?

Causes of hypothermia

The room is too cold The baby is exposed to cold draft The newborn is wet The baby is uncovered, even for short time The baby is not feeding well The baby is placed on a cold surface or near cold window or wall. The baby has an infection Baby has birth asphyxia and does not have energy to keep warm Mother and baby are not together

Nita plans to breastfeed her twins. She successfully breastfed her other two children. However, she says, "I want to breastfeed, but I really have a lot of cramping when I nurse. I don't remember having that with the other two children." What is the nurse's best response? Why is Nita having more cramping than with her other two infants? What intervention can help with this problem?

The best nursing response is to reassure Nita that the afterpains are typically short term and that analgesics can ease them. In addition, teach her that a full blad- der will worsen afterpains. Two factors that increase afterpains in Nita's case: multiparity and the uterine overdistention with two fetuses. Analgesics taken at least 30 minutes before the ex- pected time of breastfeeding can decrease afterpains. Lying in a prone position with a small pillow or folded blanket under the abdomen often helps.

What is the significance of bradycardia during the early postpartum period?

The blood volume and cardiac output increase as the blood from the uteroplacental unit returns to the central circulation and as excess extracellular fluid enters the vascular compartment for excretion. Because the stroke volume increases, the pulse decreases.

3, Three, 2 arteries, 1 vein

The cord should contain how many vessels

When Mrs. Iv finishes feeding the infant, she checks the diaper and it is dry. Mr. Iv expresses concern that he thinks the infant is becoming dehydrated. How should the nurse respond?

The infant should have 1 to 2 voids per day. Infants first 3 to 5 days of life should have 1 to 2 voids per day.

Describe the progression of maternal verbal behaviors.

The mother progresses from calling the infant "it" to referring to the infant as "he" or "she" to using the infant's given name.

What nursing measures can help the mother of twins attach to her babies?

The nurse should help parents individually interact with each twin rather than interacting with them as a "package." It is important to individually point out essential qualities and characteristics of each infant.

How should the nurse respond to the parent who is disappointed in the sex of the newbom?

The nurse should help the parent or parents acknowledge their feelings and deal with them to facilitate their attachment with the child,

Uterine Atony and lacerations, Lacerations and Uterine atony

The two most common causes of uterine hemorrhage are this

Skin and Markings

There are a lot of skin variations. The following are the most common. Look these up. Know what they are, what they look like, and if they disappear. Some of these are normal some abnormal. Variations in Color: •Dusky •Acrocyanosis vs. Cyanosis •Pale •Ruddy •Jaundiced •Racial considerations Variations in Texture/Integrity Milia Lanugo Erythema toxicum (newborn rash) Vernix caseosa Birthmarks Stork bite Port Wine Stain Strawberry mark Mongolian spot

Stretch marks, Striae Gravidarum

These will gradually fade and become silvery lines

BUBBLE HEP, BUBBLE-HEP

This acronym is a gentle reminder of the postpartum assessment components Breasts Uterus Bowel Bladder Lochia Episiotomy Homans Emotions Pain

Prolactin

This anterior pituitary hormone is responsible for promoting breast tissue growth and stimulating the production of milk Stimulates production of milk -

Homan's, Homan's sign

This assessment is done by dorsiflexing the foot

Bladder distention, Full bladder

This can interfere with uterine involution causing the uterus to push up and to the side

Postpartum Blues

This is characterized by tearfulness, insomnia, lack of appetite,is transient in nature and occurs within the 1st 2 weeks post delivery Normal reactions/ feelings after birth

Endometritis, Metritis

This is the most common cause of postpartum infection

Rhogam, RhIG

This needs to be administered 72 hours after delivery in a mom who is Rh negative with a Rh positive newborn

Tonic Neck

This reflex is also called the fencing reflex

Stepping, Stepping Reflex

This reflex is elicited when I am held so that my foot touches a solid surface

Plantar

This reflex makes my toes just curl!

Engorgement

This results in complaints of tenderness and swelling in the breast 2-3 days post delivery Local congestion of the breasts associated with lactation

Boggy, Boggy Uterus

This term describes a soft, relaxed uterus that is likely to cause hemorrhage

Transient Strabismus, Strabismus

This term for "crossed eyes" is common for the first 3-4 months

Choanal atresia

This term refers to blocked nasal passages due to a septal abnormality

Phototherapy

This treatment exposes infants to bright lights to treat hyperbilirubinemia

Menstruation, Menstrual cycle

This will resume in 7-9 weeks in nonlactating moms

Collaborative problems

Those problems which the nurse consults with the physician, the physician typically writes orders in the chart

Neonatal period

Time from birth through the first 28 days

Milia

Tiny white papules appearing on the face of the neonate You might find this across my forehead, nose, and chin

Milia

Tiny white pustules on face and chin resulting from unopened sebaceous glands

Rooting

Touch my cheek and I will turn my head

Conduction

Transfer of body heat to a cooler object by direct contact

What factor should alert the nurse to assess for the risk of jaundice?

Trauma at birth. Presence of a cephalhematoma indicates trauma during birth and bleeding has occurred. As the red blood cells break down, increased amounts of bilirubin are released into the general circulation.

Which action should the nurse implement first?

Use a bulb syringe to clear the mouth and nose. Gagging due to excessive mucus is a typical response during the transition period. Suctioning the mouth and nose should be done first.

The nurse conducts the change of shift assessment of the infant. Which finding by the nurse is consistent with a cephalhematoma?

Well-outlined swelling that does not cross suture lines. Cephalhematoma is caused by increased pressure or trauma at birth from blood collecting beneath the periosteum of the bone and therefore does not cross the suture line.

Tonic neck reflex

When head is turned to one side, arm and leg on that side extend, extremities on opposite side flex

Moro, Moro's

With sudden jarring, this reflex's response will extend and abduct my extremities and fan my fingers

Babinski's, Babinski

With this reflex, my toes will flare and my big toe will dorsiflex

Jaundice

Yellow color of the skin /mucous membrane caused by an increased bilirubin Physiologic or pathologic, either way I'm a nice yellow color with this condition

Lochia alba

You should see this type of vaginal drainage 2 weeks after delivery

Chest

•Clavicles straight and intact •Breath sounds clear •Heart rate ausculated at border of left sternum, left to midclavicle •Breast engorgement •Breast nipples symmetrical

Describe additional nursing assessments and care for the woman who gave birth by cesarean. a. Respiratory b. Abdomen c. Intake and output

a. Observe the respiratory rate and depth (every 30 minutes to 1 hour if epidural narcotics were used): monitor for apnea for epidural narcotic administration; auscultate breath sounds for re- tained secretions; assist the mother to turn, cough, and deep-breathe; use incentive spirometer. b. Assess for the return of peristalsis by auscultating bowel sounds: observe for abdominal distention: observe surgical dressing for intactness and drain- age: observe the incision line after dressingremoval for signs of infection (REEDA); gently palpate the fundus. c. Monitor the intravenous (IV) line for the rate of flow and site condition; observe the urine for the amount, color, and clarity.

Eyes

•Clear blue/slate-gray or brown in color •Pupils - equal and reactive •May have subconjunctival hemorrhage •No tears---- lacrimal structures function at about 2 months •In-coordinate eye movements

bradycardia

can occur due to 50% increase in blood volume from tissue and changes in uterine circulation

Methods of heat loss

•Convection (loss to cooler air currents) • •Radiation (indirect heat transfer from body to cooler surfaces) • •Evaporation (from wet skin) • •Conduction (direct heat loss to cooler objects)

fingertipping

initial touch characteristic between mother and newborn

baby Weight loss

may experience up to 10% of this in the first days of life

At 1 min of age, the infant is alert and active and has a strong cry. He has a heart rate of 172 and a respiratory rate of 50. The infants arms and legs are flexed, the color of his body is pink and the color of both feet is blue. The nurse continues a physical assessment of the infant looking for normal and abnormal findings. 3) which APGAR score should the nurse assign?

rationale: One point is deducted for acrocyanosis.

Lochia Rubra

reddish vaginal discharge after birth On the 2nd day after delivery, this bright red vaginal discharge is called

Risk Factors for Hyperbilirubinemia

•Delayed or poor intake •Cold stress •Asphyxia •Blood incompatibility •Sepsis •Prematurity •Sibling with jaundice •Bruising •Cephalohematoma •Polycythemia

Ballard Gestational Age Tool

•Neuromuscular and physical characteristics: Score •Age compared to size: LGA, AGA, SGA This tool is used to determine gestational age

Circulatory Adjustments

•3 Fetal Shunts: help to provide most oxygenated blood to reach vital organs • •Pressure changes at birth: created by clamping of cord and expansion of lungs • •Physiologic Murmurs: r/t adjustments Cord: Vein - well oxygenated blood

APGAR SCORE

•A score is given for each sign at one minute and five minutes after the birth. • •If there are problems with the baby an additional score is given at 10 minutes. • •A score of 7-10 is considered normal, while 4-7 might require some resuscitative measures, and a baby with apgars of 3 and below requires immediate resuscitation.

Early identification and treatment of jaundice

•Assess skin, mucous membranes •Nurses usually have standing orders to have bilirubin levels drawn when they assess jaundiceness

At Birth

•Assessment and resuscitation • •APGAR scoring • •Temperature maintenance • •Identification • •Bonding

Psychosocial adaptation

•Behavioral states ▫Deep or quiet sleep ▫Light or active sleep ▫Drowsy state ▫Quiet alert ▫Active alert ▫Crying

Biological/Physiological Adaptations of the Neonate

•Birth marks the beginning of extra-uterine life and the continuation of growth and development. • •Most organ systems are prepared to function but may not be physiologically mature. • •Careful attention is necessary to evaluate this transitional time.

Hepatic System: COH Metabolism

•Blood glucose levels for newborns should range between 40-60mg/dl •Risk factors for hypoglycemia ▫Prematurity ▫Postmaturity ▫Asphyxia ▫Cold Stress ▫Large or small for gestational age ▫Maternal Diabetes

Nutritional Needs (food eating)

•Breast milk advantages: ▫Easily digested ▫Perfectly matched nutrition ▫Filled with antibodies that protect against infection Breastfeeding •Feed q 2-3 hours •Latching on/off very important to ↓ soreness •Swallowing noises •Satisfied •Wet diapers •Supply/demand Bottle-feeding •Formula only ▫Iron -fortified •Every 3-4 hours •Clean technique for preparation •Never microwave •Never prop •Throw away leftovers after a feeding

Respiratory Adjustments: Why Babies Breathe

•Chemical Factors-↓ blood oxygen and ↑ blood CO2 and ↓ pH all stimulate respiratory center in medulla • •Thermal Factors-Sudden change in temperature as infant born. • •Mechanical Factors- chest compressed by narrow birth canal-lung fluid forced out. Chest recoils- forces air into lungs.

3 Shunts of fetal life

•Ductus arteriosus ▫Shunts blood from the pulmonary artery to the aorta and away from the developing lungs ▫ •Ductus venosus ▫Shunts blood from the umbilical vein to the inferior vena cava and away from the developing liver • •Foramen ovale ▫Shunts blood from the right atrium to the left atrium and also away from the developing lungs

Genitalia

•Female: labia majora covers labia minora • • •Male

Changes At Birth

•First Breath- ▫Foramen Ovale closes ▫Ductus Arteriosis closes- blood goes to lungs ▫Ductus Venosus closes-blood goes to liver ▫ •Umbilical arteries and vein severed-cord cut

Parent Teaching About Infant Care

•Head support •Positions •Skin/cord care •Wrapping •Bathing •Diaper area •Sleep •Behavior/ Socialization •Using a bulb syringe •Using a thermometer •Stools/Diarrhea •Urine output

Cephalocaudal or Head to Toe Assessment

•Head: ▫Molding ▫Frontal occipital circumference 2 cm greater than chest circumference. •Anterior fontanel - closes at approximately 18 months • •Posterior fontanel (occipital)- closes at 8-12 weeks

Routine Newborn Screenings

•Hearing screening: early detection of hearing loss •Critical Congenital Heart Disease Screening •State screening - view slides on STATE SCREENINGS on Blackboard ▫To detect conditions that result from inborn errors of metabolism or other genetic conditions.

Heat gain: Non-shivering Thermogenesis

•Heat is produced by increasing the metabolism especially in brown adipose tissue •Blood is warmed as it passes through the brown fat and it in turn warms the body • •Brown fat unique to newborn. • •Because of richer vascular supply, by the breakdown of brown fat, heat is produced.

Hepatic system (Liver) Conjugation of Bilirubin

•Hemolysis of RBC's →unconjugated → fat soluable (attaches to subcutaneous fat) → •Jaundice-yellow discoloration of the skin and conjunctiva •Unconjugated bili is changed to a water soluable form by a process called conjugation (via glucuronyl transferase enzyme) •Conjugated bilirubin is excreted in the stool.

Extremities: flexion

•Hips ▫Detection of congenital hip dislocation ▫Asymmetric gluteal and thigh creases. ▫ ▫Legs are equal in length

Health Promotion: Activity and Play

•Human interactions •Sensory stimulation •Tummy time

Newborn Assessment and Care

•Hygiene: providing skin care/cord assessment/bathing

Newborn Safety

•Identification bands •Abduction prevention systems •Protecting the infant: safety issues ▫Identifying the infant ▫Preventing infant abduction ▫Preventing infection: handwashing

Effects of Cold Stress Management: Cold stress

•Increased need for oxygen •Respiratory distress •Hypoxia •Decreased surfactant production •Hypoglycemia •Metabolic acidosis •Jaundice •Cover adequately - remove cold clothes and replace with warm clothes •Warm room/bed •Take measures to reduce heat loss •Ensure skin-to-skin contact with mother; if not possible, keep next to mother after fully covering the baby •Breast feeding

Newborn reflexes

•Indicators of normal development ▫Feeding Reflexes ▫Plantar / palmar grasp ▫Moro ▫Tonic neck Rooting Palmar Grasp Plantar reflex Babinski Reflex Moro (startle) reflex Tonic neck reflex Sensory Abilities •Vision •Hearing •Taste •Smell

Immune System

•Infants have little natural immunity •Decreased ability to localize infection •Tendency toward sepsis ▫Assess mother's GBS status ▫Have approximately 3-month passive immunity from mom -more if breast feeding IgG IgM IgA ▫Rationale for early immunizations

Hepatic System: Iron

•Iron storage ▫stored during last few weeks of pregnancy ▫ ▫infants who are breastfeeding don't need supplement until 4-6 months of age.

Signs of Hypoglycemia

•Jitteriness or •Lethargy •Poor muscle tone •Sweating •Tachypnea •Dyspnea/Apnea •Cyanosis •Low temperature •Poor suck SEVERE: HIGH PITCHED CRY AND COMA

Umbilical Cord Care

•Keep clean and dry •No longer using rubbing alcohol on cords

Urinary System

•Kidney Development -75% of newborn is water (extracellular) Causes danger of dehydration •Kidney function- ↑ concentration of urine; high uric acid content: rust colored urine • •Frequent, small voids

Hypothermia: why are newborns prone?

•Larger surface area per unit body weight •Decreased thermal insulation due to lack of subcutaneous fat (LBW infant) •Reduced amount of brown fat (LBW infant)

GBS Status

•Mother with GBS + results: newborn requires careful monitoring of vitals—especially temperature—for early identification of infection (sepsis) •Usual onset within first week; high mortality rates •S & S of sepsis: low temps, tachypnea, tachycardia, hypotension

Pain Assessment "The fifth vital sign"

•NIPS ▫Tool for children less than 1 year old ▫Greater than 3 indicates pain Facial Expression Cry Breathing Pattern Arms Legs State of Arousal

Nose

•Nasal breathing •Observe for blockage - choanal atresia •Sneezing

Ears

•Observe placement r/t eye level •Assess amount of cartilage and folds (gestational age parameter) •Consider parental appearance

Hyperbilirubinemia

•Physiologic jaundice - normal jaundice occurring approximately 48 hours after birth. • • •Pathologic jaundice- occurs in first 24 hours. Usually results from blood incompatibility-Rh or ABO

Hepatic System (Liver)

•Plays an important role in iron storage, carbohydrate metabolism, conjugation of bilirubin, and blood coagulation. •Immature functioning: medication toxicity

Hands & Feet

•Polydactyly •Syndactyly •Hand creases •Clubfoot •CRT

Introductory Terminology

•Preterm • •Term • •Post-term • •Neonatal Period •Perinatal Period • •Infancy • •Viability • •Extrauterine

Neutral Thermo Environment

•Range of environmental temperature in which an infant can maintain normal body temperature with minimal basal metabolic rate and least oxygen consumption

Hematologic Adaptations

•Risk of clotting deficiency ▫Low prothrombin levels during the first few days of life create a potential for hemorrhage ▫Absence of gut bacterial flora, which influences the synthesis of vitamin K. ▫Platelet counts are near adult levels. •The average blood volume for a newborn is 80-85 ml/kg •↑ Levels of RBC's •Polycythemia •Fetal red blood cells carry 20-50% more oxygen called fetal hemoglobin. •RBC's break down during neonatal period

Circumcision

•Signs of complications after circumcision ▫Early Concerns: Bleeding more than a few drops with first diaper change Failure to urinate (urethral trauma) Excessive pain ▫Later Concerns: Signs of infection: fever or low temperature, purulent or foul-smelling drainage Scarring (after healing)

Health Promotion: Rest and Sleep safety and injury prevention

•Sleep on back •Circadian rhythm •Avoid overheating, smoking near baby •Avoid soft/excessive linens, etc. Risk for SIDS or Suffocation •Crib safety •Bathing safety •Car seats

Abdomen

•Soft and rounded, bowel sounds active •Umbilical cord white with 3 vessels: remember "aVa" •Wharton's jelly is "mucousy" white tissue with high water content. •Cord turns black with drying. Falls off at approximately 1-2 weeks.

Caput succedaneum

•Soft tissue edema overlying the presenting part caused by pressure (against cervix) during labor swelling of tissue over presenting part of newborn head; crosses suture lines •Feels spongy •Present at birth •Recedes within a few days

Gastrointestinal System

•Stomach capacity small •Intestines sterile with meconium •Meconium -black, sticky; made up of bile, amniotic cells, epithelial cells. •Meconium is excreted within 24 hours in normal newborns.

Spine

•Straight, continuous •No dimpling, tufts of hair, depressions or protrusions •Extremities flexed, moveable

Cephalhematoma

•Sub-periosteal bleeding from pressure during birth process; develops first 24-48 hrs. •Appears as a "lump" or "bump" •Does not cross suture lines •Recedes slowly

Head lag

•Support head and neck of neonate

Role of Surfactant

•Surfactant development: acts as lubricant • •Need surfactant to keep alveoli open when infant exhales. If none, alveoli stick together and collapse. • •Lecithin and sphingomyelin are major components: L/S ratio

Mouth

•Symmetrical when cries •Hard and soft palate should be intact •Designed for optimal feeding •Suck and rooting reflexes

Thermal regulation factors

•Term Newborns are unable to shiver or sweat. •Brown Fat (in area of clavicle, shoulder blades and sternum of infant) generates heat for infant.

Ineffective Thermoregulation

•Thermoregulation is the maintenance of balance between heat loss and heat production. • •HYPOTHERMIA IS DANGEROUS. • •Vulnerable

Nursing Diagnoses for Newborns

•Use Ackley and Blackboard slides for ideas •Common dx: Ineffective protection Ineffective thermoregulation Hypothermia Risk for infection Risk for injury Community Resources •Home Visits •Clinic Visits •Telephone Follow-up Calls •Help Lines

Physical Assessment

•Vital Signs (take in this order) • ▫Respiratory rate 30-60 breaths/min with short periods of irregular cessation (less the 10 sec) ▫ ▫Heart rate 120-160 beats per minute ▫ ▫Temperature 36.5-37.2ºC (97.7-99.2ºF) ▫ ▫Blood pressure 80/46; varies with changes in newborn activity, blood volume. Most accurate when resting. •Evaluate vital signs per protocol (after birth and every 30 minutes to 1 hour until stable. • •If axillary temp is low (97.6 or lower) provide an intervention and re-evaluate in ½ hour.

Common Medications for the Newborn

•Vitamin K: for normal hypothrombinemia: 0.5 to 1mg given IM •Erythromycin eye ointment for Chlamydia/Gonorrhea •Hepatitis B vaccine

Measurements

•WEIGHT: •7 ½ lbs. • •LENGTH:•19-21 inches • •HEAD: •13-14 inches • •CHEST:12-13 inches

Laboratory Values

▫Blood glucose: maintaining safe levels, repeating glucose tests (40-60mg/dl) ▫RBC: 4-6 million ▫Hgb: 15-20 and Hct: 45-65 ▫WBC: 9-30,000 ▫Bilirubin: assessing level of jaundice

Newborn Assessment and Care •Thermoregulation

▫Clothing, blankets ▫Use of radiant heat warmer ▫Maintaining adequate calorie intake ▫Use of skin-to-skin contact ▫Keeping skin dry