CHA2 Exam 6 (FINAL)
Obtaining a Sample of Cord Blood
*if any acid/base imbalances *can determine if in metabolic acidosis (long term stress) *respiratory acidosis (short term stress)
Fetal Scalp Stimulation
*want acceleration of 15bpm for 15 seconds *get a response *stimulate scalp --stimulate fetus and wake them up --apply pressure to the head of child during labor *blood sampling --pH < 7.2 = acidosis (distressed)
Oxygen hood
- Small plastic hood that fits over infant's head - Use minimum flow rate (4-5L/min) to prevent CO2 build-up - Ensure neck, chin, shoulders don't rub against hood - Continuous pulse ox - needs to be warmed and humidified
Stopping preterm labor
-Initial measures --Identifying and treating infections (dehydration and infection) --Other causes for preterm --contractions --Limiting activity --Hydration *want full term if possible
intraventricular hemorrhage in babies
-bleeding around the ventricles within the brain -due to trauma/asphyxia -decrease ICP, no cry
Bimanual compression
-compress -oxytocin to contract uterine muscle -labs and monitor them
tocolytics
-decrease contractions -MGSO4 -quiet uterine activity -measure heart and lung sounds for fluid overload -calcium gluconate to reverse
Accelerating fetal lung maturity
-give betamethasone -decrease surfactant
Hands and knees position
-make head downward, move fetus inside
What is necrotizing enterocolitis (NE)? What will you see in the newborn? What are interventions for a newborn with NE?
A serious inflammatory condition of the intestines S/S: feeding intolerance. Increased abdominal girth caused by distention. Decreased bowel sounds. Visible bowel loops. Vomiting. Abdominal tenderness. Blood in stools. Signs of infection. Withhold next feeding and notify the HCP IV fluids and parenteral nutrition Position infant on the side to prevent pressure to the diaphragm due to the inflamed intestines.
A nurse is caring for a pregnant client with preterm labor receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. A. Notify the healthcare provider if urinary output is less than 30 mL per hour B. Monitor maternal vital signs every 4 hours C. Monitor renal function and cardiac function closely D. Monitor intake and output hourly E. Monitor deep tendon reflexes hourly F. Keep calcium gluconate on hand in case of a magnesium sulfate overdose G. Notify the healthcare provider if respirations are less than 18 per minute
A, C, D, E, F When caring for a client receiving magnesium sulfate therapy, the nurse must monitor the vital signs every 30-60 minutes. The physician should be notified if respirations are less than 12 breaths/minute. Magnesium sulfate may cause respiratory depression if levels are too high. Calcium gluconate is the reversal agent for elevated magnesium levels/overdose and must be kept readily available. Cardiac and renal function must be monitored closely. Deep tendon reflexes must also be closely monitored—too brisk could mean an increased risk for seizures and magnesium levels are too low and too depressed means the magnesium levels are getting too high. The urine output must also be maintained at least 30 mL/hour or more because the medication is eliminated through the kidneys.
The nurse is caring for a client in active labor at 39 weeks gestation. The patient is receiving a continuousIV Pitocin (oxytocin) infusion. What actions should the nurse take if decelerations are noted by the nurse? (SATA) A. Change the maternal position to the lateral side B. Discontinue oxytocin infusion C. Notify the HCP D. Perform a nitrazine test E. Administer oxygen via a non rebreather face mask
A,B,C,E When on oxytocin (Pitocin), the contractions are augmented. When contractions occur, the blood flow through the placenta is decreased. The nurse must monitor the contractions (frequency, strength) and monitor for fetal tolerance of the increased contractions. Decelerations may occur. If late decelerations occur, the nurse must turn the patient to the side, provide O2, stop the oxytocin, and notify the healthcare provider. Nitrazine paper is used to verify if amniotic fluid is leaking and is not needed for this situation.
he nurse assists in initiation of internal fetal monitoring. Which of the following would the nurse include when teaching the patient about placement of the monitor? (Select all that apply.) A. The cervix must be dilated to 2 cm B. The probe will be advanced through the abdominal wall C. The probe will be inserted into the scalp approximately 1 mm D. The amniotic membranes will be ruptured E. Placement of the probe is through the fontanels
A,C,D For placement of the internal fetal monitor, the provider will artificially rupture the membranes if not already done. The monitor probe is inserted through the vagina and cervix and placed on the presenting part. The cervix must be dilated at least 2 cm. The probe only is placed into the fetal tissue about 1 mm. Areas to avoid include the fontanels, fetal face and genitals. The probe is not placed through the abdominal wall.
A postpartum patient has an ecchymotic area to the side of her perineal repair a few hours after delivery.What initial action should the nurse take? A. Apply an ice pack to the area. B. Contact the healthcare provider for an antibiotic prescription. C. Encourage the patient to take a warm sitz bath. D. Assess the patient's temperature.
A. Apply an ice pack to the area. Bruising to the side of the incisional area indicates a hematoma. Ice will limit the bruising and pain. Ice packs are indicated especially during the first 24 hours. A warm sitz bath would be encouraged after the first 24 hours. (Warmth to the area may increase the ecchymosis.) Ecchymosis does not indicate an infection so taking the temperature at this time is not the priority. (Vital signs are usually done q4h for the first 24 hours after delivery.) Antibiotics are not indicated at this time.
A neonate was born in the last hour and has HR 188, RR 68, SaO2 89% on 3 L pm. Blood glucose is 52. The neonate is to be transferred to an agency with a neonatal ICU approximately 90 miles away. What is the best plan for transfer? A. Plan transport via helicopter to a Level 3 ICU. B. Plan for transport via ambulance C. Plan for transport via ambulance with paramedics. D. Plan for parents to transport the infant via car in 1-2 days.
A. Plan transport via helicopter to a Level 3 ICU. The patient is very critical and needs to be transported as soon as possible to a high-level neonatalICU. Note abnormal vital signs and oxygen level.
What is the primary etiology of transient tachypnea of the newborn? A. Retained lung fluid B. Group B strep pneumonia C. Asphyxia at birth D. Surfactant deficiency
A. Retained Lung Fluid TTN results from retained fluid in the lungs after birth. May be seen more commonly after C-section where the newborn does not experience the normal pressure from the birth canal that aids in removal of fluid from the lungs. Also may be seen in newborns after a precipitous delivery.
The nurse has just assisted with a delivery of a baby born after a long labor. Which assessment would indicate the nurse must initiate resuscitation? A. The Apgar score is 2 at 1 minute B. The newborn has a small amount of vernix caseosa C. The fingers and toes of the newborn are cyanotic D. The respiratory rate is 40 breaths per minute
A. The Apgar score is 2 at 1 minute The Apgar score is too low. Apgar scoring ranges from 0-10. An Apgar of 8-10 means the newborn is making a smooth transition to extrauterine life. An Apgar of 3 or less indicates the newborn is severely compromised and needs resuscitation. A newborn's respirator rate should be 30-60. Vernix caseosa, the wax-like substance on the infant's skin is normal at birth. Also, cyanosis in the distal extremities is called acrocyanosis and is normal the first couple of days of life.
A non reassuring pattern in noted and the healthcare provider orders a fetal scalp pH. The pH result is7.18. What assessment does the nurse make based on this value? A. There is fetal acidosis B. Oxytocin would be well-tolerated C. The fetus is healthy D. There is fetal alkalosis
A. There is fetal acidosis Fetal scalp pH should be 7.25-7.35. If the pH is 7.18, fetal acidosis is present and birth of the fetus should be hastened. This is a serious sign of fetal distress (hypoxia) and not a healthy sign.Administering oxytocin at this time would further worsen the condition. Fetal alkalosis would occur if the pH is above 7.35.
Non-reassuring fetal patterns
Absent variability --Recurrent late decelerations --Recurrent variable decelerations --Bradycardia Sinusoidal pattern --A visually undulating pattern (rare) *non-reassuring patterns --fetal hypoxia --maternal acidosis --correct (start on O2)
internal fetal monitoring
Accuracy is the main advantage of using internal devices ---**Requires ruptured membranes and about 2 cm of cervical dilation ---**Slightly increased risk for infection Fetal scalp electrode (FSE) ---The FSE detects electrical signals from the fetal heart. Intrauterine pressure catheter (IUPC) ---Two kinds of IUPCs can be used to measure uterine activity. *need to have had ruptured membranes and 2cm dilated**
Fetal Oxygenation
Adequate fetal oxygenation requires five related factors: ~Normal flow of oxygenated maternal blood into the placenta ~Normal exchange within the placenta ~Patent umbilical cord vessels ~Normal fetal circulation (functioning fetal heart) ~Oxygen carrying function (umbilican vein -> O2 vein to fetus, umbilical artery -> deO2 from fetus to placenta)
Respiratory Complications in newborns
Asphyxia --Lack of oxygen and increase in carbon dioxide Transient tachypnea of the newborn --Rapid respirations after birth (no reason at all) Dyspneic with Grunting --RDS, no formula until airway clear --breath sounds clear --give O2 --baby warm --surfactant in ET Tubes
Uterine Activity
Assessment of uterine activity has four components. --Frequency (EFM) --Duration (EFM) --Intensity of contractions (palpation) --Resting tone *relax at least 30 seconds*
Following an uncomplicated vaginal delivery, what maternal lab results would be expected? (Select all that apply.) A. Increased BUN and creatinine. B. Decreased hemoglobin and hematocrit C. Increased magnesium. D. Elevated hemoglobin and hematocrit E. Increased white blood cell count
B, E ~ Decreased hemoglobin and hematocrit, Increased white blood cell count Women are often anemic during later stages of pregnancy due to an increased plasma volume. After delivery, a woman has lost blood so remains slightly anemic. After C-section, patients are often a bit more anemic than after a vaginal delivery. The WBC is also elevated to protect the woman from infection triggered by the stress of labor and delivery creating an inflammatory response. The BUN and creatinine will not be increased unless the woman has history of renal failure or is having significant pre-eclampsia. Likewise, magnesium is not altered unless the patient has pregnancy-induced hypertension/pre-eclampsia and has been on a magnesium infusion.
A patient has been in labor for 6 hours and an amniotomy is performed. The nurse checks the fetal heart rate. What is the next action to be done? A. Decreasing the IV fluid infusion rate B. Inspect the perineum C. Preparing for immediate birth D. Taking the maternal pulse and BP
B. Inspect the perineum The release of amniotic fluid could cause umbilical cord prolapse. The fetal heart rate should be checked and then the perineum inspected. The color of the fluid should also be noted, looking for meconium staining. If a prolapse cord is noted or the fetal heart rate drops, the patient should be positioned in knee-chest or side-lying position with head lowered. The nurse may need to hold the presenting part off the umbilical cord. This is a medical emergency.
A term neonate is born by C-section was dried and placed in a warmer. Thirty minutes late, the neonate has an axillary temperature of 99.0 F., a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 55 mg/dl. Which action should the nurse take? A. Increase the temperature setting on the radiant warmer B. Obtain an order for IV fluid administration. C. Wrap the neonate warmly and place her in an open crib. D. Administer an oral glucose feeding of 10% glucose in water
B. Obtain an order for IV fluid administration. Assessment findings indicate respiratory distress. The neonate may have transient tachypnea of the newborn. Oral feedings should be avoided in respiratory distress. To maintain fluid volume, IV fluids are needed. Following birth, a neonate should be dried and placed in a warmer or may be held by the parents if stable. After C-section, the neonate is placed in a radiant warmer and suctioned as necessary. The temperature should be maintained over 97.5 degrees but not over 98.6. The infant should remain in the radiant warmer but at a setting to maintain the temperature approximately 98-98.6 F.
Late Preterm infants
Born between 34 and 36 6/7 weeks At Risk for: ~Respiratory disorders ~Problems with temperature maintenance ~Hypoglycemia ~Hyperbilirubinemia ~Feeding difficulties ~Acidosis ~Sepsis ~miscounting conception date ~MD's may induce labor too early ~ still care as premie *due to obesity, multifetal pregnancies
What should the mother be taught regarding newborn feeding relating to NE? Explain your rationale.
Breast milk is encouraged through pumping because NEC less likely to occur in breastfed infants. If noted worsen s/s: hold next feedings and notify provider.
A preterm baby required mechanical ventilation and the nurse knows the patient is at risk of intraventricular hemorrhage. What actions will the nurse take to decrease the chance of this complication? A. Assessing the heart rate and for murmurs B. Limit parental visits C. Minimal and gentle handling of the infant D. Ophthalmology exams every 2 weeks
C. Minimal and gentle handling of the infant Minimal and gentle handling of the infant will help to decrease the chance of intraventricular hemorrhage. This is a hemorrhage within the ventricles of the brain. The other options are not correct. This type of hemorrhage is difficult to diagnose but heart rate and rhythm may not change and the ventricles of the heart aren't affected. Parental visits should be limited. Eye exams aren't indicated for this problem but for the other problem that may develop as a result of the need for high oxygen levels, retinopathy of prematurity.
The nurse notes that patient in labor has a fetal monitor pattern with "shoulders" before and after a quick decline in heart rate to 70 beats per minute (bpm). What type of periodic pattern is occurring and what is the nurse's best action? A. This is a normal pattern during uterine contraction. Continue to monitor. B. Early deceleration. Perform a vaginal exam. C. Variable deceleration. Change maternal position. D> Late deceleration. Call for a C-section.
C. Variable deceleration. Change maternal position The description is most like a variable deceleration. (Not the example of variable deceleration below.) This type of deceleration is caused by umbilical cord compression and/oroligohydramnios(decreased amniotic fluid that makes cord compression more likely). Note the increase in heart rate before and after the deceleration, often called "shoulders." They rise and fall abruptly, usually lasting only about 30 seconds or less. The nurse should encourage and assist the patient in position change. This is the most common action for any deceleration. Late decelerations are ominous and indicate inadequate oxygenation of the fetus. They have a gradual rise and fall. Again, turn the patient, add oxygen, increase fluids, stop oxytocic agents, and a C-section will likely be needed. Early decelerations mirror the contraction and will require similar monitoring and actions but usually are seen as the head is compressed during contractions and is transient.
What are pharmacologic interventions for the pregnant woman in preterm labor?
Calcium channel blockers reduces risk of preterm labor, antibiotics to prevent/treat infection, pain management, corticosteroids for fetal lung development, magnesium sulfate reduce risk of cerebral palsy
Marie is now being discharged home with her infant at 2 days postpartum. The infant has been feeding well and has experienced no complications. What are priority teachings for this family? Explain your rationale.
Car seat education, when the newborn needs checkups, breastfeeding, what to watch for in your infant with jaundice (bilirubin), postpartum depression, signs of infection in newborn (changes in activity, tone, color, and feeding), birth control, diet & nutrition, teach about how long the mom can experience vaginal bleeding SIDS prevention Monitor I&O in infant
Significance of Fetal Heart Rate Patterns
Category I: Normal (reassuring) --Associated with fetal well-being --110-160 bpm Category II: Indeterminate (equivocal or ambiguous data) --Describe patterns or elements of reassuring characteristics but also data that may be non-reassuring Category III: Abnormal (non-reassuring) --Favorable signs are absent.
Uterine Rupture
Clinical manifestations --Abdominal pain and tenderness/hardness --Chest pain or pain in the shoulder area --Hypovolemic shock --Abnormal fetal heart rate patterns --Absent fetal heart sounds --Cessation of contractions --Palpation of the fetus --tear in wall of uterus --previous tear, blunt force trauma --change in fundal height with excess bleeding into the peritoneal cavity
he nurse notes an infant is jittery and irritable 12 hours after birth despite blood glucose of 54 mg/dL.What actions must the nurse take? A. Recheck the glucose levels at 30 minutes after feeding B. Swaddle the infant loosely and try to feed frequently C. Limit infant contact with the mother for the next several hours. D. Apply a bag to collect the next sample of urine
D. Apply a bag to collect the next sample of urine Suspect neonatal abstinence syndrome in this situation as the blood glucose is within normal limits. A urine specimen for toxicology may be ordered. Swaddle the infant tightly with one blanket.Monitor the vital signs and observe for tachycardia, tachypnea, and hyperthermia. The infant may feed poorly but the nurse does not need to assess the blood glucose so soon after a feeding.
Supplemental oxygen is ordered for a premature infant with respiratory distress syndrome (RDS). What action does the nurse take to reduce risk of retinopathy of prematurity? A. Apply eye patches to both eyes to protect them B. Uncover the entire body to expose to the oxygen C. Increase the oxygen to the highest setting possible via mechanical ventilation D. Verify the oxygen saturation frequently to adjust flow based on need
D. Verify the oxygen saturation frequently to adjust flow based on need Determining oxygen saturation and adjusting oxygen based on need is the best way to prevent retinopathy of prematurity (ROP). Prolonged use of oxygen concentrations exceeding those required have been linked to the occurrence of ROP. The skin doesn't absorb oxygen so uncovering the infant is not a valid action. Eyes do not need to be covered to prevent ROP. The eyes are covered only if the infant is under bili- lights for jaundice.
Prolonged Pregnancy
Defined as one that lasts longer than 42 weeks --Accurate calculation of the estimated date of delivery is essential. Complications --Insufficiency of placental function --Meconium aspiration --Dysfunctional labor due to continued fetal growth (macrosomia = bigger than 8lb 13oz) Pitocin --also control postpartum bleeding --IVPB [can be stopped quickly] --close to body Prostaglandins --ripen cervix if birth can occur, monitor O2
Signs of Fluid Imbalance in the Newborn
Dehydration -Urine output less than 2 mL/kg/h Urine specific gravity greater than 1.01 (spit up, urine, blood in labs, stool) - 1g diaper = 1mL -Weight loss greater than expected (weigh infant) -Dry skin and mucous membranes (late) -Sunken anterior fontanel (depressed = hypovolemic shock) -Poor tissue turgor Blood: elevated sodium, protein, and hematocrit levels
Hypovolemic Shock (*45% more in pregnancy)
During and after birth, women can tolerate a blood loss approaching that of blood added during pregnancy. 1500-2000 mL --can be lost and will continue to compensate Compensatory mechanisms maintain the blood pressure so that vital organs are perfused. Shock occurs with excessive blood
List common complications of premature infants.
Fetal lung immaturity, greater risk for infection, improper thermoregulation, cold stress, hypoglycemia, patent ductus arteriosus, digestive problems, anemia
Problems with Thermoregulation in babies
Heat loss is significant for the preterm infant. --Thin skin with blood vessels near the surface --Less brown fat for non-shivering thermogenesis --Little white fat for insulation (no subq fat) --A large surface area --Extended extremities --Immature temperature-control center
Interventions for non-reassuring patterns
Identify cause of the pattern --cord compression, maternal O2 is down --reposition them on side (hips elevated) --give O2 Increase placental perfusion Increase maternal blood oxygen saturation --increase NS/LR Reduce cord compression --notify provider --stop pitocin
Late Decelerations
Impaired oxygen exchange **Begin after the peak of the contraction and return to baseline after contraction ends **Not reassuring Late decelerations look similar to early decelerations but shifted to the right. Nursing intervention required to improve placental blood flow and fetal oxygen supply. 1ST!!! -STOP pitocin drip -apply O2
Neutral Thermal Environment with babies
Important to prevent the need for increased oxygen to maintain body temperature --Delivery room should be warm --Dry infant immediately after birth --Place on mother's abdomen or radiant warmer (kangaroo care) --Less than 29 weeks place in wrap or a bag --Incubators and warmed air if needed --Observe for overheating
Preterm Labor
Labor that begins after the 20th week but prior to the end of the 37th week of gestation Early indications --Complaints are often vague (back pain, cramping, discharge) --Prompt identification enables the most effective therapy to delay preterm birth Associated factors Manifestations
Problems with Respiration in premature infants
Lack of adequate surfactant --May develop respiratory distress syndrome (RDS) --adventitious LS, absent LS, effort to breathe --decrease surface tension of alveoli collapses and allows individual ability to breathe Other factors --Poor cough reflex, narrow respiratory passages, and weak muscles Positioning --Prone and side-lying positions are used for preterm infants (decreased respirations) --Increases oxygenation and reduces energy expenditure Apnea --no breathing for more than 20 seconds Periodic breathing --sensation of breathing for 5-10 seconds
What nursing interventions are indicated in the delivery room with the late preterm infant? Explain your rationale.
Maintain cardiopulmonary function, support thermoregulatory function, assessment of glucose level, assess anomalies or birth injuries and number of cord vessels. Assess APGAR. Have suction and O2 available. This is done to make sure the infant remains stable.
Uterine Atony
Manifestations --Fundus is difficult to locate --"Boggy" or soft feel to the fundus --Becomes firm when massaged, then back to boggy --Excessive lochia and clots Management --Measures to contract the uterus --Provide fluid replacement (NS, LR, blood) --massage uterus *emergent hysterectomy *oxytocin - can increase BP *methrogene
Fetal heart rate regulation
Mechanisms that regulate the fetal heart rate include: Autonomic nervous system --Baroreceptors --Chemoreceptors --Adrenal glands Central nervous system --balanced out to maintain CO
Hyperbilirubinemia
Non-physiologic or pathologic jaundice --May lead to bilirubin encephalopathy and, if severe, kernicterus which is yellow staining of the brain causing cerebropalsy and hearing loss --Excessive hemolysis results in erythroblastosis fetalis. (erythroblastosis fetalis) --Infants severely affected may develop hydrops fetalis. (abnormal build up of fluid in heart, lungs, abdomen, skin)
Dysfunctional Labor
Normal Progress of Labor --Cervical Effacement (thinning/shortening) --Cervical dilation --Fetal descent (-3 is high, +3 is low) Dystocia --difficult birth Operative birth --Persistent, non-reassuring fetal heart rate patterns --Fetal acidosis --Meconium passage
Neonatal Resuscitation
Nursing responsibilities --Equipment should be readily available and functioning properly. --All personnel should know how to perform resuscitative measures.(current on pediatric CPR) Assist the physician or nurse practitioner with... --Intubation --Insertion of umbilical vein catheters --Medication administration --place small rolled towel under shoulders for airway --put under heat --suction often --flick feet for stimulation *baby is coding*
Predisposing Factors for postpartum hemorrhage
Overdistention of the uterus --Multiple gestation --Large infant --Hydramnios Multiparity (>5) Precipitate labor or delivery Prolonged labor Use of forceps or vacuum extractor Cesarean birth Manual removal of placenta Uterine inversion Placenta previa, accreta, or low implantation Drugs --Oxytocin --Prostaglandins --Tocolytics --Magnesium sulfate General anesthesia Chorioamnionitis Clotting disorders previous postpartum hemorrhage or uterine surgery DIC Uterine leiomyomas (fibroids)
Fundal Massage
PAINFUL Prevents hemorrhage
Therapeutic Management in Hyperbilirubinemia
Phototherapy --Most common treatment --Involves placing the infant under special fluorescent lights Exchange transfusions --Performed when phototherapy cannot reduce dangerously high bilirubin quickly enough --Removes sensitized red blood cells, maternal antibodies, and unconjugated bilirubin and replace with clean blood. --loose stools --stay clean, dry, hydrated
Intrapartum Emergencies
Placental abnormalities --At risk for hemorrhage during the antepartum or intrapartum period --Placenta accreta --Placenta increta --Placenta percreta Umbilical cord prolapse --A prolapsed umbilical cord slips down after the membranes rupture and becomes compressed between the fetus and pelvis. --Prompt delivery of the fetus remains a priority. Primary intervention is to relieve pressure on the cord without compression of the blood vessels. Delivery must be expedited Factors that increase the risk for prolapsed umbilical cord --Ruptured membranes --Fetal presenting part at high station --Fetus that poorly fits pelvic inlet because of small size or abnormal presentation --Excessive volume of amniotic fluid (hydramnios)
The patient states she would like to go home the next day. She states that her other kids need her and it seems like the baby is doing fine. She states the baby has breastfed a couple of times but he is just tired. What education is appropriate at this time? Explain your rationale.
Postpartum education for her, what she needs to be monitoring of herself for complications, infection, etc. Neonatal education regarding care of her newborn and what to be monitoring for. ** talking to her about not overwhelming herself and taking it easy for a while as she just gave birth. Talking about postpartum depression is important. She may be experiencing some postpartum depression. The baby was preterm so he may need more care than her other children. The baby is also at risk for increased bilirubin, lack of feeding, etc. She needs to be very vigilant about feeding with her new baby.
Therapeutic Management in preterm birth
Predicting preterm birth -cervical length (TVUS) -fetal fibronectin (protein in fetal tissues, in vagina and cervix near time of labor) -infections Identifying preterm birth -women at risk need more prenatal visits
Problems with Fluid and Electrolyte balance in babies
Preterm infants lose fluid easily. --Increased respirations and use of oxygen increase fluid loss from lungs. --Thin skin is more permeable. (increase surface area) --Radiant warmers Ability of kidneys to concentrate or dilute urine is poor. Kidney regulation of electrolytes is poor.
Preterm Infants
Preterms (also called premature) --Born prior to the beginning of 38 weeks Low-birth-weight (LBW) --Infants weighing 2500 g at birth (5 lb, 8 oz) or less Very low-birth-weight (VLBW) --Infants weighing 1500 g or less (3 lb, 5 oz) Extremely low-birth-weight (ELBW) --Infants weighing 1000 g or less (2 lb, 3 oz)
Interventions for Hemorrhage in Pregnancy
Preventing hemorrhage --Identify predisposing factors. Collaborating with the provider --Uterine massage (fundal uterine massage) --Check bladder for distention. --Laboratory studies --Administer fluids and medication.
Abnormal Labor Duration
Prolonged labor --Maternal infection --Neonatal infection --Maternal exhaustion --Higher levels of anxiety and fears Precipitate labor --A rapid birth that occurs within 3 hours of onset of labor --stop pitocin --strong, intense contractions --increase change of decrease O2 to placenta --promote comfort and rest --assess vital signs, infection constantly
baseline fetal heart rate (when contractions are done)
Rate --Normal (110-160) --Bradycardia (< 110 for 10 minutes) --Tachycardia (>160 at 10 minutes) Variability (tolerate of birth, ANS) --Absent (BAD!) --Minimal (no variability < 5bpm) --Moderate (6-25 bpm) --Marked (> 25bpm) *DONT WANT A SIGNIFICANT INCREASE OR DECREASE* *variability decreases in fetal sleep, decrease of 28 weeks, tobacco, alcohol*
Describe assessments and interventions used for preterm infants with respiratory distress syndrome (RDS).
Recognize early and intervene Look for grunting, nasal flaring, chest retractions, cyanosis, can turn acidotic Give surfactant Oxygen Make sure to thermoregulate
What is the Apgar score? When is an infant given this score? What do the numbers mean?
Scored at 1 minute after birth of infant and at 5 minutes to tell how the baby is tolerating being born Assessing pulmonary function of infant If infant does not reach a score of at least 7, Apgar must be repeated in another 5 minutes The higher the score, the better the infant is tolerating birth
Perineal Trauma (due to no episiotomy, but heals better)
Soft tissue trauma --May cause postpartum hemorrhage (stitch up) --Predisposing factors --Lacerations --Hematomas Management --Involves repairing the trauma before excessive blood loss occurs --Visualization of lacerations may be difficult.
Accelerations in FHR
Temporary increase in FHR ---15-bpm increase for 15s from baseline Associated with fetal movement ***Reassuring May also occur --With vaginal examination --During uterine contractions --Mild cord compression --Breech presentation (not optimal) *periodic patterns temporary, associated with contractions *prolonged accelerations, >2min < 10 minutes
What additional risk factors does this infant have compared with an infant born at 39 weeks? Explain your rationale.
The infant's lungs may not be fully developed, greater risk for complications such as RDS, intracranial hemorrhage, infection and sepsis.
Clarification of Data in Intrapartum Periods
Three methods may be used during the intrapartum period ---Fetal scalp stimulation ---Vibroacoustic stimulation (sound) ---Fetal scalp blood sampling Cord blood gases and pH ---Umbilical cord blood analysis performed immediately after birth
Paper Fetal Monitoring Strip
Top Part: fetal HR Bottom Part: uterine activity, tone/contraction intensity
Overhydration in the newborn
Urine output greater than 5 mL/kg/h Urine specific gravity less than 1.002 Edema Weight gain greater than expected Bulging fontanels (CHF as well) Moist breath sounds Blood: decreased sodium, protein, and hematocrit levels
Early signs Fluid Imbalance in newborn
decreased urine output increased specific gravity
Placenta accreta
does not separate from wall, increases hemorrhage
late signs of fluid imbalance in the newborn
dry skin and mucus membranes sunken fontannel
Retinopathy of Prematurity
injury of retinal blood vessels from hypoxia (blindness) -decrease ICP no cry
lunge position
make head down, move fetus on inside
placenta percreta
penetrate entirely through uterine wall and attach to nearby organs (bladder)
placenta increta
penetrates through uterine wall
complete cord prolapse
the cord can be seen protruding from the vagina *emergent situation
cord prolapsed in front of the fetal head
the cord cannot be seen but can probably be felt as a pulsating mass during vaginal examinations *emergent situation
occult (hidden) cord prolapse
the cord is compressed between the fetal presenting part and pelvis but cannot be seen or felt during vaginal examination *emergent situation
Signs of Inadequate Thermoregulation in babies
~Axillary temperature less than 36.3°C or greater than 36.9°C ~Abdominal skin temperature less than 36°C or greater than 36.5°C ~Poor feeding or feeding intolerance (hypoglycemia, distress) ~Irritability followed by lethargy ~Weak cry or suck ~Decreased muscle tone ~Skin pale, cool to the touch, mottled, or acrocyanotic ~Hypoglycemia ~Respiratory distress (chronic) ~Poor weight gain if chronic
Preventing Preterm Birth
~Community education ~Improving access to care (prenatal visits) ~Identifying risk factors (obesity, smoking, alcohol) ~Progesterone supplementation ~Promoting adequate nutrition ~Educating and empowering women and their partners
Purposes of Fetal Surveillance
~Evaluate the fetal condition during pregnancy. ~Identify possible hypoxic insult. Two approaches to intrapartum fetal monitoring ---Intermittent auscultation with palpation of uterine activity (low tech) ---Electronic fetal monitoring (high tech) (more common)
SIDS
¡Supine position (1st year, back is best!) ¡Give pacifier (at nap/bedtime - not on a string or another object) ¡No blankets ¡No smoke or heat (clothes appropriate) ¡No cradling in bed ¡No car seats *nap and sleep in parents room but not in bed, not near a window, no toys in bed, no sleeping in sitting position*
Indeterminate Patterns (category 2)
•*Tachycardia •*Bradycardia with presence of variability •Minimal or marked baseline variability •Absent variability with no recurrent decelerations •Absence of accelerations after fetal stimulation •Periodic or episodic variations •Variable decelerations with other characteristics
Characteristics of Preterm infants
•Appearance --Frail and weak --Less developed muscles --Limp extremities --Lack subcutaneous fat (thermoregulation) --Ears contain little cartilage Behavior --easily exhausted by noise and outside activity (startled easily)
Early Decelerations
•Associated with fetal head compression •Not associated with fetal compromise (HR normal after contraction) •Consistent in appearance •Return to baseline fetal heart rate by the end of the contraction •Maternal position changes usually have no effect on pattern. •Mirror images of contraction *vagal nerve slow HR down
Variable Decelerations
•Caused by reduced flow through umbilical cord (cord compression) •Shape, duration, and degree of fall below baseline rate are variable. •Fall and rise in rate are abrupt. •May be nonperiodic •Require nursing intervention (immediate) "shoulder" on the tracing, big upside down V, bike spike, c-section is needed
Problems with the Passenger (baby)
•Fetal size •Macrosomia (bigger than 8lb 13oz) •Shoulder dystocia (lodged behind synthesis pubis) •Abnormal fetal presentation or position •Multi-fetal pregnancy •Fetal anomalies (hydrocephalus, fetal tumor)
Problems of the Power
•Ineffective contractions (dont expel fetus, hypoglycemia, maternal fatigue) •Uterine overdistention - hydramnios (too much amniotic fluid) •Hypotonic labor dysfunction (coordinate, but weak, uterine distension, INT -> fluid, pain meds, oxytocin) •Hypertonic labor dysfunction (cervix 4cm dilated, contractions uncoordinated, decrease uterine blood flow (pain meds, tropolitic meds = increase placental blood flow) •Ineffective maternal pushing (poor positioning, fear)
premature rupture of membranes
•PROM: rupture of the sac before the onset of true labor •PPROM: preterm premature rupture of membranes occurs before 37 weeks of gestation --Associated with preterm labor •Chorioamnionitis --Can be the cause and a result of PROM --inflammation of amniotic sac by infection *induce labor and have c-section if child is over 38 weeks
Dysfunctional Labor Problems
•Problems of the passage ---Pelvis ---Maternal soft tissue obstructions •Problems of the psyche ---A perceived threat caused by fear, pain, or one's situation ---Stress response of fight or flight
Postpartum Hemorrhage *act quickly*
•Remains a major cause of maternal mortality and morbidity •Early postpartum hemorrhage (PPH) -> nurse noticed ---First 24 h ---*Cumulative blood loss of 1000 mL or greater •Late PPH ---From 24 h up to 6 weeks postpartum ---Subinvolution of the uterus (uterus turned inside out) ---Retained placental fragments *saturate pad every 15 minutes, gush of blood* *uterine muscle atony* Risks: -over distension of uterus -prolonged labor -retained fragments -labor assisted by oxytocin
Electronic Fetal Monitoring
⬤Advantages --Supplies more data about the fetus and auscultation --Provides a permanent record that may be printed or stored electronically (in chart) --Gradual trends in FHR and uterine activity are apparent. ⬤Limitations --Reduced mobility is the major limitation. (mom and baby hooked up to wires)
Pathological Influences on Fetal oxygenation
⬤Maternal cardiopulmonary alterations ⬤Uterine activity ⬤Placental disruptions ⬤Interruptions in umbilical flow ⬤Fetal alterations *increase contractions, decrease blood flow! --temporary stop of maternal blood flow, fetus made to tolerate 1-2 minutes of this and use their reserve supplies (contractions)
External Fetal Monitoring
⬤Remote surveillance ⬤Ultrasound transducer (fetal HR) --Secured on the mother's abdomen with elastic straps --*Less accurate than internal devices but are noninvasive and suitable for most women in labor ⬤Toco transducer --A pressure-sensitive area detects changes and abdominal contour to measure uterine activity --frequency and duration of contractions --*MORE ACCURATE!!!