TEST Two Maternal newborn CH 13-17 ATI 11-15

uterine contractions assessment

Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The catheter is positioned in the uterine cavity through the cervix after the membranes have ruptured. It reports intensity by measuring the pressure of the amniotic fluid inside the uterus in millimeters of mercury. It is not recommended for routine use in low-risk laboring women due to the potential risk of infection and injury to the placenta or fetus. In a recent study using noninvasive technology, it was found that using a multichannel electromyogram that acquires a uterine signal and maternal and fetal electrocardiograms was more accurate than that of an external Doppler and fetal scalp electrode monitor

ch 13 key concepts

Labor is a complex, multifaceted interaction between the mother and fetus. Thus, it is difficult to determine exactly why labor begins and what initiates it. Before the onset of labor, a pregnant woman's body undergoes several changes in preparation for the birth of the newborn, often leading to characteristic signs and symptoms that suggest labor is near. These changes include cervical changes, lightening, increased energy level, bloody show, Braxton Hicks contractions, and spontaneous rupture of membranes. False labor is a condition seen during the latter weeks of some pregnancies in which irregular uterine contractions are felt, but the cervix is not affected. The critical factors in labor and birth are designated as the 10 Ps: passageway (birth canal), passenger (fetus and placenta), powers (contractions), position (maternal), psychological response, philosophy (low-tech, high-touch), partners (support caregivers), patience (natural timing), patient (client) preparation (childbirth knowledge base), and pain management (comfort measures). The size and shape of a woman's pelvis are determining factors for a vaginal birth. The female pelvis is classified according to four main shapes: gynecoid, anthropoid, android, and platypelloid. The labor process is comprised of a series of rhythmic, involuntary, usually quite uncomfortable uterine muscle contractions that bring about a shortening (effacement) and opening (dilation) of the cervix, and a bursting of the fetal membranes. Important parameters of uterine contractions are frequency, duration, and intensity. The diameters of the fetal skull vary considerably, with some diameters shortening and others lengthening as the head is molded during the labor and birth process. Pain during labor is a nearly universal experience for childbearing women. Having a strong sense of self and meaningful support from others can often help women manage labor well and reduce the sensation of pain. Mentally preparing for childbirth is important for women to enable them to work with the natural forces of labor and not against them. As the woman experiences and progresses through childbirth, numerous physiologic responses occur that assist her adaptation to the laboring process. Labor is typically divided into four stages that are unequal in length. During the first stage, the fundamental change underlying the process is progressive dilation of the cervix. It is further divided into two phases: latent phase and active phase. The second stage of labor is from complete cervical dilation (10 cm) and effacement through the birth of the infant. The third stage is that of separation and birth of the placenta. It consists of two phases: placental separation and placental expulsion. The fourth stage begins after the birth of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother (1 to 4 hours).

lochia

Lochia passes through three stages: Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. As uterine bleeding subsides, it becomes paler and more serous. Lochia serosa is the second stage. It is pinkish brown and is expelled 3 to 10 days postpartum. Lochia serosa primarily contains leukocytes, decidual tissue, red blood cells, and serous fluid. Lochia alba is the final stage. The discharge is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content. It occurs from days 10 to 14 but can last 3 to 6 weeks postpartum in some women and still be considered normal. Lochia at any stage should have a fleshy smell; an offensive odor usually indicates an infection, such as endometritis.

take note

Nurses must be aware of the thermoregulatory needs of the newborn and must ensure that these needs are met to provide the newborn with the best start possible. Maintenance of temperature stability should be focused on preventative measures. To minimize the effects of cold stress, the following interventions are helpful: Prewarming blankets and hats to reduce heat loss through conduction Keeping the infant transporter (warmed isolette) fully charged and heated at all times Drying the newborn completely after birth to prevent heat loss from evaporation Encouraging skin-to-skin contact with the mother if the newborn is stable Promoting early breast-feeding to provide fuels for nonshivering thermogenesis Using heated and humidified oxygen Always using radiant warmers and double-wall isolettes to prevent heat loss from radiation Deferring bathing until the newborn is medically stable, and using a radiant heat source while bathing (Fig. 17.5) Avoiding the placement of a skin temperature probe over a bony area or one with brown fat, because it does not give an accurate assessment of the whole-body temperature (most temperature probes are placed over the liver when the newborn is supine or side-lying)

breast feeding hormones

Prolactin levels increase at term with a decrease in estrogen and progesterone levels. Estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production. Oxytocin is released from the posterior pituitary gland to promote milk let-down. Infant sucking at each feeding provides continuous stimulus for prolactin and oxytocin release

ch 15 key points

The puerperium period refers to the first 6 weeks after delivery. During this period, the mother experiences many physiologic and psychological adaptations to return her to the prepregnant state. Involution involves three processes: contraction of muscle fibers to reduce stretched ones, catabolism (which reduces enlarged, individual cells), and regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed in lochia. Lochia passes through three stages: lochia rubra, lochia serosa, and lochia alba during the postpartum period. Maternal blood plasma volume decreases rapidly after birth and returns to normal within 4 weeks postpartum. Reva Rubin (1984) identified three phases the mother goes through to adjust to her new maternal role: the taking-in, taking-hold, and letting-go phases. The transition to parenthood for a partner is influenced by many factors, including participation in childbirth, relationships with significant others, competence in child care, the family role organization, the cultural background, and the method of infant feeding. Like mothers, partners go through a predictable three-stage process during the first 3 weeks as they too "try on" their roles as partners. The three stages include expectations, reality, and transition to mastery.

ch 16 key concepts

The transitional adjustment period between birth and parenthood includes education about baby care basics, the role of the new family, emotional support, breast-feeding or bottle-feeding support, and maternal mentoring. Sensitivity to how childbearing practices and beliefs vary for multicultural families and how best to provide appropriate nursing care to meet their needs are important during the postpartum period. A thorough postpartum assessment is key to preventing complications as is frequent hand hygiene by the nurse, especially between handling mothers and infants. The postpartum assessment that uses the acronym BUBBLE-EE (breasts, uterus, bowel, bladder, lochia, episiotomy/perineum/epidural site, extremities, and emotions) is a helpful guide in performing a systematic head-to-toe postpartum assessment. Lochia is assessed according to its amount, color, and change with activity and time. It proceeds from lochia rubra to serosa to alba. Because of shortened agency stays, nurses must use this brief time with the client to address areas of comfort, elimination, activity, rest and exercise, self-care, sexuality and contraception, nutrition, family adaptation, discharge, and follow-up. The AAP advocates breast-feeding for all full-term newborns, maintaining that breast milk should ideally be the sole nutrient for the first 6 months and continued with foods until 12 months of life or longer. Successful parenting is a continuous and complex interactive process that requires the acquisition of new skills and the integration of the new member into the existing family unit. Bonding is a vital component of the attachment process and is necessary in establishing parent-infant attachment and a healthy, loving relationship; attachment behaviors include seeking and maintaining proximity to and exchanging gratifying experiences with the infant. Nurses can be instrumental in facilitating attachment by first understanding attachment behaviors (positive and negative) of newborns and parents, and intervening appropriately to promote and enhance attachment. New mothers and their families need to be attended to over an extended period of time by nurses knowledgeable about mother care, newborn feeding (breast-feeding and bottle feeding), newborn care, and nutrition.

interpreting fetal heart rate patterns

nterpreting Fetal Heart Rate Patterns Category I: normal Predictive of normal fetal acid-base status and do not require intervention • Baseline rate (110-160 bpm) • Baseline variability moderate • Present or absent accelerations • Present or absent early decelerations • No late or variable decelerations • Can be monitored with intermittent auscultation during labor Category II: indeterminate Not predictive of abnormal fetal acid-base status, but require evaluation and continued surveillance • Fetal tachycardia (>160 bpm) present • Bradycardia (<110 bpm) not accompanied by absent baseline variability • Absent baseline variability not accompanied by recurrent decelerations • Minimal or marked variability • Recurrent late decelerations with moderate baseline variability • Recurrent variable decelerations accompanied by minimal or moderate baseline variability; overshoots, or shoulders • Prolonged decelerations >2 minutes but <10 minutes Category III: abnormal Predictive of abnormal fetus acid-base status and require intervention • Fetal bradycardia (<110 bpm) • Recurrent late decelerations • Recurrent variable decelerations—declining or absent • Sinusoidal pattern (smooth, undulating baseline)

effacement

0%: cervical canal is 2 cm long 50%: cervical canal is 1 cm long 100%: cervical canal is obliterated

Cardinal movements of labor

1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External Rotation 7. Expulsion

When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every

15-30 mins

Which assessment would indicate that a woman is in true labor?

Cervix is 4 cm dilated, 90% effaced.

The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate?

Document this as indicating a normal pattern.

lacerations

First-degree laceration: involves only skin and superficial structures above muscle Second-degree laceration: extends through perineal muscles Third-degree laceration: extends through the anal sphincter muscle Fourth-degree laceration: continues through anterior rectal wall

Which finding would lead the nurse to suspect that a postpartum woman was developing a complication?

Swollen, tender, hot area on breast

take note

Ovulation may occur before menstruation. Therefore, breast-feeding is not a totally reliable method of contraception unless the mother exclusively breast-feeds, has had no menstrual period since giving birth, and has an infant younger than 6 months

The nurse would expect a postpartum woman to experience lochia in which sequence?

Rubra, serosa, alba

When determining the frequency of contractions, the nurse would measure which period of time?

Start of one contraction to the start of the next contraction

A laboring woman is admitted to the labor and birth suite at 4-cm dilation. She would be in which phase of labor

active

heat loss

newborns have several characteristics that predispose them to heat loss: Thin skin with blood vessels close to the surface Increased skin permeability to water Lack of shivering ability to produce heat until 3 months old Limited stores of metabolic substrates (glucose, glycogen, fat) Limited use of voluntary muscle activity or movement to produce heat Large surface area-to-body mass ratio

flexion

occurs as the vertex meets resistance from the cervix, the walls of the pelvis, or the pelvic floor. As a result, the chin is brought into contact with the fetal thorax and the presenting diameter is changed from occipitofrontal to suboccipitobregmatic (9.5 cm)

When assessing a postpartum woman, which finding would lead the nurse to suspect postpartum blues?

periodic crying and insomnia

When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing?

wait until you feel the urge to push

The nurse is instructing the postpartum client who plans to bottle feed her newborn about measures to prevent breast engorgement when she is discharged. Which measure should the nurse include in the teaching plan?

wearing a tight-fitting supportive bra 24 hours daily

fetal engagement

• Presenting part reaching 0 station • Floating: no engagement; presenting part freely movable about pelvic inlet

Postpartum breast engorgement occurs 48 to 72 hours after giving birth. What physiologic change influences breast engorgement?

An increase in blood and lymph supply to the breasts

take note

Apneic periods lasting more than 15 seconds with cyanosis and heart rate changes require further evaluation

fetal station

Location of the presenting part in relation to the midpelvis or ischial spines; expressed as cm above or below the spines; station 0 is engaged, station -2 is 2 cm above the ischial spines

third stage of labor; separation and delivery of placenta

usually 5-10 minutes can last up to 3 hr

Which observation would suggest that placental separation is occurring?

uterine shape change to globular

After the nurse provides instructions to a postpartum woman about postpartum blues, which statement indicates understanding?

"I may feel like laughing one minute and crying the next minute."

second stage of labor 10 cm to birth of baby ; perineal phase

(Period of active Pushing) Nullipara: lasts up to 1 hr Multipara: lasts up to 30 mins. Contractions are every 2-3 minutes or less for 60-90 sections. Contraction intensity strong by palpation. **Strong urge to push during the later perineal phase**

True vs. False Labor

**True Labor** Progressive dilatation and effacement Regular contractions increasing in frequency, duration, and intensity Pain usually starts in the back and radiates to the abdomen Pain is not relieved by ambulation or by resting **False Labor** Lack of cervical effacement and dilatation Irregular contractions do not increase in frequency, duration, and intensity (Braxton-Hicks) Contractions occur mainly in the lower abdomen and groin Pain may be relieved by ambulation, changes of position, resting, or a hot bath or shower

TAKING IN PHASE (POST PARTUM)

- immediatly after birth (hours- couple days)- Passive dependent behavior- relies on others for comfort, rest , and care. concerned for her own needs and overall health of newborn, talkative and excited reviewing birth experience.

First Stage: Active Phase

-Cervix dilates 6-10 cm -Contractions grow stronger, lasting 40-60 secs and occurring approximately every 2-5 mins -nullipara =6 hrs multipara= 4hrs -Discomfort intensifies -Encourage client to change positions as comfortable -Administer analgesics as requested

Which interventions are underutilized in promoting a normal birth? Select all that apply.

-Oral nutrition and fluids in labor-Open glottis pushing in the second stage of labor-Skin-to-skin contact after birth for infant bonding

dilation

0 cm: external cervical os is closed 5 cm: external cervical os is halfway dilated 10 cm: external os is fully dilated and ready for birth passage

The first stage, latent phase

0-6cm dilation 0-40% effacement nullipara=20hrs multipara = 14 hrs contractions q 5-10 mins lasting 30-45 sec

take note

A danger sign is the reappearance of bright-red blood after lochia rubra has stopped. Reevaluation by a health care provider is essential if this occurs.

take note

A neonate born by cesarean section does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. Closely observe the respirations of the newborn after cesarean births.

When assessing a term newborn (6 hours old), the nurse auscultates bowel sounds and documents recent passing of meconium. These findings would indicate

A patent anus with no bowel obstruction and normal peristalsis

The nurse performs a physical examination on a newborn 2 hours after birth. Which findings indicate a need for a pediatric consultation? Select all that apply.

Absent Moro reflex when startledYellow blanching of the skin when pressure applied to the nose

Summary of Fetal to Neonatal Circulation

Clamping the umbilical cord after birth eliminates the placenta as a reservoir for blood. Onset of respirations causes a rise in PO2 in the lungs and a decrease in pulmonary vascular resistance, which... Increases pulmonary blood flow and increases pressure in the left atrium, which... Decreases pressure in the right atrium of the heart, which causes closure of the foramen ovale (closes within minutes after birth secondary to a decreased pulmonary vascular resistance and increased left heart pressure). With an increase in oxygen levels after the first breath, an increase in systemic vascular resistance occurs, which... Decreases vena cava return, which reduces blood flow in the umbilical vein (constricts, becomes a ligament with functional closing). Closure of the ductus venosus (becomes a ligament) causes an increase in pressure in the aorta, which forces closure of the ductus arteriosus within 10 to 15 hours after birth.

The nurse is explaining to a postpartum woman 48 hours after childbirth that the afterpains she is experiencing can be the result of which factor?

Contractions of the uterus after birth.

Which practice would not be included in a physiologic birth?

Early induction of labor <39 weeks' gestation

A new mother gave birth 12 hours ago. Because this is her first child, which goal planned by the nurse is most appropriate?

Effective education of both parents before discharge

Postpartum Danger Signs

Fever >100.4°F (38°C) Foul-smelling lochia or an unexpected change in color or amount Large blood clots or bleeding that saturates a peripad in an hour Severe headaches or blurred vision Visual changes, such as blurred vision or spots, or headaches Calf pain with dorsiflexion of the foot Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites Dysuria, burning, or incomplete emptying of the bladder Shortness of breath or difficulty breathing without exertion Depression or extreme mood swings

Maternal responses to labor

Heart rate increases by 10 to 20 bpm. Cardiac output increases by 12% to 31% during the first stage of labor and by 50% during the second stage of labor. Blood pressure increases by up to 35 mm Hg during uterine contractions in all labor stages. The white blood cell count increases to 25,000 to 30,000 cells/mm3 perhaps as a result of tissue trauma. Respiratory rate increases and more oxygen is consumed related to the increase in metabolism. Gastric motility and food absorption decrease, which may increase the risk of nausea and vomiting during the transition stage of labor. Gastric emptying and gastric pH decrease, increasing the risk of vomiting with aspiration. Temperature rises slightly, possibly due to an increase in muscle activity. Muscular aches and cramps occur as a result of stress on the musculoskeletal system. Basal metabolic rate increases and blood glucose levels decrease because of the stress of labor (Funai & Norwitz, 2019). A woman's ability to adapt to the stress of labor is influenced by her psychological and physical state. Among the many factors that affect her coping ability are: Previous birth experiences and their outcomes (complications and previous birth outcomes) Current pregnancy experience (planned versus unplanned, discomforts experienced, age, risk status of pregnancy, chronic illness, weight gain) Cultural considerations (values and beliefs about health status) Support system (presence and support of a valued partner during labor) Childbirth preparation (attended childbirth classes and has practiced paced breathing techniques) Exercise during pregnancy (muscles toned; ability to assist with intra-abdominal pushing) Expectations of the birthing experience (viewed as a meaningful or stressful event) Anxiety level (excessive anxiety may interfere with labor progress) Fear of labor and loss of control (fear may enhance pain perception, augmenting fear) Fatigue and weariness (not feeling adequately energized for the challenge and duration of labor)

Normal Newborn Blood Values

Lab Data Normal Range Hemoglobin 16-18 g/dL Hematocrit 46-68% Platelets 150,000-350,000/μL Red blood cells 4.5-7.0 (1,000,000/μL) White blood cells 10-30,000/mm3

The nurse is assessing Ms. Smith, who gave birth to her first child 5 days ago. What findings would the nurse expect?

Light pink or brownish lochia; uterus 4-5 finger breadths below umbilicus

10 P's

Passageway (birth canal) Passenger (fetus and placenta) Powers (contractions) Position (maternal) Psychological response These critical factors are commonly accepted and discussed by health care providers. However, five additional "P's" can also affect the labor process: Philosophy (low-tech, high-touch) Partners (support caregivers) Patience (natural timing) Patient (client) preparation (childbirth knowledge base) Pain management (comfort measures)

Fetal responses to labor include:

Periodic fetal heart rate accelerations and slight decelerations related to fetal movement, fundal pressure, and uterine contractions Decrease in circulation and perfusion to the fetus secondary to uterine contractions (a healthy fetus is able to compensate for this drop) Increase in arterial carbon dioxide pressure (PCO2) Decrease in fetal breathing movements throughout labor Decrease in fetal oxygen pressure with a decrease in the partial pressure of oxygen (PO2)

fetal attitude

Relationship of fetal body parts to one another, normal attitude is flexion he most common fetal attitude when labor begins is with all joints flexed—the fetal back is rounded, the chin is on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees (Fig. 13.5). This normal fetal position is most favorable for vaginal birth, presenting the smallest fetal skull diameters to the pelvis.

fetal position

Relationship of the landmark on the presenting fetal part to the front, sides, or back of the maternal pelvis.

When managing a client's pain during labor, nurses should

Support the client's decisions and requests

Engrossment: Partner Psychological Adaptation

Visual awareness of the newborn—the partner perceives the newborn as beautiful. Tactile awareness of the newborn—the partner has a desire to touch or hold the newborn and considers this activity pleasurable. Perception of the newborn as perfect—the partner does not "see" any imperfections. Strong attraction to the newborn—the partner focuses all their attention on the newborn when in the room. Awareness of distinct features of the newborn—the partner can distinguish the newborn from others in the nursery. Extreme elation—the partner feels a "high" after the birth of the child. Increased sense of self-esteem—the partner feels proud, "bigger," more mature, and older after the birth of the child

take note

Women who are unable to return to a healthy weight by 6 months postpartum increase their risk factors for the development of chronic diseases including metabolic syndrome, obesity, and cardiovascular disease (Siegel et al., 2019). Encourage women to lose pregnancy weight by 6 months postpartum, and refer those who don't to community weight loss programs.

Which newborn could be described as breathing normally

breathing shallowly, at a rate of 36 bpm, with short periods of apnea.Normal breathing can be described as shallow, at a rate of 36 bpm, with short periods of apnea.

After teaching a group of breast-feeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients?

calories and proteins

engagement

ccurs when the greatest transverse diameter of the head in vertex (biparietal diameter) passes through the pelvic inlet (usually 0 station

descent

downward movement of the fetal head until it is within the pelvic inlet. Descent occurs intermittently with contractions and is brought about by one or more of the following forces: Pressure of the amniotic fluid Direct pressure of the fundus on the fetus's buttocks or head (depending on which part is located in the top of the uterus) Contractions of the abdominal muscles (second stage) Extension and straightening of the fetal body

Which of these activities would best help the postpartum nurse provide culturally sensitive care for the childbearing family?

educate about cultural practices

Immediately after childbirth in the recovery area, the nurse observes the mother's partner's fascination and interest in the new child. This behavior is often termed

engrossement

After teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which student behavior indicates successful teaching?

drying newborn immediate after birth

A nursing student asks the nursery nurse why they do not bathe the newborn immediately upon admission to the nursery observation area after birth. The nurse states that this would increase the risk of

hypothermia

Because the newborn's RBCs break down much sooner than those of an adult, what might result?

jaundice

fourth stage of labor

stabilization of vital signs first four hours postpartum

stages of labor

1st: dilating stage 3 phases: Latent (0-3cm) Active (4-7cm) Traditional (8-10cm w/ urge to push) 2nd stage: delivery 3rd: placental delivery 4th: recovery- primary goal to prevent hemorrhage from uterine atony, 1st void within 1 hour and then q2-3 hrs, Rhogam

Lochia amount

1. scant (< 2.5 cm) 2. light (< 10 cm ) 3. moderate (> 10 cm) 4. heavy (saturated in 2 hours) *If woman receives an oxytocic med, the flow of lochia is often scant* until the effects of the med wear off *Amount of lochia is usually less after cesarean birth* bc the surgeon suctions the blood & fluids from the uterus Flow of lochia usually *INCREASES with ambulation & breastfeeding* - lochia tends to pool in vagina when woman is lying in bed then gushes upon standing

CH 14 Key concepts

A nurse provides physical and emotional support during the labor and birth process to assist a woman in achieving her goals. When a woman is admitted to the labor and birth area, the admitting nurse must assess and evaluate the risk status of the pregnancy and initiate appropriate interventions to provide optimal care for the client. Completing an admission assessment includes taking a maternal health history; performing a physical assessment on the woman and fetus, including her emotional and psychosocial status; and obtaining the necessary laboratory studies. The nurse's role in fetal assessment for labor and birth includes determining fetal well-being and interpreting signs and symptoms of possible compromise. Determining the FHR pattern and assessing amniotic fluid characteristics are key. FHR can be assessed intermittently or continuously. Although the intermittent method allows the client to move around during labor, the information obtained intermittently does not provide a complete picture of fetal well-being from moment to moment. Assessment parameters of the FHR are classified as baseline rate, baseline variability, and periodic changes in the rate (accelerations and decelerations). The nurse monitoring the laboring client needs to be knowledgeable about which category the FHR pattern is in so that appropriate interventions can be instituted. For a category III FHR pattern, the nurse should notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. In addition to interpreting assessment findings and initiating appropriate inventions for the laboring client, accurate and timely documentation must be carried out continuously. Today's women have many safe nonpharmacologic and pharmacologic choices for the management of pain during childbirth. They may be used individually or in combination to complement one another. Nursing management for the woman during labor and birth includes comfort measures, emotional support, information and instruction, advocacy, and support for the partner. Nursing care during the first stage of labor includes taking an admission history (reviewing the prenatal record), checking the results of routine laboratory work and special tests done during pregnancy, asking the woman about her childbirth preparation (birth plan, classes taken, coping skills), and completing a physical assessment of the woman to establish baseline values for future comparison. Nursing care during the second stage of labor focuses on supporting the woman and her partner in making decisions about her care and labor management, implementing strategies to prolong the early passive phase of fetal descent, supporting involuntary bearing-down efforts, providing support and assistance, and encouraging the use of maternal positions that can enhance descent and reduce the pain. Nursing care during the third stage of labor primarily focuses on immediate newborn care and assessment and being available to assist with the delivery of the placenta and inspecting it for intactness. The focus of nursing management during the fourth stage of labor involves frequently observing the mother for hemorrhage, providing comfort measures, and promoting family attachment.

external rotation

After the head is born and is free of resistance, it untwists, causing the occiput to move about 45 degrees back to its original left or right position (restitution). The sagittal suture has now resumed its normal right-angle relationship to the transverse (bisacromial) diameter of the shoulders

take note

An infant born between 34 0/7 and 36 6/7 weeks' gestation is identified as "late preterm" and experiences many of the same health issues as other preterm birth infants

Which suggestion would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight?

Avoid empty-calorie foods, breast-feed, increase exercise.

A nurse observes a 3-day-old term newborn who is starting to appear mildly jaundiced. What might explain this condition?

Physiologic jaundice secondary to breast-feeding

cervical changes

Before labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur. These changes can occur 1 month to 1 hour before actual labor begins. ripening and softening of the cervix are essential for effacement and dilation, which reflect the enhanced collagen breakdown that was previously inhibited by progesterone

In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the woman's behavior to be characterized in what way?

Being passive and dependent

Which activity would the nurse include in the teaching plan for parents with a newborn and an older child to reduce sibling rivalry when the newborn is brought home?

Planning a daily "special time" for the older sibling

Newborn sensory capabilities

Hearing—well developed at birth, responds to noise by turning to sound Taste—ability to distinguish between sweet and sour by 72 hours old Smell—ability to distinguish between mother's breast milk and breast milk from others Touch—sensitivity to pain, responds to tactile stimuli Vision—incomplete at birth; maturation is dependent on nutrition and visual stimulation. Newborns have the ability to focus only on close objects (8 to 10 in away) with a visual acuity of 20/140; they can track objects in midline or beyond (90 in). This is the least mature sense at birth. The ability to fix, follow, and be alert is indicative of an intact CNS (King et al., 2019).

Which assessment finding indicates positive bonding between the parents and their newborn?

Holding the infant close to the body

The major purpose of the first postpartum home care visit is to

Identify complications that require interventions

Leopold maneuver sequence

Instruct woman to empty her bladder first. Place woman in dorsal recumbent position, supine with knees flexed to relax abdominal muscles Palpate client's fundus to identify fetal part determine location of fetal back palpate fetal part presenting at inlet identify attitude of head Use the palm for palpation not the fingers. Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) Maneuver 3: What is the presenting part? Maneuver 4: Is the fetal head flexed and engaged in the pelvis?

fetal presentation

Manner in which the fetus enters the birth canal.

Factors Increasing a Woman's Risk for Postpartum Complications

Risk Factors for Postpartum Infection Operative procedure (forceps, cesarean birth, vacuum extraction) History of diabetes, including gestational-onset diabetes Prolonged labor (more than 24 hours) Use of indwelling urinary catheter Anemia (hemoglobin <10.5 mg/dL) Multiple vaginal examinations during labor Prolonged rupture of membranes (>24 hours) Manual extraction of placenta Compromised immune system (HIV-positive) Risk Factors for Postpartum Hemorrhage Precipitous labor (less than 3 hours) Uterine atony Placenta previa or abruptio placenta Labor induction or augmentation Operative procedures (vacuum extraction, forceps, cesarean birth) Retained placental fragments Prolonged third stage of labor (more than 30 minutes) Multiparity, more than three births closely spaced Uterine overdistention (large infant, twins, hydramnios)`

Taking hold phase

Second phase characterized by dependent and independent maternal behavior . This phase typically starts on the second to third day postpartum and may last several weeks. As the client regains control over her bodily functions during the next few days, she will be taking hold and becoming preoccupied with the present.

ch 17 key concepts

The neonatal period is defined as the first 28 days of life. As the newborn adapts to life after birth, numerous physiologic changes occur. At birth, the cardiopulmonary system must switch from fetal to neonatal circulation and from placental to pulmonary gas exchange. One of the most crucial adaptations that the newborn makes at birth is the adjustment of a fluid medium exchange from the placenta to the lungs and that of a gaseous environment. Neonatal RBCs have a lifespan of 80 to 100 days in comparison with the adult RBC lifespan of 120 days. This difference in RBC lifespan causes several adjustment problems. Thermoregulation is the maintenance of balance between heat loss and heat production. It is a critical physiologic function that is closely related to the transition and survival of the newborn. The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Brown fat is a special kind of highly vascular fat found in all humans. Heat loss in the newborn is the result of four mechanisms: conduction, convection, evaporation, and radiation. Responses of the immune system serve three purposes: defense (protection from invading organisms), homeostasis (elimination of worn-out host cells), and surveillance (recognition and removal of enemy cells). In the newborn, congenital reflexes are the hallmarks of maturity of the CNS, viability, and adaptation to extrauterine life. The newborn usually demonstrates a predictable pattern of behavior during the first several hours after birth, characterized by two periods of reactivity separated by a sleep phase.

take note

The process of cervical effacement and dilation is analogous to that of pulling a turtleneck sweater over your head.The soft tissues of the passageway consist of the cervix, the pelvic floor muscles, and the vagina. Through effacement, the cervix effaces (thins) to allow the presenting fetal part to descend into the vagina.

lightening

The process or time during late pregnancy when the fetal head begins to descend into the mother's pelvis, resulting in a lessening of pressure on the diaphragm. With this descent, the woman usually notes that her breathing is much easier and that there is a decrease in gastric reflux. However, she may complain of increased pelvic pressure, leg cramping, dependent edema in the lower legs, and low back discomfort. She may notice an increase in vaginal discharge and more frequent urination

take note

Transient functional cardiac murmurs may be heard during the neonatal period as a result of the changing dynamics of the cardiovascular system at birth. Usually, they are benign (Ungerleider et al., 2019).

During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern?

Uterine fundus palpated to the right of the umbilicus

extension

With further descent and full flexion of the head, the nucha (the base of the occiput) becomes impinged under the symphysis. Resistance from the pelvic floor causes the fetal head to extend so that it can pass under the pubic arch. Extension occurs after internal rotation is complete

cRITICAL ATTRIBUTES OF ATTACHMENT

e terms "bonding" and "attachment" are often used interchangeably, even though they involve different time frames and interactions. Attachment stages include proximity, reciprocity, and commitment. Proximity refers to the physical and psychological experience of the parents being close to their infant. This attribute has three dimensions: Contact: The sensory experiences of touching, holding, and gazing at the infant are part of proximity-seeking behavior. Emotional state: The emotional state emerges from the affective experience of the new parents toward their infant and the parental role. Individualization: Parents are aware of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately, making the attachment process also, in a way, one of detachment.

By the end of the second stage of labor, the nurse would expect which of the following events?

fetus born and on moms chest

Cultural Influences during the Postpartum Period

frican American Mother may share care of the infant with extended family members. Experiences of older women within the family influence infant care. Mothers may protect their newborns from strangers for several weeks. Mothers may not bathe their newborns for the first week. Oils are applied to skin and hair to prevent dryness and cradle cap. Silver dollars may be taped over the infant's umbilicus in an attempt to flatten the slightly protruding umbilical stump. Sleeping with parents is a common practice. Amish Women consider childbearing their primary role in society. Generally oppose birth control. Pregnancy and childbirth are considered a private matter; may conceal it from public knowledge. Women typically do not respond favorably when hurried to complete a self-care task. Nurses need to take cues from women indicating their readiness to complete morning self-care activities. Appalachian Infant colic is treated by passing the newborn through a leather horse's collar or administering weak catnip tea. An asafetida bag (a gum resin with a strong odor) is tied around the infant's neck to ward off disease. Women may avoid eye contact with nurses and health care providers. Women typically avoid asking questions even if they do not understand directions. The grandmother may rear the infant for the mother. Filipino American Grandparents often assist in the care of their grandchildren. Breast-feeding is encouraged, and some mothers breast-feed their children for up to 2 years. Women may feel uncomfortable discussing birth control and sexual matters. Strong religious beliefs predominate, and bedside prayer is common. Families are close-knit and numerous visitors can be expected at the hospital after childbirth. Japanese American Cleanliness and protection from cold are essential components of newborn care. Nurses should bathe the infant daily. Newborns are routinely not taken outside the home because it is believed that they should not be exposed to outside or cold air. Infants are kept in a quiet, clean, warm place for the first month of life. Breast-feeding is the primary method of feeding. Many women stay in their parents' home for 1 to 2 months after birth. Bathing the infant can be the center of family activity at home. Mexican American The newborn's grandmother lives with the mother for several weeks after birth to help with housekeeping and child care. Many women will breast-feed for more than 1 year. The infant is carried in a rebozo (shawl) that allows easy access for breast-feeding. Women may avoid eye contact and may not feel comfortable being touched by a stranger. Nurses need to respect this preference. Some women may bring religious icons to the hospital and may want to display them in their rooms. Muslim Modesty is a primary concern; nurses need to protect the client's modesty. Muslims often will not eat pork; check all food items before serving. Muslims may prefer a same-sex health care provider; male-female touching is prohibited except in an emergency situation. A Muslim woman often stays in the house for 40 days after birth, being cared for by female members. Most women will breast-feed, but some holidays and religious events call for periods of fasting, which may increase the risk of dehydration or malnutrition. Women are exempt from obligatory five-times-daily prayers as long as lochia is present. Extended family is likely to be present throughout much of the woman's hospital stay. They may need an empty room to perform prayers without having to leave the hospital. Native American Women may be secretive about pregnancies and choose to not reveal them early. Touching is not a typical female behavior, and eye contact is brief. Resent being hurried and need time for sitting and talking. Most mothers breast-feed and practice birth control.

After birth, the nurse would expect which fetal structure to close as a result of increases in the pressure gradients on the left side of the heart?

foraman ovale

internal rotation

fter engagement, as the head descends, the lower portion of the head (usually the occiput) meets resistance from one side of the pelvic floor. As a result, the head rotates about 45 degrees anteriorly to the midline under the symphysis.

Physiologic preparation for labor would be demonstrated by

lightening

Which fetal lie is most conducive to a spontaneous vaginal birth?

longitudinal

Anatomic and Physiologic Comparison of the Fetus and Newborn

opic of Comparison Fetus Newborn Respiratory system Fluid-filled, high-pressure system causes blood to be shunted from the lungs through the ductus arteriosus to the rest of the body. Air-filled, low-pressure system encourages blood flow through the lungs for gas exchange; increased oxygen content of blood in the lungs contributes to the closing of the ductus arteriosus (becomes a ligament). Site of gas exchange Placenta Lungs Circulation through the heart Pressures in the right atrium are greater than in the left, encouraging blood flow through the foreman ovale. Pressures in the left atrium are greater than in the right, causing the foreman ovale to close. Hepatic portal circulation Ductus venosus bypasses; maternal liver performs filtering functions. Ductus venosus closes (becomes a ligament); hepatic portal circulation begins. Thermoregulation Body temperature is maintained by maternal body temperature and the warmth of the intrauterine environment. Body temperature is maintained through a flexed posture and brown fat.

As the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is

progressive cervical changes occur in the in true labor

When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating the

second period of reactivity

fetal lie

the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother

expulsion

the rest of the body occurs more smoothly after the birth of the head and the anterior and posterior shoulders

Letting go phase

the third phase of maternal adaptation, the woman reestablishes relationships with other people. She adapts to parenthood in her new role as a mother. She assumes the responsibility and care of the newborn with a bit more confidence (Jordan et al., 2019). The focus of this phase is to move forward by assuming the parental role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy.

The most intense time during labor is during the

transition phase