ADN 240 Postpartum and Newborn - Exam 2

Cephalohematoma

Swelling caused by bleeding between the osteum and periosteum of the skull due to pressure from being born Fluid filled consistency - can have fluid wave This swelling does not cross suture lines Commonly seen in babies who had a vacuum assisted delivery Hemorrhagic effect Takes 2-3 weeks to months to heal

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in?

Taking-in phase

The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss?

"This is a normal response."

Chilling =

Greater O2 consumption Hypoglycemia More need for more calories Increased risk for metabolic acidosis Lower surfactant production

An infant born via a cesarean delivery appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant?

Tachypnea

Coombs test

Used in evaluation of a jaundiced infant a blood test to diagnose hemolytic anemias in a newborn

On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as:

acrocyanosis

Hypovolemia

decreased/low blood volume in the body

Never do what when a DVT/blood clot is detected...

dorsiflexion (Homan's sign)

Facial Paralysis

loss of action of the facial muscles often from forceps, can occur from laying on a nerve usually disappears after a few days or few weeks can be hard for baby to feed affected side up, eye patch for affected eye

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?

radiation, convection, and conduction

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment?

yellow sclera

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days?

yellow-green, pasty, unpleasant-smelling stool

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn?

bringing the newborn into the room

Caput Succedaneum

edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma Crosses suture lines Superficial tissue trauma Resolves in a few days Goes away without treatment

Cervitis

inflammation of the cervix

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate.

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant?

6

Newborn Nursing Interventions - Respiratory

Position ^ O2 - Semiprone/Side lying Maintain respiratory tract patency Stimulate -- Reminds them to breathe Monitor O2 therapy Assess respiratory effort - grunting/nasal flaring/apnea/cyanosis = requires immediate interventions for baby

What supplies would the nursery nurse collect in preparation of doing a bath on a newborn infant?

A washcloth Warm tub of water Thermometer

Postpartum assessment - BUBBLE

B = Breasts U = Uterus B = Bowels B = Bladder L = Lochia E = Episiotomy/C-section incision E---can also stand for maternal emotions about the outcomes of the birth and the new baby

The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?

Bladder distension

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

Blood sugar

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus

A nurse is caring for a nonbreast-feeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?

Wear a well-fitting bra

Postpartum Depression

a new mother's feelings of inadequacy and sadness in the days and weeks after giving birth Okay for about 2 weeks after birth More common for mothers who have had it before or who had a traumatic/stressful experience during pregnancy/birth Anytime medicated for mental health in a year after birth would fall into postpartum depression

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?

a respiratory rate of 15 breaths per minute with nasal flaring

Postpartum Psychosis

a severe postpartum psychological disorder that may include delusions, hallucinations, and extreme mental disorganization Irrational thoughts turn into actions

Newborn heat loss

-evaporation: drying the newborn prevents heat loss via evaporation (liquid converts to vapor) -convection: maintain an ambient room temp of 75.2 degree (flow of heat from the body surface to a cooler ambient air) -conduction: using a protective cover prevents contact with the scale -radiation: place the newborn's bassinet away from the outside windows (loss of heat from the body surface to a cooler, solid surface not in direct contact with newborn but in relative proximity)

The nursing instructor is teaching a class on the physiologic properities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?

It keeps alveoli from collapsing with breaths.

A laboring mother requests that she be allowed to participate in kangaroo care following delivery. The nurse understands that this involves what action?

Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket.

Subinvolution

failure of uterus to return to non-pregnant state

Parametritis

inflammation around/outside of the uterus

thrombophlebitis

inflammation of a vein associated with a clot formation

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported?

temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention

Newborn assessment components—"APGAR"

"APGAR" Appearance Pulse Grimace Activity Respiratory effort

The nurse is administering a postpartal woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care?

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable."

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant?

"I know you are hurting, but you can have another baby in the future."

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."

The mother of a 1-day-old newborn calls the nurse alarmed and asks the nurse to hurry to her room because there is something wrong with her baby. The nurse arrives to find the newborn lying on his crib on his side, awake and crying with one side of his body a dark red color and the other side of his body is pale. What would the nurse tell this mother?

"This is a harlequin sign and is a normal finding in newborns. It usually occurs when the infant is crying or when he is lying on his side."

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?

"You might try using a water-soluble lubricant to ease the discomfort."

Baby sleeps..

16-20 hours a day for the first 2 weeks

How long is the neonatal period for a newborn?

28 days

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

Anesthetic may not be effective during the procedure

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?

Blood pressure

A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client?

Body secreting the excess fluids from pregnancy

Fractured Clavicle

Break in long bone of shoulder girdle May palpate crepitus Most common is mid-clavicle break Shoulder gets stuck in mother's pelvis Occasionally done intentionally to ease tension during birth Splinting 2-4 weeks recovery

The nurse notices that there is no Vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.

Newborn Assessment - Circulatory System

Closure of ductus arteriosus, foramen ovale, and ductus venosus Increased pulmonary circulation Transitory murmurs Hands and feet = Acrocyanosis Heart rate from 120-160 bpm

A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm?

Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus.

A postpartal woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf.

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

Duiresis

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal?

E. coli

All the options are signs of respiratory distress in the newborn except: A. grunting B. nasal flaring C. chest retractions D. central cyanosis E. respiratory rate of 50 breaths per minute F. coughing

E. respiratory rate of 50 breaths per minute

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure the ice packs are changed frequently

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?

Evaporative

The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse?

Hip for dislocation

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination.

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn?

Lack of subcutaneous fat

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?

Lethargy and hypotonia

Newborn lung maturation

Lung function after 26 weeks gestation Surfactant is okay at 35 weeks gestation

Newborn Nursing Interventions - Temperature

Minimize cold stress Maintain skin temp 96.8-97.7 Continually monitor temp Prevent rapid cooling or warming Use a hat to prevent heat loss from head

Newborn baby's head

Molding Elongating Caput succedaneum = edema Fontanelles - Bulging? or sunken?

Newborn Nursing Interventions - Food & Fluids

Monitor for hypoglycemia (especially in larger babies) Assess tolerance of oral/tube feedings Monitor hydration Assess for gastric residue, bowel sounds, change in stool patterns, abdominal girth Monitor for weight gain or loss

The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?

Moro

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?

On admission to the nursery

Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which medication would the nurse administer as prescribed after repositioning?

Oxytoxic agent

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?

Uterus 1cm below the umbilicus

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which

Postpartum psychosis

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder?

Postpartum psychosis

Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care?

Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.

Brachial Palsy Injuries

Stretching of the neck/head More likely with a larger baby or a difficult birth Shoulder dystocia Present with a pronated wrist Affected arm hangs limp Arm and hand function affected Usually resolves in a few weeks to few months for arms/hand Cervical nerve root injury results in temporary paralysis which can take a few months to recover from Normal activity after some time Interventions needed such as PT

A nurse working in the neonatal nursery anticipates the primary care provider to prescribe which medication for a premature newborn having difficulty breathing?

Surfactant

The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance?

Vernix

The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?

Teach that adequate hydration helps clear the infection quicker.

When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the infant's blood?

The foramen ovale closes, preventing blood exchange from right to left in the heart.

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?

The infant is attempting self-consoling maneuvers.

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?

Touching

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

Touching

Newborn respiratory system - respiratory effort

Within the first minute of birth: loud and lusty cry no dyspnea no retractions respiratory rate from 30-50 a minute diaphragmatic and abdominal muscles used nose breather mouth = circumoral cyanosis

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?

You should not lift anything heavier than your infant in its carrier.

Subgaleal Hemorrhage

blood crosses suture lines boggy scalp, pallor, tachycardia Commonly seen with vacuum assisted delivered babies forward, lateral positioning of ears risk for jaundice, severe blood loss Can take weeks to months to reabsorb and heal

Mastitis

inflammation of the breast/milk ducts; most commonly occurs in women who are breastfeeding

Endometritis

inflammation of the endometrium (inner layer of the uterine wall)

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression?

loss of confidence decreased interest in life inability to concentrate

Pitocin is given to prevent what condition?

postpartum bleeding

When assessing the newborn's umbilical cord, what should the nurse expect to find?

two smaller arteries and one larger vein