Maternity ATI

foods high in iron

beef liver red meat fish poultry dried peas and beans fortified cereals and breads

varicose veins and lower-extremity edema education

2nd and 3rd trimesters rest with legs elevated avoid constricting clothing wear support hose avoid sitting or standing in one position for extended periods of time don't sit with legs crossed sleep in left-lateral position exercise moderately frequent walking

shortness of breath education

maintain good posture sleep with extra pillows contact provider if symptoms worsen

leg cramps

3rd trimester extend the affected leg keep knee straight dorsiflex foot application of heat over affected muscle foot massage with leg extended

pharmacological analgesia during labor

SEDATIVES (barbiturates): secobarbital, pentobarbital, phenobarbital typically used during the early or latent phase of labor to reduce anxiety and induce sleep ADE: neonate respiratory depression secondary to medication crossing the placenta, unsteady ambulation, inhibition of mother's ability to cope w pain of labor should not be administered if birth is expected in 12-24 h will cause drowsiness, request assistance w ambulation dim lights, provide a quiet atmosphere lower position of bed & elevate side rails assist mother to cope w labor assess neonate for respiratory depression OPIOID ANALGESICS: meperidine hydrochloride, fentanyl, butorphanol, nalbuphine IM or IV (IV recommended during labor) ADE: crosses placenta, can cause neonatal respiratory depression, reduces gastric emptying (increased risk for n/v), increases the risk for aspiration of food or fluids in the stomach, bladder & bowel elimination can be inhibited, sedation, altered mental status, tachycardia, hypotension, decreased FHR variability, allergic rxn will cause drowsiness, request assistance w ambulation verify that labor is well established administer antiemetics as prescribed monitor maternal vitals, uterine contraction pattern, continuous FHR monitoring have naxalone ready butorphanol and nalbuphine provide pain relief w/o causing significant respiratory depression in mother or fetus ONDANSETRON/METOCLOPRAMIDE: control nausea & anxiety, used w opioids ADE: dry mouth, sedation provide ice chips or mouth swabs provide safety measures EPIDURAL & SPINAL REGIONAL ANALGESIA: fentanyl, sufentanil, short-acting opioids that are administered as a motor block into the epidural or intrathecal space w/o anesthesia ADE: decreased gastric emptying (n/v), inhibition of bowel & bladder elimination, bradycardia, tachycardia, hypotension, respiratory depression, allergic rxn & pruritus, elevated temperature institute safety precautions (side rails), may experience dizziness and sedation assess for n/v, administer antiemetics as prescribed monitor maternal vitals monitor for allergic rxn continue FHR pattern monitoring

circumcision care

a personal choice made by the newborn's family for reasons of health & hygiene, religious conviction, tradition, culture, or social norms should not be done immediately following birth because the newborn's level of vitamin K is at a low point, & risk of hemorrhage is increased health benefits include easier hygiene, decreased risk of UTIs, decreased risk of STIs & HIV, prevention of penile problems, such as phimosis, decreased risk of penile cancer & cervical cancer in female partners contraindications include newborns born with hypospadias and epispadias because the prepuce skin can be needed for surgical repair of the defect, familiar hx of bleeding disorders newborns who are circumcised & whose parents decline vit K can be more likely to experience bleeding at site anesthesia is required (ring block, dorsal-penile nerve block, topical, & concentrated oral sucrose), nonpharmacologic methods such as swaddling & nonnutritive sucking can also be used Gomco (Yellen) or Mogen clamp, or Plastibell device provider applies Gomco or Mogen clamp to penis, loosens the foreskin, & inserts the cone under the foreskin to provide a cutting surface for removal of the foreskin to protect the penis, wound is covered with sterile petroleum gauze to prevent infection & control bleeding provider slides the Plastibell device between the foreskin & the glans of the penis, ties a suture tightly around the foreskin at the coronal edge of the glans, this applies pressure as the excess foreskin is removed from the penis, after 5-7 days it drops off, leaving a clean, healed excision, no petroleum is used preprocedure assess for hx of bleeding tendencies in the family, hypospadias or epispadias, amibuous genitalia, illness or infection informed consent from parents, gather & prepare supplies, admin meds, assist by placing newborn on the restraining board, provide a radiant heat source to prevent cold stress, don't leave unattended, have bulb syringe readily available, comfort newborn as needed, document time & type of circumcision postprocedure assess for bleeding every 15-30 mins for the first hour and hourly for the next 4-6 hours swaddle for comfort, monitor voiding, apply gauze lightly, fan-fold diapers to prevent pressure, liquid acetaminophen 10-15 mg/kg repeated every 4-6 hours for a max of 30-45 mg/kg/day explain that the baby won't be able to bottle feed for up to 2-3 h prior to procedure teach parents to keep the area clean, change diaper at least every 4 h, clean penis w warm water every time with clamp procedures, apply petroleum kelly w each diaper change for at least 24 h after circumcision don't wrap in tight gauze don't give tub bath until healed notify provider of any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying firm yellowish mucus can form over the glans by day 2, don't wash it off avoid using premoistened towelettes to clean penis (alcohol containing) can be fussy or sleep for several hours after will heal completely within a couple of weeks

nutritional assessment

obtain subjective and objective dietary info journal of client's food habits, eating pattern, cravings nutrition-related questionnaires client's weight on first prenatal visit and follow-up visits lab findings (Hgb and iron levels) determine caloric intake (write down everything in a 24 hr period)

engagement

occurs when the presenting part, usually biparietal (largest) diameter of the fetal head passes through the pelvic inlet at the level of the ischial spines station 0

acme

peak intensity of the contraction

decrement

the decline of the contraction intensity as the contraction is ending

positive signs of pregnancy

-fetal heart sounds -visualization of fetus by ultrasound -fetal movement palpated by an experienced examiner

GTPAL

-gravidity (pregnancies) -term births (38+ weeks) -preterm births (viability-37 weeks) -abortions/miscarriages (prior to viability) -living children

five P's

1. PASSENGER fetus & placenta size of fetal head presentation: part of the fetus that is entering the pelvic inlet first and leads through the birth canal during labor; can be back of head (OCCIPUT), chin (MENTUM), shoulder (SCAPULA), breech (SACRUM or FEET) lie: relationship of maternal longitudinal axis (spine) to the fetal longitudinal axis (spine); TRANSVERSE when the fetal long axis is horizontal, forms a right angle to maternal axis, & will not accommodate vaginal birth, shoulder is presenting part & can require delivery by cesarean if it does not rotate spontaneously; PARALLEL or LONGITUDINAL when fetal long axis is parallel to maternal long axis, either a cephalic or breech presentation, breech can require a cesarean birth attitude: relationship of fetal body parts to one another; FLEXION when chin is flexed to chest, extremities are flexed into torso; EXTENSION when chin is extended away from chest and extremities are extended fetopelvic or fetal position: the relationship of the presenting part of the fetus (sacrum, mentum, or occiput), preferably the occiput, in reference to its directional position as it relates to one of the 4 maternal pelvic quadrants, labeled with three letters: RIGHT (R) or LEFT (L): side of maternal pelvis OCCIPUT (O), SACRUM (S), MENTUM (M) or SCAPULA (Sc): references the presenting part of the fetus ANTERIOR (A), POSTERIOR (P), or TRANSVERSE (T): references the part of the maternal pelvis station: measurement of fetal descent in cm with 0 being level of the ischial spines, - superior to them, and + being inferior to them 2. PASSAGEWAY size and shape of the bony pelvis must be adequate to allow the fetus to pass through it cervix must dilate and efface in response to contractions & fetal descent 3. POWERS uterine contractions cause effacement during the 1st stage of labor & dilation of the cervix that occurs once labor has begun & the fetus is descending involuntary urge to push and voluntary bearing down in the 2nd stage helps to expel the fetus 4. POSITION engage in frequent position changes during labor to increase comfort, relieve fatigue, and promote circulation position during 2nd stage is determined by maternal preference, provider preference, and condition of mother and fetus gravity can aid in fetal descent in upright, sitting, kneeling, and squatting positions 5. PSYCHOLOGICAL RESPONSE maternal stress, tension, & anxiety can produce physiological changes that impair the progress of labor

Braxton Hicks contractions education

1st trimester onward change or position and walking should cause them to subside

weight gain during pregnancy

25-35 lbs (11.3-15.9 kg) gain 2.2-4.4 lb (1-2 kg) per week in the first trimester gain 1 lb (0.4 kg) per week in the second and third trimesters underweight women should gain 28-40 lbs overweight women should gain 15-25 lbs

false labor

CONTRACTIONS: painless, irregular frequency, and intermittent decrease in frequency, duration & intensity with walking or position changes felt in lower back or abdomen above umbilicus often stop w sleep or comfort measures such as oral hydration or emptying of the bladder CERVIX: no significant change in dilation or effacement often remains in posterior position no significant bloody show FETUS: presenting part is not engaged in pelvis

fetal tachycardia

FHR > 160 bpm for 10+ min causes/complications: -maternal infection, chorioamnionitis -fetal anemia -fetal cardiac dysrhythmias -maternal use of cocaine or methamphetamines -maternal dehydration -maternal or fetal infection -maternal hyperthyroidism nursing interventions: -administer prescribed antipyretics for maternal fever if present -administer oxygen by mask at 10 L/min via nonrebreather -administer IV fluid bolus

newborn nutrition assessment

NEWBORN: -maturity level -hx of labor & delivery -birth trauma -maternal risk factors -congenital defects -physical stability -state of alertness -presence of bowel sounds MATERNAL: -previous experience w breastfeeding -knowledge about breastfeeding -cultural factors -feelings about breastfeeidng -physical features of breasts -physical/psychological readiness -support of family & significant others

female sterilization (bilateral tubal ligation)

a surgical procedure consisting of severance and/or burning or blocking the fallopian tubes to prevent fertilization permanent contraception can be done immediately after childbirth within 24-48 h sexual function is unaffected a surgical procedure carrying risks related to anesthesia, complications, infection, hemorrhage, or trauma considered irreversible in the event that a client desires conception no STI protection risk of ectopic pregnancy

primigravida

a woman in her first pregnancy

calendar method

a woman records her menstrual cycle by calculating fertile period based on assumption that ovulation occurs about 14 days before onset of next cycle and and avoids intercourse during that period also take into account that sperm are viable for 48 to 120 hours and the ovum is viable for about 24 hours accurately record the # of days in each cycle counting from the 1st day of period of at least 6 cycles start of fertile period is figured by subtracting 18 days from # of days in shortest cycle end of fertile period is established by subtracting 11 days from the # of days from the longest cycle most useful when combined with basal body temperature or cervical mucus method inexpensive not very reliable no protection of STIs requires accurate record-keeping requires compliance regarding abstinence during fertile periods various factors can affect and change the time of ovulation and cause unpredictable cycles risk of pregnancy

multigravida

a woman who has had 2 or more pregnancies

abstinence

abstaining from having sexual intercourse to eliminate the possibility of sperm entering the vagina refrain from sexual intercourse say no, or say yes to other gratifying sexual activities (affectionate touching, communication, holding hands, kissing, massage, oral and manual stimulation) most effective method of birth control only during fertile periods (rhythm method) can be used can eliminate the risk of STIs requires self control

physiologic changes preceding labor

backache: constant low, dull backache caused by pelvic muscle relaxation weight loss: 0.5 to 1.5 kg (1 to 3.5 lb) lightening: fetal head descends into true pelvis ~14 days before labor, feeling that the fetus has dropped, easier breathing but more pressure on bladder, more pronounced in primigravida contractions: begin w irregular uterine contractions (Braxton Hicks) that eventually progress in strength & regularity increased vaginal discharge or bloody show: expulsion of the cervical mucus plug may occur, brownish or blood-tinged mucus plug resulting from the onset of cervical dilation or effacement energy burst: sometimes called "nesting" response GI changes: less common, include n/v, indigestion cervical ripening: cervix becomes soft (opens) and partially effaced, can begin to dilate ROM: SROM can initiate labor or can occur anytime during labor, labor usually occurs within 24 h of rupture, prolonged rupture (> 24 h) can lead to infection, immediately following the nurse should assess FHR for abrupt decelerations assessment of amniotic fluid: completed once the membranes rupture, should be watery, clear, and pale to straw-yellow in color, odor should not be foul, volume between 500-1200 mL, use nitrazine paper to confirm fluid (deep blue with pH 6.5-7.5 if amniotic fluid, remains yellow if urine)

gonorrhea

bacterial infection primarily spread by genital-to-genital contact women are frequently asymptomatic can lead to PID and infertility if left untreated risk factors: multiple partners, unprotected sex male: dysuria, urethral discharge female: dysuria, vaginal bleeding between periods, dysmenorrhea, yellow/green discharge, easily induced endocervical bleeding urine culture for males endocervical culture for females administer erythromycin to all infants after delivery ceftriazone IM and azithromycin PO

newborn feeding

can be started immediately breastfeeding is initiated ASAP formula feeding is usually started 2-4 h after birth, a few sips of sterile water can be given to assess sucking & swallowing reflexes & ensure that there are no anomalies such as tracheoesophageal fistula newborn is fed on demand, which is normally q3-4h for bottle-fed newborns & more frequently for breastfed newborns monitor & document feedings per facility protocol

newborn bathing

can begin once the newborn's temp has stabilized to at least 36.5 C (97.7 F) a complete sponge bath should be given within the 1st 1-2 h under a radiant heat source to prevent heat loss 1st bath can be postponed until thermoregulation stabilizes gloves should be worn until the newborn's 1st bath to avoid exposure to body secretions

presumptive signs of pregnancy

changes that make a woman think she could be pregnant may be subjective or objective signs can be explained by other phenomena -amenorrhea -fatigue -nausea and vomiting -urinary frequency -breast changes: darkened areolae, enlarged Montgomery's glands -quickening: slight fluttering movements of the fetus felt by a woman, usually between 16-20 weeks of gestation -uterine enlargement

newborn chest assessment

chest should be barrel-shaped respirations are primarily diaphragmatic clavicles should be intact absence of retractions nipples should be prominent, well formed & symmetrical breast nodules can be 3-10 mm

fourth stage of labor

delivery of placenta to maternal stabilization of vital signs 1-4 hr achievement of vital sign homeostasis lochia scant to moderate rubra

initial prenatal visit

determine estimated date of birth based on LMP medical and nursing history social supports review of systems physical assessment (baseline weight, vitals, pelvic exam) lab tests (Hgb, Hct, WCB, blood type, Rh, rubella titer, urinalysis, renal function test, Pap test, cervical cultures, HIV antibody, hepatitis B surface antigen, toxoplasmosis, RPR or VDRL

contraception education

discuss use of contraception upon resumption of sexual activity inform the client that pregnancy can occur while breastfeeding even though menses has not returned clients who are lactating should be advised that OCs should not be taken until milk production is well established (usually 4 wks) menses for nonlactating clients might not resume until 4-10 wks, however ovulation can occur 1 mo after delivery menses for lactating clients might not resume for 3 mos or until cessation of breastfeeding

pharmacological anesthesia during labor

eliminates pain perceptions by interrupting nerve impulses to the brain REGIONAL BLOCKS: most commonly used pudendal block: local anesthetic administered transvaginally into the space in front of the pudendal nerve; no maternal/fetal systemic effects; local anesthesia to the perineum, vulva, & rectal areas during delivery, episiotomy, & episiotomy repair; administered during the late second stage 10-20 mins before delivery; ADE include broad ligament hematoma & compromise of maternal bearing down reflex; coach client about when to bear down; assess for hematoma postpartum epidural block: local anesthetic along with an analgesic injected into the epidural space at the level of the 4th-5th vertebrae; eliminates all sensation from the level of the umbilicus to the thighs; administered when the client is in active labor and dilated 4+ cm; suitable for all stages of labor; ADE include maternal hypotension, fetal bradycardia, inability to feel the urge to void, loss of the bearing down reflex; administer a bolus of IV fluids to offset hypotension; help position and steady into a sitting or side-lying modified Sims position w back curved to widen the intervertebral space; remain in side-lying position after insertion; coach in pushing efforts; monitor maternal BP and HR; assess FHR; maintain IV line, have suction and oxygen ready; assess for orthostatic hypotension & be prepared to administer an IV vasopressor such as ephedrine; assess bladder for distention; monitor for return of sensation spinal anesthesia (block): local anesthetic injected into the subarachnoid space into the spinal fluid at the 3rd, 4th, or 5th lumbar interspace; can be in combo w analgesic; blocks all sensation from nipples to feet; commonly used for cesarean births; not used for labor; administered in late 2nd stage for C section; ADE include maternal hypotension, fetal bradycardia, loss of bearing down reflex, potential headache from leakage of cerebrospinal fluid, higher incidence of maternal bladder and uterine atony; assess vitals q10 mins; administer IV fluid bolus if hypotensive; assess uterine contractions; assess level of anesthesia; assess FHR patterns; raise side rails of bed; recognize signs of impending birth (sitting on one buttock, grunting, bulging or perineum); if headache, place in supine position, promote bed rest in dark room, administer oral analgesics, caffeine or fluids GENERAL ANESTHESIA: rarely used for vaginal or cesarean births w/o complications only used in an emergency when there is a contraindication to nerve block analgesia or anesthesia produces unconsciousness monitor vitals, FHR patterns ensure that client has had nothing by mouth ensure IV infusion in place apply antiembolic stockings or sequential compression devices premedicate w oral anticid administer a histamine 2-receptor antagonist to decrease gastric acid production (ranitidine) administer metoclopramide to increased gastric emptying place a wedge under one hip to displace uterus maintain open airway & cardiopulmonary function assess postpartum for decreased uterine tone, which can lead to hemorrhage and be produced by pharmacological agents used in general anesthesia

birth plan

goals for the birthing process birthing methods pain control options (epidural, natural)

circumcision complications

hemorrhage:

transcervical sterilization

insertion of small flexible agents through the vagina & cervix into the fallopian tubes develops scar tissue in the tubes to prevent conception examination must be done after 3 mos to ensure blockage normal activities can be resumed by most clients within 1 day of the procedure quick procedure that requires no general anesthesia nonhormonal means of birth control 99.8% effective rapid return to normal activities of daily living not reversible not intended for use in postpartum client delay in effectiveness for 3 mos changes in menstrual patterns no STI protection perforation can occur unwanted pregnancy can occur if a client has unprotected sex within the first 3 mos increased risk of ectopic pregnancy

fatigue education

might occur during 1st and 3rd trimesters engage in frequent rest periods

gastrointestinal system changes in pregnancy

nausea and vomiting might occur due to hormonal changes and/or an increase of pressure within the abdominal cavity as the pregnancy client's stomach and intestines are displaced within the abdomen constipation might occur due to increased transit time of food through the gastrointestinal tract and this, increased water absorption

newborn neck assessment

neck should be short, thick, surrounded by skin folds, and exhibit no webbing move freely from side to side and up and down absence of head control can indicate prematurity or Down syndrome

crying interventions

newborns cry when they are hungry, overstimulated, wet, cold, hot, tired, bored, or need to be burped assure mother that she will learn what the cry means instruct mother not to feed newborn every time he/she cries overfeeding can lead to stomach aches & diarrhea after checking the newborn, it is ok to let them cry for short periods of time

female diagnostic procedures for infertility

pelvic examination: assesses for uterine or vaginal anomalies hormone analysis: evaluates hypothalamic-pituitary-ovarian axis to include serum prolactin, FSH, LH, estradiol, progesterone, thyroid hormones postcoital test: evaluates coital technique and mucus secretions ultrasonography: a transvaginal or abdominal ultrasound procedure performed to visualize female reproductive organs hysterosalpingography: outpatient radiological procedure in which dye is used to assess the patency of fallopian tubes (assess for hx of allergies to iodine and seafood prior to procedure) hysteroscopy: a radiographic procedure in which the uterus is examined for signs of defect, distortion, or scar tissue that can impair impregnation laparoscopy: a procedure in which gas insufflation under general anesthesia is used to observe internal organs

early deceleration of FHR

slowing of FHR with start of contraction with return of FHR to baseline at end of contraction causes/complications: -compression of the fetal head resulting from uterine contraction -uterine contractions -vaginal exam -fundal pressure nursing interventions: -none required

contraceptive sponge

small, round, polyurethane sponge containing spermicide designed to fit over the cervix, one size fits all should be left in place 6 hr after intercourse and provides protection for up to 24 hr no STI protection

newborn spine assessment

straight flat midline easily flexed

Nagele's rule

take the first day of the woman's last menstrual cycle, subtract 3 months, and then add 7 days and 1 year, adjusting for the year as necessary

extension

the fetal occiput passes under the symphysis pubis & the head is deflected anteriorly and is born by extension of the chin away from the fetal chest

endocrine system changes in pregnancy

the placenta becomes an endocrine organ that produces large amounts of hCG, progesterone, estrogen, human placental lactogen, and prostaglandins hormones are very active during pregnancy and function to maintain pregnancy and prepare the body for delivery

viability

the point in time when an infant has the capacity to survive outside the uterus not a specific time 22-25 weeks is considered on the threshold of viability

respiratory rate changes in pregnancy

unchanged or slightly increases attributed to the elevation of the diaphragm by as much as 4 cm as well as changes to the chest wall to facilitate increased oxygen demands some SOB may be noted

preterm labor

uterine contractions & cervical changes that occur between 20-37 wks risk factors: infections of the urinary tract/vagina/amniotic sac (chorioamnionitis), previous preterm birth, multifetal pregnancy, hydramnios, age < 17 or > 35, low SES, smoking, substance use, intimate partner violence, hx of multiple miscarriages or abortions, DM, chronic HTN, preeclampsia, lack of prenatal care, recurrent premature dilation of the cervix, placenta previa or abtuptio placentae, PROM, short interval between pregnancies, uterine abnormalities, 2nd tri bleeding, low prepregnancy weight expected findings: uterine contractions, pressure in pelvis & menstrual-like cramping, persistent low backache, GI cramping (sometimes w diarrhea), urinary frequency, vaginal discharge increase, change, odor, or blood in discharge change in cervical dilation regular uterine contractions w a frequency of every 10 min or greater, lasting 1 hr or longer PROM lab tests: fetal fibronectin, cervical cultures, CBC, urinalysis obtain swab of vaginal secretions for fetal fibronectin between 24-34 weeks, protein can be found in vaginal secretions and related to inflammation of the placenta that can lead to preterm birth measure endocervical length w ultrasound to assess for shortened cervix which precedes preterm labor use home uterine activity monitoring (HUAM) obtain cervical cultures to detect presence of infection perform BPP and NST to assess fetal well-being activity restriction: rest in left lateral position, avoid sexual intercourse ensuring hydration: dehydration stimulated pituitary gland to secrete an ADH and oxytocin which can stimulate contractions identify/treat infection: report vaginal discharge (amount, color, consistency, odor), monitor vitals and temp chorioamnionitis: elevated temp and tachycardia monitor FHR and contraction pattern fetal tachycardia: can indicate infection medications: nifedipine (calcium channel blocker that suppresses contractions by inhibiting calcium from entering smooth muscle; monitor for headache, flushing, dizziness, nausea; do not administer w magnesium sulfate; change position slowly), magnesium sulfate (tocolytic that relaxes smooth muscle of uterus to suppress contractions; do not use if active vaginal bleeding, dilation > 6 cm, chorioamnionitis, > 34 weeks, acute fetal distress; discontinue if signs of pulmonary edema like chest pains, SOB, respiratory distress, wheezing, crackles, productive cough w bloody sputum; monitor for magnesium sulfate toxicity including loss of deep tendon reflexes, urine output < 30 mL/hr, respiratory depression, pulmonary edema, chest pain), indomethacin (NSAID that blocks the production of prostaglandins, discontinue if signs of pulmonary edema, treatment should not exceed 48 h, only used < 32 wks, monitor for postpartum hemorrhage, take with food or rectally, notify if blurred vision, headache, nausea, vomiting, difficulty breathing), betamethasone (glucocorticoid IM in 2 injections 24 h apart, ehances fetal lung maturity and surfactant production in fetuses between 24-34 wks, administer into gluteal muscle 24 and 48 h prior to birth, monitor for maternal hyperglycemia, assess preterm infant's lung sounds)

reproductive system changes in pregnancy

uterus increases in size and changes shape and position ovulation and menses cease during pregnancy

newborn ear assessment

when examining placement of ears, draw an imaginary line through the inner to the outer canthus of the newborn's eye eye should be even w the upper tip of the pinna of the newborn's ear ears that are low-set can indicate a chromosome abnormality or kidney disorder cartilage should be firm & well formed, lack of cartilage indicates prematurity newborn should respond to voices & other sounds inspect ears for skin tags

ultrasound

~ 20 mins uses high-frequency sound waves to visualize internal organs and tissues by producing a real-time 3D image of the developing fetus and maternal structures external abdominal: safe, noninvasive, painless, more useful after the 1st trimester, have a full bladder for procedure transvaginal: invasive, probe inserted vaginally, no need for full bladder, useful in obese moms and those in 1st tri to detect ectopic pregnancy, identify abnormalities, & establish gestational age, also used in 3rd tri to evaluate for preterm labor doppler: noninvasive, used to study the maternal-fetal blood flow by measuring velocity at which RBCs travel, reflects sound waves, especially useful in fetal intrauterine growth restriction and poor placental perfusion, 2D, 3D, or 4D potential diagnoses: confirming pregnancy, confirming gestational age, multifetal pregnancy, site of fetal implantation, fetal growth and development, maternal structures, fetal viability, fetal abnormalities, site of placental attachment, amniotic fluid volume, fetal movement, fetal position, placental grading, adjunct for other procedures client presentation: vaginal bleeding, questionable fundal height, decreased fetal movements, preterm labor, questionable rupture of membranes

first stage of labor

~12.5 h duration LATENT PHASE: P: 6 h M: 4 h -cervical dilation 0-3 cm -onset of labor -contractions: irregular, mild to moderate, every 5-30 mins, for 30-45 s -some dilation & effacement -talkative & eager ACTIVE PHASE: P: 3 h M: 2 h -cervical dilation 4-7 cm -contractions: more regular, moderate to strong, every 3-5 mins, for 40-70 s -rapid dilation & effacement -some fetal descent -feelings of helplessness -anxiety & restlessness increase as contractions become stronger TRANSITION: 20-40 mins -cervical dilation 8-10 cm -contractions: strong to very strong, every 2-3 mins, for 45-90 s -tired, restless, & irritable -feeling out of control, often stating "cannot continue" -can have n/v -urge to push -increased rectal pressure & feelings of needing to have a bowel movement -increased bloody show -most difficult part of labor

symptom-based method (cervical method)

fertility awareness method based on ovulation ovulation occurs 14 days before the next cycle following ovulation, the cervical mucus becomes thin and flexible under the influence of estrogen and progesterone ability for the mucus to stretch between the fingers is greatest during ovulation engage in good hand hygiene prior to and following assessment begin examining mucus from the last day of the menstrual cycle do not douche prior to assessment self-evaluation can be very accurate some women are uncomfortable with touching their genitals and mucus no STI protection assessment of cervical mucus characteristics can be inaccurate if mixed with semen, blood, contraceptive foams, or discharge from infections risk of pregnancy

expected findings during pregnancy

fetal heart tones of 110-160 bpm with reassuring FHR accelerations noted, indicating fetal CNS heart change sin size and shape with resulting cardiac hypertrophy to accommodate increased blood volume and CO heart sounds change to accommodate increase in blood volume with a more distinguishable splitting of S1 and S2 S1 more easily heard following 20 weeks heart size and shape return to normal shortly after delivery uterine size changes from a uterine weight of 50 to 1,000 g by 36 weeks, top of uterus will reach xiphoid process, maybe causing SOB as the uterus pushes on the diaphragm cervical changes are obvious as a purplish-blue color extends into the vagina and labia, and the cervix becomes markedly soft breast changes occur due to hormones of pregnancy, with the breasts increasing in size and the areolas darkening

birth by expulsion

after birth of the head and shoulders, the trunk of the neonate is born by flexing it towards the symphysis pubis

nulligravida

a woman who has never been pregnant

maternal identity

accomplished around 4 months postpartum

increment

beginning of the contraction as intensity is increasing

musculoskeletal system changes in pregnancy

body alterations and weight increase necessitate an adjustment in poster pelvic joints relax

primipara

has completed one pregnancy to stage of viability

coagulopathies

idiopathic thrombocytopenic purpura (ITP): autoimmune disorder in which the life span of platelets is decreased by antiplatelet antibodies, can result in severe hemorrhage following a cesarean birth or lacerations disseminated intravascular coagulation (DIC): clotting & anticlotting mechanisms occur at the same time, at risk for both internal & external bleeding, damage to organs resulting from ischemia caused by microclots suspected when the usual measures to stimulate uterine contractions fail to stop vaginal bleeding ITP risk factors: genetic DIC risk factors: can occur secondary to... -abruptio placentae (most common) -amniotic fluid embolism -missed abortion -fetal death in utero -severe preeclampsia or eclampsia, HELLP syndrome -septicemia -cardiopulmonary arrest -hemorrhage -hydatidiform mole unusual spontaneous bleeding from the gums and nose oozing, trickling, or flow of blood from incision, lacerations or episiotomy petechiae and ecchymoses excessive bleeding from venipuncture, injection sites, or slight traumas hematuria tachycardia, hypotension, diaphoresis GI bleeding oliguria CBC w differential, blood typing & crossmatch platelet levels decreased fibrinogen levels decreased prolonged PT fibrin split product levels increased D-dimer test increased assess skin, venipuncture, injection sites, laceration & episiotomy for bleeding monitor vitals & hemodynamic status monitor urinary output (catheter) transfuse platelets prepare for splenectomy if ITP does not respond to medical management DIC: focus on & assess for underlying cause (removal of dead fetus or placental abruption, treatment of infection, preeclampsia or eclampsia) administer fluid volume replacement (blood & blood products) administer pharmacological interventions (antibiotics, vasoactive medications, uterotonic agents) administer supplemental oxygen provide protection from injury volume expansion, blood products & clotting factors hysterectomy for DIC

foods high in folic acid

leafy vegetables dried peas and beans seeds orange juice breads cereals other grains

newborn posture assessment

lying in a curled-up position w arms & legs in moderate flexion resistant to extension of extremities

urinary frequency education

might occur during 1st and 3rd trimesters empty her bladder frequently decrease fluid intake before bedtime use perineal pads perform Kegel exercises to reduce stress incontinence

nullipara

no pregnancy beyond the stage of viability

gravidity

number of pregnancies

newborn abdomen assessment

umbilical cord should be odorless and exhibit no intestinal structures abdomen should be round, dome-shaped, and nondistended bowel sounds should be present 1-2 h after birth

newborn sleep

6 states along a continuum: deep sleep, light sleep, drowsy, quiet alert, active alert, crying newborns sleep ~ 16-19 h/day w periods of wakefulness gradually increasing newborns are positioned supine "safe sleep" to decrease the incidence of SIDS no bumper pads, loose linens, or toys should be placed in the bassinet mothers should sleep in close proximity but not in a shared space, higher incidence rates are noted for SIDS & suffocation w bed sharing/co-sleeping educate parents about the need for immunizations as a measure to prevent SIDS

Bishop score

used to determine maternal readiness for labor by evaluating whether the cervix is favorable by rating the following: -cervical dilation -cervical effacement -cervical consistency -cervical position -station of presenting part 5 factors are assigned a numerical value of 0-3 and total score is calculated

category 1

FHR tracing includes: baseline FHR of 110-160 bpm baseline FHR variability moderate accelerations: present or absent early decelerations: present or absent variable or late decelerations: absent

labor preprocedures

Leopold maneuvers: abdominal palpation of the # of fetuses, the fetal presenting part, lie, attitude, descent, & probable location where fetal heart tones can best be heart external electronic monitoring (tocotransducer): separate transducer applied to the maternal abdomen over the fundus that measures uterine activity, displays uterine contraction patterns, easily applied by the nurse but must be repositioned w maternal movement external fetal monitoring (EFM): transducer applied to the abdomen of the client to assess FHR patterns during labor & birth group B strep analysis: culture is obtained if results are not available from screening at 35-37 wks; if positive, IV prophylactic antibiotic is prescribed urinalysis: clean-catch urine sample obtained to ascertain maternal hydration status (specific gravity), nutritional status (ketones), proteinuria (can be indicative of gestational HTN or preeclampsia), glucosuria (can be indicative of GDM), UTI vis bacterial count blood tests: CBC, ABO typing and Rh-factor if not previously done

external rotation (restitution)

after the head is born, it rotates to the position it occupied as it entered the pelvic inlet (restitution) in alignment with the fetal body & completes a quarter turn to face transverse as the anterior shoulder passes under the symphysis

multiple gestation

assisted reproductive technology is associated with an increase incidence of multiple gestations poses a risk for the mother and infants

first trimester danger signs

burning on urination (infection) severe vomiting (hyperemesis gravidarum) diarrhea (infection) fever/chills (infection) abdominal cramping and/or vaginal bleeding (miscarriage, ectopic pregnancy)

monitoring newborn for adequate growth

daily weight in newborn nursery see follow-up appt within 72 hours after discharge place newborn's weight on growth chart adequate growth should be within 10th-90th percentile poor weight gain would be below 10% and too much would be above 90% assess mom's ability to feed her newborn, whether by breast or bottle calculate the newborn's 24 hr I&O if indicated

hemorrhage in newborns

due to improper cord care or placement of clamp ensure that the clamp is tight if seepage of blood is noted, a second clamp should be applied notify the provider if bleeding continues

intervening for newborn nutrition

education regarding: hand-to-mouth or hand-to-hand motions sucking motions rooting mouthing

multipara

has completed two or more pregnancies to stage of viability

newborn diagnostic procedures

hearing screening

diapering interventions

keep clean & dry to avoid diaper rash diapers should be changed frequently perineal area cleaned with warm water or wipes & dried thoroughly to prevent skin breakdown

supine hypotension education

lie in side-lying or semi-sitting position with knees slightly flexed

diagnostic testing for fetal well-being

nonstress test biophysical profile ultrasound contraction stress test

rest/sleep education

plan at least 1 daily rest period rest when the infant naps

category 3

sinusoidal pattern absent baseline FHR variability and any of the following: -recurrent variable decelerations -recurrent late decelerations -bradycardia

swaddling intervention

swaddling helps the newborn to feel more secure swaddling brings the newborn's extremities in closer to his trunk, which is similar to intrauterine position

internal rotation

the fetal occiput ideally rotates to a lateral anterior position as it progresses from the ischial spines to the lower pelvis in a corkscrew motion to pass through the pelvis

gestational hypertension

vasospasm contributing to poor tissue perfusion is the underlying mechanism associated with placental abruption, kidney failure, hepatic rupture, preterm birth, and fetal/maternal death GH: begins after the 20th week, elevated BP at 140/90 mmHg or greater on 2 occasions at least 4 hr apart, no proteinuria, BP returns to baseline by 6 weeks postpartum mild preeclampsia: GH w the addition of proteinuria > or = to 1+, report of transient headache might occur w episodes of irritability, edema can be present severe preeclampsia: BP that is 160/110 or greater, proteinuria > 3+, oliguria, elevated serum creatinine greater than 1.1 mg/dL, cerebral or visual disturbances (headache, blurred vision), hyperreflexia w possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and RUQ pain, thrombocytopenia eclampsia: severe preeclampsia manifestations w the onset of seizure activity or coma, usually preceded by headache, severe epigastric pain, hyperreflexia, hemoconcentrations HELLP syndrome: severe preeclampsia involving hepatic dysfunction, Hemolysis resulting in anemia and jaundice; Elevated Liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, n/v; Low Platelets (less than 100,000/mm3) resulting in thrombocytopenia, abnormal bleeding & clotting time, bleeding gums, petechiae & possibly disseminated intravascular coagulopathy risk factors include maternal age <19 or >40, 1st pregnancy, morbid obesity, multifetal gestation, chronic renal disease, chronic HTN, family hx of preeclampsia, DM, RA, systemic lupus erythematosus expected findings include severe continuous headache, nausea, blurring of vision, flashes of lights or dots before the eyes, HTN, proteinuria, periorbital/facial/hand/abdominal edema, pitting edema or lower extremities, vomiting, oliguria, hyperreflexia, scotoma, epigastric pain, RUQ pain, dyspnea, diminished breath sounds, seizures, jaundice, worsening liver involvement, kidney failure, worsening HTN, cerebral involvement, developing coagulopathies abnormal lab findings: elevated liver enzymes (LDH, AST), increased creatinine, increased plasma uric acid, thrombocytopenia, decreased Hgb, hyperbilirubinemia lab tests: liver enzymes; serum creatinine, BUN, uric acid, magnesium increase as renal function decreases; CBC; clotting studies; chemistry profile diagnostic procedures: dipstick testing of urine for proteinuria, 24 hr urine collection for protein & creatinine clearance, NST, contraction stress test, BPP, serial ultrasounds, doppler blood flow analysis to assess fetal well-being assess LOC, obtain pulse ox, monitor urine, obtain daily weights, monitor vitals, encourage lateral positioning, perform NST and daily kick counts, monitor I&O daily low dose of aspirin therapy be initiated late in the 1st trimester if hx of early onset preeclampsia antihypertensive medications include methyldopa, nifedipine, hydralazine, labetalol (avoid ACE inhibitors and angiotensin II receptor blockers) anticonvulsant medications include magnesium sulfate: maintain reg flow rate w infusion control device; initially may feel flushed, hot, or sedated with bolus; monitor vitals, deep-tendon reflexes, LOC, urinary output, headache, visual disturbances, epigastric pain, uterine contractions, FHR & activity; monitor for magnesium sulfate toxicity (absence of patellar deep tendon reflexes, urine output < 30 mL/hr, RR < 12/min, decreased LOC, cardiac dysrhythmias; if suspected, discontinue, administer antidote (calcium gluconate or calcium chloride), prepare to prevent respiratory or cardiac arrest bed rest, encourage side-lying promote diversional activities avoid foods high in sodium, alcohol, tobacco, & limit caffeine drink 6-8 glasses of water/day dark quiet environment to avoid seizure patent airway in the event of a seizure

flexion

when the fetal head meets the resistance of the cervix, pelvic wall, or pelvic floor head flexes, bringing the chin close to the chest, presenting a smaller diameter to pass through

second stage of labor

10 cm to birth P: 30 min to 2 hr M: 5 to 30 min full dilation progresses to intense contractions every 1-2 mins pushing often results in birth of fetus

body image changes in pregnancy

1st trimester: physiological changes are less obvious, most women look forward to changes so that it will be noticeable 2nd trimester: enlargement of abdomen and breasts, skin changes (stretch marks, hyperpigmentation), mobility changes, losisng balance, back or leg discomfort, fatigue leas to negative body image may make statements of resentment toward the pregnancy and anxiousness for it to be over

blood pressure changes in pregnancy

1st trimester: pre-pregnancy range systolic: slight or no increase diastolic: slight decrease from 24-32 weeks, will gradually return to pre-pregnancy level by the end of pregnancy position may affect it supine: might appear lower due to weight and pressure of the gravid uterus on the vena cava, decreasing venous blood flow to the heart maternal hypotension and fetal hypoxia may occur -- supine hypotensive syndrome or supine vena cava syndrome S&S: dizziness, lightheadedness, pale/clammy skin encourage the left-lateral side lying position, semi-Fowler's position, or supine with a wedge placed under one hip to alleviate pressure on the vena cava

syphilis

3 stages: primary (presence of chancre), secondary (skin rashes), tertiary (damage to internal organs) Black, Hispanic & other minorities are disproportionately affected can be transmitted orally, vaginally, anally as well as to unborn child screen at first prenatal visit and in 3rd tri if high risk risk factors: multiple partners, unprotected sex primary stage: chancre sore in genital area secondary stage: skin rashes, such as rash on palms of hands and soles of feet tertiary stage: damage to internal organs serology tests: nontreponemal (VDRL and rapid plasma reagin) and treponemal (enzyme immunoassay, immunoassays) nontreponemal tests for screening, treponemal to detect antibodies specific for syphilis medications: penicillin G IM single dose abstain from sexual contact until sores are completely healed partners need to be tested & treated

true labor

CONTRACTIONS: can begin irregularly, but become regular in frequency stronger, last longer, and are more frequent felt in lower back, radiating to abdomen walking can increase intensity continue despite comfort measures CERVIX: progressive change in dilation and effacement moves to anterior position bloody show FETUS: presenting part engages in pelvis

phases of maternal role attainment

DEPENDENT: -taking in phase -first 24-48 h -focus on meeting personal needs -rely on others for assistance -excited, talkative -need to review birth experience w others DEPENDENT-INDEPENDENT: -taking hold phase -begins on day 2 or 3 -lasts 10 days-several weeks -focus on baby care & improving caregiving competency -want to take charge but need acceptance from others -want to learn & practice -dealing w physical & emotional discomforts, can experience baby blues INDEPENDENT: -letting go phase -focus on family as a unit -resumption of role (intimate partner, individual)

newborn medications

ERYTHROMYCIN: -prophylactic eye care is the mandatory instillation of antibiotic ointment into the eyes to prevent ophthalmia neonatorum -infections can be transmitted during descent through the birth canal -ophthalmia neonatorum is caused by gonorrhea and chlamydia and can cause blindness -use a single-dose unit to avoid cross contamination -apply a 1-2 cm ribbon of ointment to the lower conjunctival sac of each eye, from inner to outer -a possible side effect is chemical conjunctivitis, causing redness, swelling, drainage, & temporarily blurred vision for 24-48 h, reassure parents that this will resolve on its own -application can be delayed for 1 hr after birth to facilitate baby-friendly activities during the 1st period of newborn reactivity VITAMIN K: -administered to prevent hemorrhage disorders -not produced in the GI tract of the newborn until around day 7 -produced in the colon by bacteria that forms once formula or breast milk is introduced into the gut of the newborn -admin 0.5-1 mg IM into the vastus lateralis within 1 hr after birth HEPATITIS B IMMUNIZATION: -protection against hep B -admin to all newborns -informed consent must be obtained -recommended dosage schedule is at birth, 1 mo, 6 mos -for mothers infected with hep B, immunoglobulin and vaccine is given within 12 h of birth, hep B vaccine is given alone at 1 mo, 2 mos, and 12 mos do not give vitamin K and hep B in the same thigh

fetal bradycardia

FHR < 110 bpm for 10+ min causes/complications: -uteroplacental insufficiency -umbilical cord prolapse -maternal hypotension -prolonged umbilical cord compression -fetal congenital heart block -anesthetic medications -viral infection -maternal hypoglycemia -fetal heart failure -maternal hypothermia nursing interventions: -discontinue oxytocin if administered -assist to side-lying position -administer oxygen by mask at 10 L/min via nonrebreather -insert IV catheter if one is not in place & administer maintenance IV fluids -administer tocolytic medication -notify provider

sources of pain during labor

FIRST STAGE: presents as internal visceral pain that can be felt as back and leg pain dilation, effacement & stretching of the cervix distention of the lower segment of the uterus contractions of the uterus w resultant uterine ischemia SECOND STAGE: presents as pain that is somatic & occurs w fetal descent & expulsion pressure & distention of the vagina & the perineum, described as burning, splitting, and tearing pressure & pulling on the pelvic structures (ligaments, fallopian tubes, ovaries, bladder, & peritoneum) lacerations of soft tissues (cervix, vagina, perineum) THIRD STAGE: presents as pain with the expulsion of the placenta, similar to pain experienced during the 1st stage uterine contractions pressure and pulling of pelvic structures FOURTH STAGE: pain caused by distention & stretching of the vagina & perineum incurred during the 2nd stage w splitting, burning, and tearing sensation

appropriate pain relief measures during labor

FIRST STAGE: -opioid agonist analgesics -opioid agonist-antagonist analgesics -epidural (block) analgesia -combined spinal-epidural (CSE) analgesia -nitrous oxide SECOND STAGE: -epidural (block) analgesia -nitrous oxide -local infiltration anesthesia -nerve block analgesia & anesthesia -pudendal block -spinal (block) anesthesia VAGINAL BIRTH: -epidural (block) analgesia -epidural (block) anesthesia -combined spinal-epidural (CSE) analgesia -nitrous oxide -local infiltration anesthesia -pudendal block -spinal (block) anesthesia CESAREAN BIRTH: -epidural (block) anesthesia -spinal (block) anesthesia -general anesthesia

newborn lab tests

Hgb and Hct if prescribed blood glucose for hypoglycemia metabolic screening: -newborn genetic screening, a capillary heel stick should be done at 24 h following birth, for results to be accurate newborn must have received formula or breastmilk for 24+ h, if newborn is d/c before 24 h the test should be repeated in 1-2 wks -all states require testing for phenylketonuria (PKU) (a defect in protein metabolism in which the accumulation of the amino acid phenylalanine can result in mental retardation), treatment in 1st 2 mos of life can prevent retardation other genetic testing: galactosemia, cycstic fibrosis, maple syrup urine disease, hypothyroidism, sickle cell disease serum bilirubin on all newborns prior to d/c collecting blood samples: -heel stick blood samples are obtained by the nurse, who dons clean gloves -warm the newborns heel 1st to increase circulation -cleanse area w antiseptic and allow for drying -a spring-activated lancet is used so that the skin incision is made quickly & painlessly -the outer aspect of the heel should be used & the lancet should go no deeper than 2.4 mm to prevent necrotizing osteochondritis resulting from penetration of bone w the lancet -apply pressure w dry gauze (do not use alcohol bc it will cause bleeding to continue) until bleeding stops, & cover w an adhesive bandage -cuddle & comfort the newborn when the procedure is completed to reassure the newborn & promote feelings of safety

culturally competent care during labor

Hispanic: prefer mother to be present rather than partner African American: prefer female family members for support Asian American: might prefer mother to be present, partner not an active participant, labor in silence, cesarean birth is undesirable Native American: prefer female nursing personnel, family involved in birth, use of herbs during labor, squatting position for birth European American: birth is a public concern, focus on technology, partner expected to be involved, provider seen as head of health care team

premature rupture of membranes/ preterm premature rupture of membraens

PROM: spontaneous rupture of the amniotic membranes 1 hr or more to the onset of true labor, signifies the onset of true labor if at term PPROM: premature spontaneous rupture of membranes after 20 wks and prior to 37 wks risk factors: infection, chorioamnionitis expected findings: gush or leakage of clear fluid from vagina, temp elevation, increased maternal HR or FHR, foul-smelling fluid or vaginal discharge, abdominal tenderness assess for prolapsed umbilical cord: abrupt FHR variable or prolonged deceleration, visible or palpable cord at the introitus lab tests: a positive nitrazine paper test (blue, pH 6.5-7.5) or positive ferning test is conducted on amniotic fluis to verify ROM prepare for birth if indicated obtain vaginal/rectal cultures for streptococcus B-hemolytic, obtain vaginal cultures for chlamydia and gonorrhea avoid vaginal exams assess vitals every 2 h, notify provider if temp > 100 provide reassurance to reduce anxiety assess FHR & contractions adhere to bed rest encourage hydration CBC perform daily fetal kick counts medications: ampicillin (antibiotic to treat infection of amniotic fluid), betamethasone (glucocorticoid IM in 2 injections 24 h apart, single dose given w PROM at 24-31 wks, administer into gluteal muscle 24 & 48 h prior to birth, monitor for pulmonary edema, monitor for hyperglycemia or mother and baby, monitor neonate HR changes) client will be discharged home if dilation < 3 cm, no evidence of infection, no contractions & no malpresentation adhere to limited activity, encourage hydration encourage self-assessment for uterine contractions record daily kick counts monitor for foul-smelling vaginal discharge do not insert anything into vagina, abstain from intercourse avoid tub baths wipe front to back take her own temp every 4 h when awake & report if over 100 (38 C)

puerperal infections

RISK FACTORS: -UTI, mastitis, pneumonia, or hx of previous venous thrombosis -hx of DM, immunosuppression, anemia, or malnutrition -hx of alcohol or drug use disorder -cervical dilation that provides the uterus w exposure to external environment -well-supplied exposed blood vessels -wounds from lacerations, incisions, hematomas -alkalinity of amniotic fluid, blood & lochia during pregnancy & the early postpartum period, decreasing the acidity of the vaginal secretions -cesarean birth -prolonged ROM -retained placental fragments & manual extraction -chorioamnionitis -internal fetal/uterine pressure monitoring -multiple vaginal examinations after ROM -prolonged labor -postpartum hemorrhage -operative vaginal birth -epidural analgesia/anesthesia -hematomas -episiotomy or lacerations EXPECTED FINDINGS: -flu-like clinical findings (body aches, chills, fever, malaise) -anorexia, nausea -elevated temp of at least 100.4 (38 C) for 2+ consecutive days -tachycardia LAB TESTS: -blood, intracervical, intrauterine bacterial cultures -WBC: leukocytosis -RBC sedimentation rate: distinctly increased -RBC count: anemia obtain frequent vitals assess pain assess fundal height, position, consistency observe lochia inspect incisions, episiotomy, lacerations inspect breasts use aseptic technique for appropriate procedures provide education about preventive measures (handwashing, hygiene) maintain IV access admin antibiotics IV provide comfort measures (warm blankets, cool compresses, depending on findings) educate about signs or worsening conditions & adherence to antibiotics encourage diet high in protein

postpartum depression

RISK FACTORS: -hormonal changes w a rapid decline in estrogen & progesterone levels -postpartum physical discomfort/pain -individual socioeconomic factors -decreased social support system -anxiety about assuming new role as mom -unplanned/unwanted pregnancy -hx of previous depressive disorder -low self esteem -hx of intimate partner abuse POSTPARTUM BLUES: -effects 50-85% of women -continues for up to 10 days -feelings of sadness -lack of appetite -sleep pattern disturbances -feeling of indequacies -crying easily for no apparent reason -restlessness, insomnia, fatigue -headache -anxiety, anger, sadness POSTPARTUM DEPRESSION: -occurs within 6 mos -occurs in 10-15% of women -feelings of guilt and inadequacies -irritability -anxiety -fatigue persisting beyond a reasonable amount of time -feeling of loss -lack of appetite -persistent feelings of sadness -intense mood swings -sleep pattern disturbances -crying -weight loss -flat affect -rejection of infant -severe anxiety/panic attack POSTPARTUM PSYCHOSIS: -1st 2-3 wks -pronounced sadness -disorientation -sadness -confusion -paranoia -behaviors indicating hallucinations or delusional thoughts of self-harm or harming thee infant monitor interactions between mom & baby encourage bonding activities monitor mood & affect reinforce that feeling down is normal & self-limiting encourage communication of feelings, validate & address personal conflicts, reinforce personal power & autonomy reinforce compliance w any prescribed medication regimen contact community resource to schedule follow-up ask about self-harm, suicide, harming infant thoughts antidepressants or antipsychotics/ mood stabilizers advise plenty of rest & nap when infant sleeps take time for self provide info about community resources encourage counseling

newborn reflex assessment

SUCKING AND ROOTING: -elicit by stroking the cheek or edge of mouth -newborn turns head to side that is touched and starts to suck -usually disappears after 3-4 mos but can persist up to 1 yr PALMAR GRASP: -elicit by placing examiner's finger in palm of newborn's hand -newborn's fingers curl around examiner's fingers -lessens by 3-4 mos PLANTAR GRASP: -elicit by placing examiner's finger at base of newborn's toes -newborn curls toes downward -birth to 8 mos MORO REFLEX: -elicit by allowing head and trunk of newborn in a semisitting position to fall backward at angle of 30 degrees -newborn will symmetrically extend and then abduct the arms at the elbows and fingers spread to form a C -birth to 6 mos TONIC NECK REFLEX: -with newborn in supine, neutral position, turn newborn's head quickly to one side -newborn's arm and leg on that side extend and opposing arm and leg flex -birth to 3-4 mos BABINSKI REFLEX: -elicit by stroking outer edge of sole of foot and move upward toward toes -toes will fan upward and out -birth to 1 yr STEPPING REFLEX: -elicit by holding newborn upright w feet touching a flat surface -newborn responds w stepping movements -birth to 4 wks

newborn senses assessment

VISION: -should be able to focus on objects 8-12 in from face -~ distance from mother's face when breastfeeding -eyes sensitive to light, prefer dim -pupils reactive to light -blink reflex easily stimulated -can track high-contrast objects -prefers bright colors and patterns -term newborns can see up to 2.5 feet -within 2-3 mos, can discriminate colors HEARING: -similar to adult once amniotic fluid drains from ears -selective listening to familiar voices and rhythms of intrauterine life -turns toward general direction of sound TOUCH: -should respond to tactile messages of pain and touch -mouth is most sensitive to touch TASTE: -can taste -prefer sweet to salty, sour, bitter SMELL: -highly developed sense of smell -prefer sweet smells -can recognize mom's smell HABITATION: -protective mechanism where newborn becomes accustomed to environmental stimuli -respinse to constant or repetitive stimulant is decreaed -allows newborn to select stimuli that promoted continued learning, avoiding overload

trichomoniasis

a STI caused by the protozoan parasite if left untreated in women, can cause PID and infertility more likely to have preterm delivery and babies with LBW risk factors: multiple partners, unprotected sex male: penile itching or irritation, dysuria, urethral discharge female: yellow/green frothy vaginal discharge with foul odor, dyspareunia and itching, dysuria, strawberry spots on cervix, cervical bleeding easily wet mount and whiff test pH greater than 4.5 wet mount saline prep indicates presence of trichomonads whiff test can be positive or negative medications: metronidazole or tinidazole (oral single dose) avoid alcohol while taking meds decrease effectiveness of OCs

diaphragm and spermicide

a dome-shaped cup with a flexible rim made of silicone that fits over the cervix with spermicidal cream or gel placed into the dome and around the rim different sizes, should be properly fitted replaced every 2 years and refitted for a 20% weight fluctuation, after abdominal or pelvic surgery, and after pregnancy requires proper insertion and removal can be inserted up to 6 hr before intercourse and must stay in place 6 hr after but for no more than 24 hr spermicide must be reapplied with each act a client should empty bladder prior to insertion diaphragm should be washed with mild soap and warm water after each use gives a woman more control over contraception inconvenient, interfere with spontaneity, require reapplication with spermicidal requires prescription and visit to provider must be inserted correctly no STI protection not recommended for clients with history of toxic shock syndrome or frequent/recurrent UTIs increased risk of acquiring TSS, which is caused by bacterial infection (high fever, faint feeling, drop in BP, watery diarrhea, headache, muscle aches) proper hand hygiene aids in prevention of TSS risk for allergic rxn

deep-vein thrombosis

a thrombus that is associated w inflammation in the lower extremities-can be of superficial or deep veins, which are most often the femoral, saphenous, or popliteal greatest risk for deep-thrombosis leading to a pulmonary embolism risk factors: -pregnancy -cesarean birth (doubles risk) -operative vaginal birth -pulmonary embolism or varicosities -immobility -obesity -smoking -multiparity -age > 35 -hx of thromboembolism -DM leg pain & tenderness unilateral area of swelling, warmth & redness hardened vein over the thrombosis calf tenderness Doppler ultrasound scanning, computed tomography, magnetic resonance imaging PREVENTION: maintain sequential compression device until ambuulation if bed rest is prolonged > 8 h, perform active & passive ROM to promote circulation initiate early & frequent ambulation avoid prolonged periods of standing, sitting or immobility elevate legs when sitting avoid crossing logs maintain 2-3L of fluid/day discontinue smoking measure lower extremities for fitted elastic thromboembolic hose to lower extremities MANAGEMENT: encourage rest facilitate bed rest & elevation of extremity above level of heart administer intermittent or continuous warm moist compresses do not massage affected limb to prevent thrombus from dislodging measure leg circumferences provide thigh-high antiembolism stockings administer NSAIDs administer anticoagulants MEDICATIONS: heparin: -anticouagulant -given IV to prevent formation of clots & enlargement of existing clots -continuous infusion for 3-5 d initially -antidote: protamine sulfate -monitor aPTT (1.5-2.5x control level of 30-40 s) -report bleeding from gums or nose, increased vaginal bleeding, blood in urine, frequent bruising warfarin: -anticoagulant -orally for 3 mos -antidote: phytonadione -monitor PT (1.5-2.5x control level of 11-12.5) -INR (2-3) -watch for bleeding from gums or nose, increased vaginal bleeding, blood in urine, frequent bruising -use birth control but not OCs, warfarin is teratogenic avoid taking aspirin or ibuprofen while on anticoagulants use an electric razor for shaving avoid alcohol use (inhibits warfarin) brush teeth gently w soft toothbrush avoid rubbing/massaging legs avoid periods of prolonged sitting or crossing legs

cervical insufficiency (premature cervical dilation)

a variable condition whereby expulsion of the products of conception occurs thought to be related to tissue changes and alterations in the length of the cervix risk factors include hx of cervical trauma (cervical tears, excessive dilations, curettage for biopsy, surgical procedures involving cervix), short labors, pregnancy loss in early gestation, advanced cervical dilation at earlier weeks of gestation, in utero exposure to diethylstilbestrol ingested by mother, congenital structural defects of the uterus or cervix increase in pelvic pressure or urge to push pink-stained vaginal discharge or bleeding possible gush of fluid (rupture of membranes) uterine contractions with the expulsion of the fetus postoperative (cerclage) monitoring for uterine contractions, rupture of membranes, and signs of infection ultrasound showing short cervix (less than 25 mm in length), presence of cervical funneling (beaking), or effacement of the cervical os prophylactic cervical cerclage is the surgical reinforcement of the cervix w a heavy ligature that is placed submucosally around the cervix to strengthen it and prevent premature dilation, best results occur if done at 12-14 weeks, removed at 37 weeks or when spontaneous labor begins assess vaginal discharge monitor reports of pressure or contractions check vitals administer tocolytics prophylactically to inhibit contractions activity restriction or bed rest encourage hydration to promote a relaxed uterus avoid intercourse, tampons, and douching provide education about clinical findings to report to the provider for preterm labor, rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, urge to push instruct client about using the home uterine activity monitor to evaluate contractions

bathing interventions

after initial bath, newborn's face, diaper area & skin folds are cleansed daily complete bathing is performed 2-3x/week using a mild soap that does not contain hexachlorophene bathing by immersion is not done until the newborn's umbilical cord has fallen off & the circumcision has healed if applicable wash area around cord, taking care not to get cord wet move from the cleanest area to dirtiest part of newborn's body, beginning w his eyes, face, & head, proceed to the chest, arms & legs, & wash the groin area last teach parents proper bathing techniques bathing should take place at the convenience of the parents, but not immediately after feeding to prevent spitting up & vomiting organize all equipment so that the newborn is not left unattended, never leave the newborn alone in the tub or sink make sure the hot water heater is set at 49 C (120.2 F) or less, room should be warm & bath water should be 36.6 to 37.2 C (98 to 99 F), test the water for comfort on inner wrist prior to bathing avoid drafts or chilling, expose only body part being bathed & dry thoroughly to prevent chilling & hypothermia newborn's eyes should be cleaned using a clean portion of the wash cloth, clear water should be used to clean each eye, inner to outer wrap in a towel, swaddle in a football hold to shampoo head, rinse from head & dry head to avoid chilling to cleanse an uncircumcised penis, wash with soap & water & rinse the penis, foreskin should not be forced back or constriction can result wash vulva by wiping front to back to prevent contamination of the vagina urethra from rectal bacteria apply a fragrance-free, hypoallergenic, moisturizing emollient immediately after bathing to prevent dry skin

nutritional risk factors

age culture education socioeconomic issues adolescents might have poor nutritional habits (a diet low in vitamins and protein, not taking prescribed iron supplements) vegetarians might have low protein, calcium, iron, zinc, and vitamin B12 nausea/vomiting during pregnancy anemia eating disorders: anorexia nervosa or bulimia nervosa pregnant clients diagnosed with the appetite disorder pica, might diminish the amount of nutritional foods ingested excessive weight gain can lead to macrosomia and labor complications inability to gain weight could result in low birth weight of the newborn financially unable to purchase/access food

female fertility assessment

age: >35 can affect fertility duration of infertility: more than 1 year of unprotected sex medical hx: atypical secondary sexual characteristic (abnormal body fat distribution or hair growth) indicative of an endocrine disorder, hormonal and adrenal gland disorders surgical hx: particularly pelvic and abdominal procedures obstetric hx: past episodes of sp abs, evaluation of hormone levels throughout cycle to provide info about anovulation, amenorrhea, and premature ovarian failure gynecologic hx: abnormal uterine contours or any hx of disorders that can contribute to the formation of scar tissue causing blockage sexual hx: intercourse frequency, number of partners, hx of STIs occupational/environmental exposure risk assessment: hazardous teratogenic materials in the home or workplace weight: overweight or underweight, anorexia substance use: alcohol, tobacco, heroin, methadone

newborn complications

airway obstruction related to mucus: -mouth and nose are suctioned w bulb syringe -gentle percussion over the chest can help loosen secretions hypothermia: -monitor axillary temp -if temp is unstable, place newborn in radiant warmer, maintain skin temp -ideal method for promoting warmth = skin to skin contact w mom -assess axillary temp every hr until stable -all exams & assessments should be performed under a radiant warmer or during skin to skin w mother inadequate oxygen supply: -related to obstructed airway, poorly functioning cardiopulmonary system, or hypothermia -monitor respirations & skin for cyanosis -stabilize body temp or clear airway as indicated -admin O2 -prepare for resuscitation

category 2

all FHR tracings not categorized as category 1 or 3 baseline rate: tachycardia, bradycardia not accompanied by absent baseline variability baseline FHR variability: minimal baseline variability, absent baseline variability not accompanied by recurrent decelerations, marked baseline variability episodic or periodic decelerations: prolonged FHR deceleration = or > 2 min but < 10 min, recurrent late decelerations w moderate baseline variability, recurrent variable decelerations w minimal or moderate baseline variability, variable decelerations w additional characteristics (overshoots, shoulders, slow return to baseline FHR) accelerations: absence of induced accelerations after fetal stimulations

anaphylactoid syndrome of pregnancy

amniotic fluid embolism occurs when there is a rupture in the amniotic sac or maternal uterine veins accompanied by high intrauterine pressure that causes infiltration of the amniotic fluid into the maternal circulation the amniotic fluid travels to and obstructs pulmonary vessels & causes respiratory distress & circulatory collapse can occur during labor, birth, or within 30 min after birth meconium-stained amniotic fluid or fluid containing particulate matter can cause devastating maternal damage, clogs pulmonary veins completely serious coagulation problems can occur (disseminated intravascular coagulopathy aka DIC) risk factors: -multiparity & AMA -placenta previa or abruption -preeclampsia -eclampsia -oxytocin admin -DM -cesarean birth -forceps-assisted birth -uterine rupture -cervical laceration -meconium-stained amniotic fluid report of sudden chest pain and/or SOB indications of respiratory distress: restlessness, cyanosis, dyspnea, pulmonary edema, respiratory arrest indications of coagulation failure: bleeding from incisions & venipuncture sites, petechiae & ecchymosis, uterine atony indications of circulatory collapse: tachycardia, hypotension, shock, cardiac arrest administer O2 8-10 L/min face mask assist w intubation & mechanical ventilation if necessary perform CPR administer IV fluids position client on side w pelvis tilted at 30 degree angle administer blood products insert catheter, measure hourly output monitor maternal & fetal status prepare for emergency C section if fetus is not delivered

gestational diabetes mellitus

an impaired tolerance to glucose w the first onset or recognition during pregnancy ideal blood glucose level during pregnancy = 70-110 mg/dL symptoms can disappear a few weeks after delivery but ~ 50% of women will develop type II DM within 5 yrs increased risk to fetus include spontaneous abortion (related to poor glycemic control), infections (urinary, vaginal, related to increased glucose in the urine and decreased resistance bc of altered carbohydrate metabolism), hydramnios (which can cause overdistention of the uterus, PROM, preterm labor, hemorrhage), ketoacidosis (from diabetogenic effect of pregnancy aka increased insulin resistance, untreated hyperglycemia, or inappropriate insulin dosing), hypoglycemia (caused by overdosing in insulin, skipped or late meals, or increased exercise), hyperglycemia (which can cause excessive fetal growth aka macrosmia) risk factors include obesity, HTN, glycosuria, maternal age over 25, family hx of DM, previous delivery of an infant that was large or stillborn hypoglycemia: nervousness, headache, weakness, hunger, blurred vision, tingling of mouth or extremities hyperglycemia: polydipsia, polyphagia, polyuria, nausea, abdominal pain, flushed dry skin, fruity breath expected findings: hypoglycemia, shaking, clammy pale skin, shallow respirations, rapid pulse, hyperglycemia, vomiting, excess weight gain during pregnancy routine urinalysis w glycosuria glucola screening test/1 hr glucose tolerance test: 50 g oral glucose load, followed by plasma glucose analysis 1 hr later performed at 24-28 wks, fasting not necessary, a + blood glucose screening is 130-140 mg/dL or greater, additional testing w 3 hr oral glucose tolerance test (OGTT) is indicated OGTT: following overnight fasting, avoidance of caffeine, and abstinence from smoking for 12 hr prior to testing, a fasting glucose is obtained, a 100 g oral glucose load is given, and serum glucose levels are determined at 1, 2, & 3 hr following glucose ingestion presence of ketones in urine to assess severity of ketoacidosis BPP to ascertain fetal well-being amniocentesis with alpha-fetoprotein NST to assess fetal well-being monitor blood glucose monitor fetus!! initially managed with diet and exercise alone, insulin is begun after if necessary perform daily kick counts educate about diet & exercise instruct about self-admin of insulin educate about need for postpartum testing to include OGTT and blood glucose levels

episiotomy

an incision made into the perineum to enlarge the vaginal opening to facilitate birth and minimize soft tissue damage indications: shorten the 2nd stage of labor, facilitate forceps-assisted or vacuum-assisted delivery, prevent cerebral hemorrhage in a fragile preterm fetus, facilitate birth of a macrosomic (large) infant median (midline): extends from the vaginal outlet toward the rectum, most commonly used, effective, easily repaired, generally least painful, associated w a higher incidence of 3rd and 4th degree lacerations mediolateral: extends from the vaginal outlet posterolateral, either to the left or right of the midline, & is used when posterior extension is likely, 3rd degree laceration can occur, blood loss is greater, repair is more difficult & painful, local anesthetic is administered prior to incision encourage alternate labor positions to reduce pressure on the perineum & promote perineal stretching to reduce the necessity for this procedure

mastitis

an infection of the breast involving the interlobular connective tissue usually unilateral can progress to abscess if untreated occurs most commonly in mothers breastfeeding for the 1st time & well after the establishment of milk (6 wks) staphylococcus aureus is usually the infecting organism RISK FACTORS: -milk stasis from a blocked duct -nipple trauma and cracked or fissured nipples -poor breastfeeding technique w improper latching -decrease in breastfeeding frequency due to supplementation w bottle feeding -poor hygiene & inadequate hand washing EXPECTED FINDINGS: -painful or tender localized hard mass & reddened area, usually on one breast -chills -fatigue -axillary adenopathy in the affected side (enlarged tender axillary lymph nodes) w area of inflammation that can be red, swollen, warm, tender instruct to thoroughly wash hands b4 breastfeeding maintain cleanliness of breasts, frequent changes of breast pads allow nipples to air-dry proper infant positioning & latching on techniques completely empty breasts w each feedings use ice packs or warm packs on breasts continue breastfeeding frequently (2-4 h) especially on affected side manually express breast milk or use pump if too painful to feed encourage rest, analgesics, fluid intake of 3 L/day encourage well-fitting bra for support admin antibiotics

external cephalic version

an ultrasound-guided hands-on procedure to externally manipulate the fetus into cephalic lie done at 36-37 weeks in a hospital high risk of placental abruption, umbilical cord compression, emergent cesarean birth contraindications: uterine anomalies, previous cesarean birth, cephalopelvic disproportion, placenta previa, multifetal gestation, oligohydramnios indications: a malpositioned fetus in a breech or transverse position after 36 wks obtain informed consent provider will perform ultrasound screening prior to the procedure to evaluate fetal position, locate the umbilical cord, assess placental placement to rule out placenta previa, determine the amount of amniotic fluid, determine fetal age, assess for the presence of anomalies, evaluate pelvic adequacy for delivery, guide the direction of the fetus during the procedure perform a NST to evaluate fetal well-being ensure that Rho(D) immune globulin was administered at 28 wks if mom is Rh- administer IV fluid and tocolytics to relax uterus to permit easier manipulation continuously monitor FHR & assess for bradycardia and variable decelerations during the version and for 1 hr following the procedure monitor vitals assess for hypotension monitor for report of pain Rh- clients require a Kleihauer-Betke test to detect for fetal blood in maternal circulation (if 15+ mL, Rho(D) is required) monitor uterine activity, contraction frequency, duration, intensity monitor for ROM monitor for bleeding until maternal condition is stable monitor for a decrease in fetal activity

newborn anogenital assessment

anus should be present, patent, and not covered by a membrane meconium should be passed within 24-48 h genitalia of male should include rugae on scrotum testes present in scrotum male urinary meatus located on penile tip genitalia of female should include labia majora covering labia minora and clitoris, usually edematous vaginal blood-tinged d/c can occur caused by maternal pregnancy hormones a hymenal tag should be present urine should be passed within 24 h after birth, uric acid crystals will produce a rust color in urine first couple days of life

behaviors that indicate a lack of mother-infant bonding

apathy when the infant cries disgust when the infant voids, stools, or spits up expresses disappointment in the infant turns away from the infant does not seek close physical proximity to the infant does not talk about the infant's unique features handles the infant roughly ignores the infant entirely does not include the infant in the family context perceives the infant behavior as uncooperative

newborn extremity assessment

assess for full range, symmetry of motion, and spontaneous movements extremities should be flexed assess for bowed legs & flat feet, which should be present bc lateral muscles are more developed than the medial muscles no click should be heard when abducting the hips gluteal folds should be symmetrical soles should be well-lined over 2/3 of the feet nail beds should be pink and no extra digits

newborn mouth assessment

assess for palate closure & strength of sucking lip movements should be symmetrical saliva should be scant, excessive can indicate a tracheoesophageal fistula Epstein's pearls: small white cysts found on gums & at junction of the soft & hard palates are expected findings, result from the accumulation of epithelial cells & disappear a few weeks after birth tongue should move freely, be symmetrical in shape, and not protrude soft & hard palate should be intact gums & tongue should be pink, gray-white patches on tongue can indicate thrush (fungal infection caused by Cadida)

newborn eye assessment

assess for symmetry in size & shape each eye and the space between the eyes should = 1/3 the distance from the inner to the outer canthus of both eyes to rule out chromosomal abnormalities eyes are usually blue or gray following birth lacrimal glands are immature w minimal or no tears subconjunctival hemorrhages can result from pressure during birth pupillary & red reflex are present eyeball movement will demonstrate random, jerky movements

comfort level postpartum

assess pain related to episiotomy, lacerations, incisions, afterpains, sore nipples assess location, type, quality of pain administer pain meds as prescribed

pre-labor assessment

assess prior to admission orient client and partner to the unit conduct admission history, review of antepartum care, and review of the birth plan obtain lab reports monitor baseline fetal heart tones and uterine contraction patterns for 20-30 mins obtain maternal vitals check the status of the amniotic membranes perform maternal & fetal assessments continuously throughout the labor process & immediately after birth avoid vaginal exams in the presence of vaginal bleeding or until placenta previa or abruptio placentae is ruled out (if necessary, let provider do it) cervical dilation is the single most important indicator of the progress of labor progress of labor is affected by size of fetal head, fetal presentation, fetal attitude, and fetal position the frequency, duration, and strength (intensity) of the uterine contractions cause fetal descent and cervical dilation

labor postprocedures

assessments include: maternal vitals, fundus, lochia, perineum, urinary output, maternal/newborn baby-friendly activities assess BP and pulse at least every 15 mins for the first 2 hr after birth, temp every 4 hr for the first 8 hr then at least every 8 hr assess fundus & lochia every 15 mins for the first hr then according to policy massage uterine fundus &/or administer oxytocics as prescribed to maintain uterine tone to prevent hemorrhage assess the client's perineum & provide comfort measures as indicated encourage voiding to prevent bladder distention promote maternal/newborn bonding tell client to notify nurse if increased vaginal bleeding, passage of blood clots assistance w breastfeeding provide reassurance

nursing care at prenatal visits

assist with Leopold maneuvers assist with gynecological examination have client empty her bladder and take deep breaths during pelvic exam administer RhO(D) immune globulin IM around 28 weeks gestation if Rh-negative

prenatal health promotion

avoid all OTC medications, supplements, and prescription medications no alcohol (birth defects) or tobacco (LBW) substance use of any kind is to be avoided during pregnancy and lactation exercising yields positive benefits (30 mins of moderate exercise daily) avoid hot tubs and saunas consume 8-10 glasses of water each day need for flu immunization no smoking treatment for current infections genetic testing and counseling exposure to hazardous materials

sexual intercourse education

avoid sexual intercourse until the episiotomy/laceration is healed and vaginal discharge has turned white (lochia alba), usually takes 2-4 wks OTC lubricants might be needed for the 1st 6 wks to 6 mos physiological rxns to sexual activity can be slower & less intense for the first 3 mos following birth

Group B streptococcus

bacterial infection that can be passed to a fetus during labor & delivery risk factors: hx of positive culture with previous pregnancy, maternal age < 20, African American or Hispanic, positive culture with pregnancy, prolonged rupture of membranes, preterm delivery, LBW, use of intrauterine fetal monitoring, intrapartum maternal fever physical findings: premature rupture of membranes, preterm labor and delivery, chorioamnionitis, infections of the urinary tract, maternal sepsis vaginal and rectal cultures are performed at 35-37 weeks administer antibiotics to: client who has GBS bacteriuria during pregnancy, client who has GBS positive screening during pregnancy, client who has unknown GBS status who is delivering at <37 weeks, client who has maternal fever, client who has ROM for 18 hr or longer penicillin G or ampicillin are most commonly prescribed (penicillin 5 million units via IV bolus, followed by 2.5 million units intermittent IV bolus q4h; ampicillin 2 g IV initialaly, followed by 1 g q4g)

gate control theory of pain

based on the concept that the sensory nerve pathways that pain sensations use to travel to the brain will allow only a limited # of sensations to travel at any given time by sending alternate signals through these pathways, the pain signals can be blocked from ascending the neurological pathway & inhibit the brain's perception & sensation of pain

sensory stimulation strategies to reduce pain

based on the gate-control theory to promote relaxation and pain relief aromatherapy breathing techniques imagery music use of focal points subdued lighting

cutaneous stimulation strategies to reduce pain

based on the gate-control theory to promote relaxation and pain relief therapeutic touch and massage: back rubs and massage walking rocking effleurage: light, gentle, circular stroking of the client's abdomen w the fingertips in rhythm w breathing during contractions sacral counterpressure: consistent pressure is applied by the support person using the heel of the hand or fist against the client's sacral area to counteract pain in the lower back application of heat/cold transcutaneous electrical nerve stimulation (TENS) therapy hydrotherapy (whirlpool or shower) increases maternal endorphin levels acupuncture frequent maternal position changes to promote relaxation and pain relief (semi-sitting, squatting, kneeling, kneeling and rocking back and forth, supine position only w the placement of a wedge under one of the client's hips to tilt the uterus & avoid supine hypotension syndrome)

second trimester education

benefits of breastfeeding common discomforts and relief measures lifestyle: sex and pregnancy, rest and relaxation, posture, body mechanics, clothing, seat belt safety and travel fetal movement complications: preterm labor, gestational HTN, gestational DM, premature rupture of membranes preparation for childbirth and childbirth education classes review of birthing methods development of a birth plan: verbal or written agreement about what client wishes during labor and delivery

third stage of labor

birth to delivery of placenta 5-30 mins placental separation and expulsion Schultze presentation: shiny fetal surface of placenta emerges first Duncan presentation: dull maternal surface of placenta emerges first

routine prenatal lab tests

blood type, Rh factor, presence of irregular antibodies: determines the risk for maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia, indirect Coombs' test identifies clients sensitized to Rh-positive blood, for those who are Rh-negative and not sensitized, the indirect Coombs' test is repeated between 24-28 weeks of gestation CBC with differential, Hgb and Hct: detects infection and anemia Hgb electrophoresis: identified hemoglobinopathies (sickle cell anemia, thalassemia) Rubella titer: determines immunity to rubella Hepatitis B screen: identifies carriers of hepatitis B Group B Streptococcus (GBS): obtain a vaginal/anal culture at 35-37 weeks of gestation to assess for GBS infection urinalysis with microscopic examination of pH, specific gravity, color, sediment, protein, glucose, albumin, RBCs, WBCs, cases, acetone, & hCG: identifies pregnancy, DM, gestational HTN, renal disease, infection 1-hour glucose tolerance (oral ingestion of IV admin of concentrated glucose with venous sample taken 1 hr later: identifies hyperglycemia, done at initial visit for at-risk clients and at 24-28 weeks of gestation for all pregnant women (>140 mg/dL requires follow up) 3-hour glucose tolerance (fasting overnight prior to oral ingestion or IV admin of concentrated glucose with a venous sample taken 1, 2, and 3 hours later): used if 1-hour elevated glucose test as a screening tool for DM, diagnosis of gestational diabetes requires 2 elevated blood-glucose readings Papanicolaou (Pap) test: screening tool for cervical cancer, herpes simplex type 2, HPV vaginal/cervical culture: detects strep B hemolytic, bacterial vaginosis, STIs PPD (tuberculosis screening), chest x-ray after 20 weeks with PPD test: identifies exposure to tuberculosis venereal disease research laboratory (VDRL): syphilis screening mandated by law HIV: detects HIV infection toxoplasmosis, other infections, rubella, cytopmegalovirus, and herpes virus screening: infections capable of crossing the placenta and adversely affect fetal development maternal serum alpha-fetoprotein (MSAFP): screening occurs between 15-22 weeks, rules out Down syndrome , neural tube defects,

newborn respiratory complications

bradypnea: respirations <30 tachypnea: respirations > 60 abnormal breath sounds: expiratory grunting, crackles, and wheezes respiratory distress: nasal flaring, retractions, grunting, gasping, and labored breathing newborn can clear most secretions w cough reflex, routine suctioning of the mouth then the nasal passages w a bulb syringe is done to remove excess mucus newborns delivered by cesarean birth are more susceptible to fluid remaining in the lungs than newborns born vaginally if bulb suctioning is unsuccessful, mechanical suction and/or back blows & chest thrusts can be used, as well as the institution of emergency procedures the bulb syringe should be kept w the newborn, and family should be instructed how to use family members should be asked to perform a demonstration to show they understand -compress bulb before insertion into 1 side of mouth -avoid center of mouth to prevent stimulating gag reflex -aspirate mouth first, one nostril, then second

equipment for newborn assessment

bulb syringe: used for suctioning excess mucus from mouth & nose stethoscope w pediatric head: used to evaluate HR, breath sounds, & bowel sounds axillary thermometer: used to monitor temp & prevent hypothermia, rectal temps are avoided (can injure delicate rectal mucosa) BP cuff 2.5 cm wide: palpation or electronic method, can be done in all 4 extremities if evaluating for cardiac problems scale w protective cover in place: scale should be at 0, weight should include lbs, oz, g tape measure in cm: measure from crown to heel of foot, measure head circumference at greatest diameter, measure chest circumference beginning at nipple line, abdominal circumference above umbilicus clean gloves

cardiovascular system changes in pregnancy

cardiac output increases 30-40% blood volume increases 30-45% at term heart rate increases during pregnancy beginning around week 5 and reaches a peak (10-15 bpm) around 32 weeks

cervix, vagina, & perineum postpartum

cervix is soft directly after birth; can be edematous, bruised, small lacerations within 2-3 days, cervix shortens, regains its form, & becomes firm w the os gradually closing lacerations can delay production of estrogen-influenced cervical mucus & predispose infection vagina gradually returns to its prepregnancy size with the reappearance of ruggae & thickening of vaginal mucosa soft tissues of perineum can be erythematous, edematous hematomas & hemorrhoids can be present pelvic floor muscles can be overstretched & weak assess episiotomy or lacerations for approximation, drainage, quantity, quality stool softeners proper cleansing: wash hands thoroughly before and after voiding, use squeeze bottle filled w warm water or antiseptic solution, clean perineal area from front to back, blot dry don't wipe, sparingly use topical antiseptic cream/spray, perineal pad should be changed from front to back apply ice packs for the 1st 24-48 hr to reduce edema and provide anesthetic effect encourage sitz baths 2x/day at temp of 100-104 (38-40 C) admin analgesia (NSAIDs, opioids, nonopioids) topical anesthetics (benzocaine spray) or witch hazel compresses to rectal area for hemorrhoids

probable signs of pregnancy

changes that make the examiner suspect pregnancy can be caused by physiological factors other than pregnancy -abdominal enlargement: related to changes in uterine size, shape, position -Hegar's sign: softening and compressibility of the lower uterus -Chadwick's sign: deepened violent-bluish color of cervix and vaginal mucosa -Goodell's sign: softening of cervical tip -ballottement: rebound of unengaged fetus -Braxton Hicks contractions: false contractions that are painless, irregular, and usually relieved by walking -positive pregnancy test -fetal outline

newborn vital sign assessment

checked in the following sequence: respirations, heart rate, BP, temp respiratory rate: -varies from 30-60 bpm w short periods of apnea (<15 s) occurring most frequently during the rapid eye movement sleep cycle -periods of apnea lasting longer than 15 s should be evaluated -crackles & wheezing are manifestations of fluid or infection in the lugns -grunting & nasal flaring are clinical findings of respiratory distress heart rate: -normal = 110-160 bpm w brief fluctuations above and below this range depending on activity level (crying, sleeping) -apical pulse rate is assessed for 1 full min, preferably when the newborn is sleeping -the pediatric stethoscope head is placed on the 4th or 5th intercostal space at the L midclavicular line over the apex of the newborn's heart -heart murmurs are documented & reported blood pressure: -should be 60-80 mmHg systolic and 40-50 mmHg diastolic temperature: -normal range is 97.7 to 99.5 F (36.5 to 37.5 C) axillary -newborn is at risk of hypothermia and hyperthermia until thermoregulation (ability to produce heat & maintain normal body temp) stabilizes -if newborn becomes chilled (cold stress), O2 demands can increase and acidosis can occur

intrauterine device (IUD)

chemically active T-shaped device inserted through the cervix & places into the uterus releases a chemical substance that damages sperm in transit to the uterine tubes and prevents fertilization can be used by nulliparous and multiparous women must be monitored monthly by clients after menstruation to ensure the presence of the string that hands into the vagina to rule out migration or expulsion can maintain effectiveness for 1-10 years (hormonal 3-5 years, copper 10) can be inserted immediately after abortion, miscarriage, childbirth, and while breastfeeding contraception can be reversed with immediate return to fertility does not interfere with spontaneity safe for mothers who are breastfeeding it is 99% effective in preventing pregnancy hormonal IUDs: decreased menstrual pain and heavy bleeding copper IUDs: no hormones so it's safe for women cautioned against hormonal birth control methods can increase risk of PID, uterine perforation, ectopic pregnancy can be expelled report late or abnormal spotting or bleeding, abdominal pain, pain w intercourse, abdominal or foul-smelling vaginal discharge, fever, chills, a change in string length, or if lost no STI protection hormonal: spotting, irregular bleeding, headache, nausea, depression, breast tenderness copper: increase in menstrual pain and bleeding risk of bacterial vaginosis, uterine perforation, uterine expulsion must be removed in the event of pregnancy contraindications: active pelvic infection, abnormal uterine bleeding, severe uterine distortion (for copper, also Wilson's diseases and copper allergy)

third trimester education

childbirth classes or birth plan coping methods breathing and relaxation techniques use of effleurage and counter pressure application of heat/cold, touch and massage, and water therapy use of transcutaneous electrical nerve stimulation (TENS) acupressure and acupuncture music and aromatherapy discussion regarding pain management during labor and birth (natural childbirth, epidural) use of doula during labor indications of preterm labor and labor labor process infant care postpartum care

cognitive strategies to reduce pain

childbirth education preparation methods, such as Lamaze and patterned breathing exercises doulas can assist clients using nonpharmacological pain methods assess for signs of hyperventilation (lightheadedness, tingling of the fingers) hypnosis biofeedback

potential complication education

chills or fever > 100.4 (38 C) for 2+ days change in vaginal d/c w increased amount, large clots, change to a previous lochia color, foul odor episiotomy, laceration, or incisional pain that does not resolve w analgesics, foul-smelling drainage, redness, and/or edema pain or tenderness in the abdominal or pelvic areas that does not resolve w analgesics breasts w localized areas of pain and tenderness w firmness, heat, & swelling, and/or nipples w cracks, redness, bruising, blisters or fissures calves w localized pain, tenderness, redness, & swelling; a lower extremity w either areas or redness and warmth or coolness and paleness urination w burning, pain, frequency, urgency, urine that is clouded or bloody postpartum depression (feeling apathy toward infant, can't provide self or infant care, feelings that she might hurt herself or infant) follow up appt in 4-6 wks (2 wks if cesarean)

skin changes in pregnancy

chloasma: an increase of pigmentation on the face linea nigra: dark line of pigmentation from the umbilicus extending to the pubic area striae gravidarum: stretch marks most notably found on the abdomen and thighs

perineal care education

cleanse from front to back w warm water after each voiding and BM blot perineal area from front to back remove & apply perineal pads from front to back

postpartum hemorrhage

client loses more than 500 mL of blood after vaginal birth or more than 1,000 mL of blood after cesarean birth can lead to hypovolemic shock or anemia risk factors: -uterine atony -overdistended uterus -previous hx of uterine atony -prolonged labor -oxytocin-induced labor -high parity -ruptured uterus -complications during pregnancy -precipitous delivery -admin of magnesium sulfate during labor -lacerations & hematomas -inversion of uterus -subinvolution of uterus -retained placental fragments -coagulopathies increase or change in lochial pattern (return to previous stage, clots) uterine atony (hypotonic, boggy) blood clots > quarter perineal pad saturation in 15 min or less constant oozing, trickling, or frank flow or bright red blood from the vagina tachycardia, hypotension skin pale, cool, clammy w loss of turgor & pale mucous membranes oliguria Hgb & Hct, coagulation profile (PT), blood type & crossmatch firmly massage uterine fundus monitor vitals assess for source of bleeding (assess fundus, assess lochia, assess for lacerations, hematomas, episiotomy) assess bladder for distention, insert catheter to assess kidney function, monitor output maintain or initiate IV fluids (lactated ringer's, 0.9% NaCl, colloid volume expanders, blood products) provide O2 at 2-3L/min per nasal cannula MEDICATIONS: oxytocin: -uterine stimulant -promotes contractions -assess uterine tone & bleeding -monitor for ADE of water intoxication (lightheadedness, n/v, h/a, malaise, can progress to seizures, coma, death) methylergonovine -uterine stimulant -controls hemorrhage -assess uterine tone & bleeding -do not admin if HTN -monitor for ADE including HTN, n/v, h/a misoprostol: -uterine stimulant -controls hemorrhage -assess uterine tone & vaginal bleeding carboprost tromethamine -uterine stimulant -controls hemorrhage -assess uterine tone & bleeding -monitor ADE such as fever, HTN, chills, h/a, n/v, diarrhea limit physical activity to conserve strength increase iron and protein intake to promote rebuilding of RBC volume take iron w vit C to enhance absorption

backaches education

common during 2nd and 3rd trimesters exercise regularly perform pelvic tilt exercises use proper body mechanics by using legs to lift side-lying position

urinary tract infection education

common during pregnancy wipe front to back avoid bubble baths wear cotton underwear avoid tight-fitting pants consume plenty of water urinate before/after intercourse to flush bacteria from the urethra that are present or introduced during intercourse urinate as soon as the urge comes notify provider if urine is foul-smelling, cloudy, contains blood

urinary tract infections

common postpartum secondary to bladder trauma incurred during the delivery or break in aseptic technique during bladder catheterization progression to pyelonephritis w permanent kidney damage RISK FACTORS: -postpartal hypotonic bladder or urethra (urinary stasis/retention) -epidural anesthesia -frequent pelvic exams -urinary bladder catheterization -genital tract injuries -hx of UTIs -cesarean birth EXPECTED FINDINGS: -reports of urgency, frequency, dysuria, discomfort in pelvic area -fever -chills -malaise -change in vitals (elevated temp) -cloudy, blood-tinged, malodorous, sediment visible urine -urinary retention -pain in suprapubic area -pain at costovertebral angle urinalysis for WBC, RBC, protein, bacteria obtain urine sample admin antibiotics acetaminophen to reduce discomfort proper perineal hygiene (front to back) increase fluid intake to 3 L/day drink cranberry & prune juice to promote urine acidification & prevent bacteria multiplication

uterine rupture

complete rupture involves uterine wall, peritoneal cavity and/or broad ligament, internal bleeding is present incomplete rupture occurs w dehiscence at the site, internal bleeding might not be present rare but life-threatening risk factors: -congenital uterine abnormality -uterine trauma due to accident or surgery -overdistention of uterus from fetus who is large for gestational age, multifetal gestation or polyhydramnios -hyperstimulation of uterus, either spontaneous or from oxytocin -external or internal fetal version done to correct malposition -forceps-assisted birth -multigravida sensation of "ripping" or "tearing" or sharp pain abdominal pain, uterine tenderness nonreassuring FHR w indications of distress (bradycardia, variable & late decelerations, absent or minimal variability) change in uterine shape & fetal parts palpable cessation of contractions & loss of fetal station manifestations of hypovolemic shock: tachypnea, hypotension, pallor, cool/clammy skin administer IV fluids, O2, blood product transfusions prepare for immediate cesarean birth

apgar scoring

completed at 1 and 5 mins of life 0-3 = severe distress 4-6 = moderate difficulty 7-10 = minimal or no difficulty adjusting to extrauterine life HEART RATE: 0 = absent 1 = slow, < 100 bpm 2 = > 100 bpm RESPIRATORY RATE: 0 = absent 1 = slow, weak cry 2 = good cry MUSCLE TONE: 0 = flaccid 1 = some flexion of extremities 2 = well-flexed REFLEX IRRITABILITY: 0 = none 1 = grimace 2 = cry COLOR: 0 = blue, pale 1 = pink body, cyanotic hands/feet (acrocyanosis) 2 = completely pink

pain assessment during labor

consider cultural beliefs & behaviors as fear & anxiety increase, muscle tension increases as well as the experience of pain fear, tension & pain slow the progression of labor assess beliefs & expectations related to discomfort, pain relief, & birth plans regarding pain relief methods assess level, quality, frequency, duration, intensity & location of pain through verbal & nonverbal cues indicate severity on 0-10 scale behavioral manifestations such as crying, moaning, screaming, gesturing, writhing, avoidance or withdrawal, & inability to follow instructions increasing BP, tachycardia, and hyperventilation can indicate pain help client maintain proper position during admin of pharmacological interventions, assist client w positioning for comfort during labor and birth provide client safety by putting bed in a low position, maintaining side rails in the up position, place call light within reach, call for assistance if she needs to get up evaluate response to pain relief methods

behaviors that facilitate & indicate mother-infant bonding

considers the infant a family member holds the infant face-to-face maintaining eye contact assigns meaning to infant behavior and views this positively identifies the infant's unique characteristics & relates them to those of other family members names the infant, indicating bonding is occurring touches the infant and maintains close physical proximity and contact provides physical care for the infant, such as feeding and diapering responds to infant's cries smiles at, talks to, and sings to the infant

transdermal contraceptive patch

contains norelgestromin (progesterone) and ethinyl estradiol, which is delivered at continuous levels through the skin into SQ tissue apply to dry skin overlying SQ tissue of the buttocks, abdomen, upper arm, or torso (not breast area) patch replacement weekly apply for the same day of the week for 3 weeks with no application on the fourth week maintains consistent blood levels of hormone avoids liver metabolism decreases risk of forgetting daily pill no STI protection same ADE as oral contraceptives risk of DVT and VTE can be slightly higher skin rxn can occur same complications/contraindications as oral contraceptives avoid applying to skin rashes or lesions less effective if over 198 lbs

contraceptive vaginal ring

contrains etonogestrel and ethinyl estradiol that is delivered at continuous levels vaginally inserts ring vaginally requires replacement after 3 weeks, insertion should occur on the same day of the week monthly does not have to be fitted decreases risk of forgetting to take pill vaginal route of delivery increases bioavailability of hormones enabling lower dose and reducing ADE no STI protection same ADE as oral contraceptives some report discomfort during intercourse can be removed for up to 3 h without reducing effectiveness risk of blood clots, HTN, stroke, MI, vaginal irritation, increased vaginal secretions, headache, weight gain, and nausea

diagnostic & therapeutic procedures following birth

cord blood is collected to determine ABO blood type and Rh status CBC by capillary stick to evaluate for anemia, polycythemia, infection, clotting problems blood glucose to evaluate for hypoglycemia Hgb: 14-24 g/dL platelets: 150,000 to 300,000/mm3 Hct: 44-64% glucose: 40-60 mg/dL RBC: 4.8 x 10^6 to 7.1 x 10^6 Bilirubin: 2-6 mg/dL (24 hr), 6-7 mg/dL (48 hr), 4-6 mg/dL (3-5 d) leukocytes: 9,000 to 30,000/mm3

cord care interventions

cord clamp is removed before discharge prevent cord infection by keeping the cord dry, & keep top of the diaper folded underneath it sponge baths are given until the cord falls off, which occurs @ days 10-14 tub bathing & submersion can follow after it falls off cord infection (a complication of improper cord care) can result if the cord is not kept clean & dry monitor for manifestations of a cord that is moist & red, foul odor, purulent drainage

fetal movement

count and record to ascertain fetal well-being count 2-3x/day for 2 hr after meals or bedtime <3 movements/hr or movements that cease entirely for 12 hrs indicate a need for further evaluation

male sterilization (vasectomy)

cutting of the vas deferens in the male as a form of permanent sterilization reinforce need for alternate forms of birth control for 20 ejaculations or 1 week to several months to allow all of the sperm to clear the vas deferens following procedure, scrotal support and moderate activity for a couple of days sterility is delayed until the proximal portion of the vas deferens is cleared of all remaining sperm follow-up is important for sperm count permanent short, safe, simple procedure sexual function is not impaired requires surgery reversal is possible but not always successful no STI protection complications are rare but include bleeding, infection, and anesthesia reaction

cardiovascular system and fluid & hematologic status postpartum

decrease in blood volume related to blood loss during childbirth (avg = 300-500 mL in vaginal and 500-1,000 in cesarean), diaphoresis and diuresis of excess fluid accumulated during last part of pregnancy hypovolemic shock does not usually occur Hct levels drop moderately for 3-4 d & begin to increase and reach nonpregnant levels by 8 weeks WBC values between 20,000-25,000 mm3 are common during first 4-7 d coagulation factors & fibrinogen levels increase during pregnancy & remain elevated for 2-3 wks hypercoagulability predisposes to thrombus formation and thromboembolism BP usually unchanged but may slightly increase possible orthostatic hypotension in 1st 48 h elevation of HR, SV, & CO for 1st h postpartum and decrease to nonpregnant levels by 8-10 wks elevation of temp to 100.4 (38 C) resulting from dehydration can occur in 1st 24 h but should return to normal after that inspect legs for redness, swelling, warmth (venous thrombosis) encourage early ambulation apply antiembolism stockings

decrease or loss of FHR variability

decrease or loss of irregular fluctuations in the baseline of the FHR causes/complications: -medications that depress the CNS, such as narcotics, barbiturates, tranquilizers, or general anesthetics -fetal hypoxemia and metabolic acidemia -fetal sleep cycle (minimal variability sleep cycles usually do not last longer than 30 min) -congenital abnormalities nursing interventions: -stimulate the fetal scalp -assist with application of scalp electrode -place client in left-lateral position

fourth stage of labor assessment

delivery of placenta to 1-4 hr after birth maternal vitals fundus lochia urinary output baby-friendly activities of the family BP and HR q15 mins for 2 hr and determine temp at beginning of recovery period then assess q4h for the 1st 8 h then at least every 8 h assess fundus & lochia q15 mins for 1st hr then according to protocol massage the uterine fundus and/or administer oxytocics as prescribed to maintain uterine tone and to prevent hemorrhage encourage voiding to prevent bladder distention assess episiotomy or laceration repair for erythema promote an opportunity for parental-newborn bonding after they have had a chance to bind with the baby and eat, most new moms are ready for a nap

activity education

do not perform housework requiring heavy lifting for 3+ wks (nothing heavier than the infant) avoid sitting for prolonged periods of time w legs crossed limit stair climbing for the 1st few weeks postpartum clients who have had a cesarean birth should wait until the 4-6 wk follow-up visit before performing strenuous exercise, heavy lifting, or excessive stair climbing don't drive for 1st 2 weeks postpartum or while taking opioids

dystocia

dysfunctional labor a difficult or abnormal labor related to the 5 P's of labor atypical uterine contraction patterns prevent the normal process of labor & its progression contractions can be hypotonic (weak, inefficient, completely absent) or hypertonic (excessively frequent, uncoordinated, strong intensity w inadequate relaxation) with failure to efface and dilate the cervix risk factors: -short stature, overweight -age > 40 -uterine abnormalities -pelvic soft tissue obstructions or pelvic contracture -cephalopelvic disproportion -congenital anomalies -fetal macrosomia -fetal malpresentation, malposition -multifetal pregnancy -hypertonic/hypotonic uterus -maternal fatigue, fear, dehydration -inappropriate timing of anesthesia or analgesics lack of progress in dilation, effacement, or fetal descent hypotonic uterus: easily indentable, even at peak of contractions hypertonic uterus: cannot be indented, even between contractions ineffective in pushing w no voluntary urge to bear down diagnostic procedures: ultrasound, amniotomy, oxytocin infusion, vacuum-assisted birth, cesarean birth assist w application of scalp electrode or IUPC assist w amniotomy encourage regular voiding, position changes, ambulation, hydrotherapy and other relaxation techniques apply counterpressure using fist or heel of hand to sacral area prepare forceps or vacuum assisted birth or cesarean birth if necessary continue monitoring FHR hypertonic contractions: -maintain hydration -promote rest & relaxation -place client in lateral position -provide O2 by mask oxytocin: used to augment labor & strengthen uterine contractions

nursing interventions for infertility

encourage couples to express & discuss their feelings explain role of genetic counselor, reproductive specialist, geneticist, pharmacist in providing psychosocial and medical care monitor for adverse effects associated with medications advise that the use of medications to treat female infertility can increase the risk of multiple births by more than 25% provide info regarding assisted reproductive therapies (in vitro, embryo transfer, intrafallopian gamete transfer, surrogate parenting, adoption) make referrals to grief and infertility support groups

newborn infection control

essential in preventing cross-contamination from newborn to newborn & between newborns & staff newborns are at risk for infection during the 1st few months of life bc of immature immune systems provide individual bassinets equipped w a thermometer, diapers, T-shirts, and bathing supplies all personnel who care for a newborn should scrub w microbial soap from elbows to finger tips before entering the nursery

hyperemesis gravidarum

excessive n/v possibly related to elevated hCG levels that is prolonged past 12 weeks and results in a 5% weight loss from prepregnancy weight, electrolyte imbalance, acetonuria, and ketosis risk to the fetus for intrauterine growth restriction or preterm birth if the condition persists risk factors include maternal age younger than 30 years, hx of migraines, obesity, 1st pregnancy, multifetal gestation, gestational trophoblastic disease or fetus with chromosomal anomaly, psychosocial issues and high levels of emotional stress, clinical hyperthyroid disorders, diabetes, GI disorders, family hx of hyperemesis excessive vomiting for prolonged periods dehydration w possible electrolyte imbalance weight loss increased HR decreased BP poor skin turgor & dry mucous membranes urinalysis for ketones and acetones (breakdown of protein and fat) is the most important initial lab test: elevated urine specific gravity chemistry profile revealing electrolyte imbalances: Na, K, Cl reduced from low intake; metabolic acidosis secondary to starvation; metabolic alkalosis due to excessive vomiting; elevated liver enzymes; bilirubin level thyroid test indicating hyperthyroidism CBC: Hct concentration is elevated because of inability to retain fluid resulting in hemoconcentration monitor I&O assess skin turgor/mucous membranes monitor vitals monitor weight NPO for 24-48 h give IV lactated ringer's for hydration give pyridoxine (vit B6) and other vitamin supplements as tolerated antiemetic medications (ondansetron, metoclopramine) cautiously for uncontrollable n/v use corticosteroids to treat refractory hyperemesis gravidarum clear liquids after 24 h of no vomiting advance diet as tolerated, frequent small meals, start with dry toast, crackers, or cereal then move to soft diet, finally a normal diet enteral nutrition per feeding tube or total parenteral nutrition can be considered in severe cases

fourth degree laceration

extends through skin, muscles, anal sphincter, and anterior rectal wall

second degree laceration

extends through the skin and muscles into the perineum but not the anal sphincter

first degree laceration

extends through the skin of the perineum and does not involve the muscles

third degree laceration

extends through the skin, muscles, perineum, and external anal sphincter muscle

initial newborn assessment

external: skin color, peeling, birthmarks, foot creases, breast tissue, nasal patency, meconium staining chest: pt of max impulse location, east of breahting, auscultation for HR & quality of tones, respirations for crackles, wheezes & equality of bilateral breath sounds abdomen: rounded & umbilical cord w 1 vein and 2 arteries neurologic: muscle tone & reflex rxn (Moro), palpation for presence & size of fontanels & sutures, assessment of fontanels for fullness or bulge other: inspection for gross structural abnormalities weight: 2500 to 4000 g (5.5-8.8 lb) length: 45-55 cm (18-22 in) head circumference: 32-36.8 cm (12.5-14.5 in) chest circumference: 30-33 cm (12-13 in)

nursing considerations for mother-infant bonding

facilitate bonding by placing infant skin-to-skin or in the en face position promote rooming-in as a quest and private environment promote early breastfeeding encourage parents to bond through cuddling, bathing, feeding, diapering, and inspection provide frequent praise, support, and reassurance encourage parents to express feelings, fears, and anxieties

paternal adaptation

father has skin-to-skin, holds the infant, and maintains eye contact observes infant for features similar to his own talk, sing, read to infant three stage process: 1. expectations & intentions: father desires to be deeply & emotionally connected w infant 2. confronting reality: father discovers that his expectations may not be met (may feel sad, frustrated, jealous), embraces need to be actively involved in parenting 3. creating the role of the involved father: father decides to become actively involved in the care of the infant 4. reaping rewards: infant smiles and a sense of completeness and meaning provide education about infant care when the father is present, encourage father to take hands-on approach

formula feeding

feed every 3-4 hours babies should be awaken at least every 4 hours during the night teach parents how to prepare formula, bottles, nipples importance of hand washing teach about different forms of formula (ready-to-feed, concentrated, powder) bottles & accessories can be put in dishwasher, boiled, or washed by hand in hot soapy water using a good bottle & nipple brush teach parents to wash lid of can of concentrated formula with hot soapy water & shake before opening use tap water to mix concentrated or powder formula if water source is questionable, boil tap water first prepared formula can be refrigerated for up to 48 hours teach the parents to check the flow of formula from the last bottle to ensure it is not coming out too slow or too fast do not use formula past expiration date show parents how to cradle the newborn in their arms in a semi-upright position, newborn should not be placed in the supine position during feeding to prevent aspiration hold close at 45 degree angle place nipple on top of newborn's tongue keep nipple filled w formula to prevent the newborn from swallowing air always hold bottle & never prop give newborn opportunities to burp several times during a feeding place newborn on his back after feedings tell parents to discard any unused formula remaining in the bottle from the bottle, possible bacterial contamination teach how to tell if newborn is being adequately fed (gaining weight, BMs yellow soft & formed, satisfaction between feedings) less frequent BMs than breastfed babies 6+ wet diapers/day

manifestations of mood swings, conflict about maternal role, or personal insecurity

feelings of being "down" feelings of inadequacy feelings of anxiety related to ineffective breastfeeding emotional liability w frequent crying flat affect and being withdrawn feeling unable to care for the infant

vasa previa

fetal umbilical vessels implant into the fetal membranes rather than the placenta velamentous insertion of the cord: cord vessels begin in the branch at the membranes and then course to the placenta succenturiate insertion of the cord: placenta has divided into 2 or more lobes and not one mass battledore insertion of the cord: a marginal insertion, increased risk of fetal hemorrhage ultrasound for fetal well-being and vessel assessment closely monitor for excessive bleeding during labor & delivery

renal system changes in pregnancy

filtration rate increases secondary to the influence of pregnancy hormones and an increase in blood volume and metabolic demands the amount of urine produced remains the same urinary frequency is common

hypoglycemia in newborns

frequently occurs in the 1st few hrs of life secondary to the use of energy to establish respirations & maintain body heat newborns of mothers who have DM, are small or large for gestational age, are less than 37 wks, or are greater than 42 wks are at risk for hypoglycemia & should be monitored for blood glucose within the 1st 2h of life monitor for jitteriness, twitching, a weak and high-pitched cry, irregular respiratory effort, cyanosis, lethargy, eye rolling, seizures, & blood glucose level < 40 mg/dL by heel stick have mom breastfeed immediately or give donor breast milk or formula to elevate blood glucose levels brain damage can result if brain cells are depleted of glucose

candidiasis

fungal infection 2nd most common type of vaginal infection in the U.S. all women who have symptoms should be tested risk factors include pregnancy, DM, OCs, recent antibiotic treatment, obesity, diet high in refined sugars vulvar and vaginal pruritus thick, creamy, white, cottage cheese-like vaginal discharge vulvar and vaginal erythema & inflammation white patches on vaginal walls gray-white patches on the tongue and gums in a neonate test pH of discharge, wet mount, whiff test pH less than 4.5 wet mount potassium hydroxide prep indicates presence of yeast buds, hyphae, and pseudohyphae negative whiff test medications: fluconazole (single low dose, topical therapies if pregnant, antifungal agent, fungicidal action) or OTC treatments avoid tight-fitting clothing wear cotton-lined underpants limit wearing damp clothing avoid douching increase dietary intake of yogurt with active cultures

gingivitis, nasal stuffiness, and epistaxis education

gently brush teeth observe good dental hygiene use a humidifier use normal saline nose drops or spray

second and third trimester danger signs

gush of fluid from vagina before 37 weeks (rupture of amniotic fluid) vaginal bleeding (placental problems) abdominal pain (premature labor, abruptio placentae, ectopic pregnancy) changes in fetal activity (fetal distress) persistent vomiting (hyperemesis gravidarum) severe headaches (gestational HTN) elevated temp (infection) dysuria (UTI) blurred vision (gestational HTN) edema of face & hands (gestational HTN) epigastric pain (gestational HTN) concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, increased thirst & urination, headache (hyperglycemia) concurrent occurrence of clammy pale skin, weakness, tremors, irritability, lightheadedness (hypoglycemia)

newborn head assessment

head should be 2-3 cm larger than chest circumference if head circumference is > or equal to 4 cm larger than the chest circumference, this can be an indication of hydrocephalus (excessive cerebral fluid within the brain cavity surrounding the brain if head circumference is < or equal to 32 cm, this can be an indication of microcephaly (abnormally small head) anterior fontanel should be palpated and ~ 5 cm or smaller and diamond shaped posterior fontanel should be smaller and triangle shaped fontanels should be soft and flat fontanels can bulge when newborn cries, coughs or vomits, and are flat when newborn is quiet bulging fontanels can indicate increased ICP, infection, or hemorrhage depressed fontanels can indicate dehydration sutures should be palpable, separated and can be overlapping (molding), a normal occurrence from head compression during labor caput succedaneum: localized swelling in the soft tissues of the scalp caused by pressure on the head during labor, an expected findings that can be palpated as a soft edematous mass & can cross over suture lines, usually resolves in 3-4 days cephalohematoma: collection of blood between the periosteum and the skull bone that it covers, does not cross suture line, results from trauma during birth, appears in the 1st 1-2 days and resolves in 2-3 wks

chorionic villus sampling

high-risk pregnancy assessment of a portion of the developing placenta, which is aspirated through a thin sterile catheter or syringe inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance 1st tri alternative to amniocentesis with one of its advantages being earlier diagnosis of any abnormalities ideally performed at 10-13 weeks potential diagnoses: risk for giving birth to a neonate who has a genetic chromosomal abnormality cannot determine spina bifida or anencephaly drink plenty of fluid to fill bladder prior to procedure to assist in positioning the uterus for catheter insertion complications: spontaneous abortion, risk for fetal limb loss (greater prior to 9 weeks), miscarriage, chorioamnionitis and rupture of membranes

quad marker screening

high-risk pregnancy blood test that ascertains info about the likelihood of fetal birth defects can be performed instead of AFP, more reliable tests for hCG, AFP, estriol, inhibin A client presentation: preferred at 16-18 weeks, risk for giving birth to a neonate who has a genetic chromosomal abnormality low levels of AFP can indicate a risk for Down syndrome high levels of AFP can indicate a risk for neural tube defects levels higher than the expected reference range of hCG and inhibin A indicates a risk for Down syndrome lower levels than the expected reference range of estriol can indicate a risk for Down syndrome

percutaneous umbilical blood sampling

high-risk pregnancy cordocentesis most common method used for fetal blood sampling and transfusion passes a fine-gauge, fiber-optic scope into the amniotic sac using amniocentesis technique, needle is advanced into the umbilical cord under the ultrasound guidance, blood is aspirated from the umbilical vein blood studies consist of: Kleihauer-Betke test that ensures that fetal blood was obtained, CBC count with differential, indirect Coombs' test for Rh antibodies, karyotyping, blood gases potential diagnoses: fetal blood type, RBC, and chromosomal disorders, karyotyping of malformed fetuses, fetal infection, altered acid-base balance of fetuses with IUGR evaluates for isoimmune fetal hemolytic anemia and assesses the need for a fetal blood transfusion complications: cord laceration, preterm labor, amnionitis, hematoma, fetomaternal hemorrhage

combined oral contraceptives

hormonal contraception containing estrogen and progestin by suppressing ovulation, thickening the cervical mucus to block semen and alter the uterine decidua to prevent implantation requires prescription and follow-up appts requires consistent and proper use observe for adverse effects and danger signs (chest pain, SOB, leg pain, headache, eye problems from stroke, HTN) if miss one dose, take one ASAP; if miss 2-3, follow instructions and use alternative contraception highly effective if taken correctly and consistently noncontraceptive benefits include decreased menstrual blood loss, decreased anemia, regulation of menorrhagia and irregular cycles, reduced incidence of dysmenorrhea and premenstrual symptoms offers protection against endometrial, ovarian, and colon cancer, reduces incidence of benign breast disease, improves acne, protects against ovarian cyst formation no STI protection can increased risk of thromboembolism, stroke, heart attack, HTN, gallbladder disease, liver tumor exacerbates conditions affected by fluid retention (migraine, epilepsy, asthma, kidney or heart disease) ADE: headache, nausea, breast tenderness, breakthrough bleeding ADE estrogen component: nausea, breast tenderness, fluid retention ADE progestin component: increased appetite, tiredness, depression, breast tenderness, oily skin/scalp, hirsutism contraindications: hx of thromboembolic disorders, stroke, MI, coronary artery disease, gallbladder disease, cirrhosis or liver tumor, headache with focal neurological symptoms, uncontrolled HTN, DM with vascular involvement, breast or estrogen-related cancers, pregnancy, lactating, <6 weeks postpartum, smoking if over 35 effectiveness decreases when taking medications that affect liver enzymes (anticonvulsants, some antibiotics)

donor milk feeding

if the mother is not able to produce milk, pasteurized donor milk from a milk bank is available obtain informed consent likely not readily accessible

measurement of fundal height

in centimeters from the symphysis pubis to the top of the uterine fundus (between 18-32 weeks) approximates the gestational age

risk factors for impaired newborn nutrition

inadequate breastfeeding newborn illness/infection malabsorption other conditions that increase energy needs inadequate or slow milk production inadequate emptying of the breast inappropriate timing of feeding inadequate breast tissue pain w feeding maternal hemorrhage maternal illness/infection

nutritional education

increase calories: +340 calories/day during the 2nd tri, +462 calories/day during 3rd tri, +450-500 calories/day while breastfeeding increase protein intake: essential to basic growth, intake foods high in folic acid for neurological development and prevention of neural tube defects, take 400 mcg/day of folic acid if of childbearing age and 600 mcg/day while pregnant iron supplements: facilitate an increase of the RBC mass, best absorbed between meals and when given with vitamin C, milk and caffeine interfere with absorption, may need a stool softener to decrease constipation calcium: involved in bone/teeth formation take 1,000 mg/day if pregnant or of ages 19-50 take 1,300 mg/day if under 19 fluid: 8-10 glasses (2.3 L) per day (water, fruit juice, milk) limit caffeine: no more than 200 mg/day, 500-750 mg/day could increase the risk of spontaneous abortion of fetal intrauterine growth restriction abstain from alcohol consumption during pregnancy

postpartum nutritional planning

increase protein & caloric intake while adhering to a recommended, well-balanced diet increase oral fluids, but avoid alcohol and caffeine avoid food substances that do not agree with the newborn (foods that can cause altered bowel function) the client should take calcium supplements if she consumes an inadequate amount of dietary calcium

gastrointestinal system & bowel function postpartum

increased appetite following delivery constipation w bowel evacuation delayed until 2-3 d after birth hemorrhoids assess for bowel sounds, spontaneous BM may not occur for 2-3 d secondary to decreased intestinal muscle tone & prelabor diarrhea and dehydration anticipate discomfort w defecation bc of perineal tenderness, episiotomy, lacerations, hemorrhoids operative vaginal birth and anal sphincter lacerations increase risk of anal incontinence that usually resolves in 6 mos increase fluids, high-fiber enemas & suppositories are contraindicated for 3rd & 4th degree lacerations

pulse changes in pregnancy

increases 10-15 bpm around 32 weeks remains elevated throughout the remainder of the pregnancy

cervical ripening

increases cervical readiness for labor through promotion of cervical softening, dilation, and effacement can eliminate the need for oxytocin administration to induce labor, lower the dosage of oxytocin needed and promote a more successful induction administration of a low-dose infusion of oxytocin is used for cervical priming a balloon catheter is inserted into the intracervical canal to dilate the cervix membrane stripping and an amniotomy may be performed hygroscopic dilators may be inserted to absorb fluid from surrounding tissues and then enlarge fresh dilators may be inserted if further dilation is required laminaria tents are made from desiccated seaweed synthetic dilators contain magnesium sulfate chemical agents based on prostaglandins are used to soften and thin the cervix, they can be in the form of oral medication of vaginal suppositories or gels indications: any condition in which augmentation or induction of labor is indicated, failure of the cervix to dilate and efface, failure of labor to progress assess for: urinary retention, ROM, uterine tenderness or pain, contractions, vaginal bleeding, fetal distress obtain informed consent obtain baseline data on fetal and maternal well-being assist the client to void prior to the procedure document # of dilators and/or sponges inserted during procedure remain in side-lying position assist w augmentation or induction of labor as prescribed monitor FHR and uterine activity after administration of cervical-ripening agents notify provider of hyperstimulation or fetal distress monitor for potential side effects such as n/v, diarrhea, fever, uterine tachysystole proceed w caution in clients who have glaucoma, asthma, cardiovascular or renal disorders complications: -hyperstimulation: administer subcutaneous injection of terbutaline -fetal distress: apply oxygen face mask at 10 L/min, position client on er left side, increase rate of IV fluids, notify provider

cold stress in newborns

ineffective thermoregulation that can lead to hypoxia, acidosis, and hypoglycemia newborns who have respiratory distress are at a higher risk of hypothermia monitor for manifestations of of cold stress: cyanotic trunk, depressed respirations newborn should be warmed slowly over a period of 2-4 h correct hypoxia by administering oxygen correct acidosis & hypoglycemia

endometritis

infection of the uterine lining or endometrium most frequently occurring postpartum infection usually begins on 2nd-5th days postpartum, generally starting as localized infection at the placental attachment site & spreading to include entire uterine endometrium EXPECTED FINDINGS: -pelvic pain -chills -fatigue -loss of appetite -uterine tenderness & enlargement -dark, profuse lochia -lochia that is either malodorous or purulent -temp > 100.4 (38 C) typically on the 3rd-4th postpartum day -tachycardia collect vaginal & blood cultures admin IV antibiotics admin analgesics teach hand hygiene encourage interaction w infant clindamycin, cephalosporins, penicillins, gentamicin -antibiotics -treatment of bacterial infections -take all meds as prescribed -notify provider or watery, bloody diarrhea -notify provider if breastfeeding

successful storage of breast milk obtained by a breast pump

inform mom that milk can still be provided during periods of separation by using a breast bump or hand expression breast pumps can be manual, electric or battery-operated & pumped directly into a bottle or freezer bag one or both breasts can be pumped & suction is adjustable for comfort teach parents that breast milk must be stored according to guidelines for proper containers, labeling, refrigerating, & freezing breast milk can be stored at room temp for up to 8 hours, it can be refrigerated in sterile bottles for use within 8 days, or can be frozen for up to 6 months or stored in a deep freezer for 12 months thawing milk in fridge for 24 h is the best way to preserve the immunoglobulins present in it, also can be thawed by holding the container under running lukewarm water or placing it in a container of lukewarm water, bottle should be rotated often but not shaken thawing by microwave is contraindicated, it destroys some immune factors & lysozomes, leads to development of hot spots in the milk because of uneven heating do not refreeze thawed milk used portions of breast milk must be discarded

fundus postpartum

involution occurs w contractions of the uterine smooth muscle rapidly decreases in size from ~1 kg (2.2 lb) to 60-80 g at 6 weeks fundal height steadily descends into the pelvis ~ 1 fingerbreadth (1 cm) per day @ end of 3rd stage of labor, the uterus should be palpable at midline and 2 cm below to halfway between umbilicus & symphysis pubis 1 hr after delivery fundus should rise to level of umbilicus every 24 hr, the fundus should descend ~1-2 cm should be halfway between the umbilicus & symphysis pubis by 6th day after 2 weeks, should lie within the pelvis and no longer be palpable assess fundal height, uterine placement, & uterine consistency at least q8h use clean gloves & perineal pad to observe lochia flow while fundus is palpated cup one hand above the symphysis pubis & palpate abdomen w other hand if fundus is boggy, lightly massage administer oxytocics IM or IV to promote uterine contractions (oxytocin, methylergonovine, carboprost or misoprostol which is a prostaglandin) encourage early breastfeeding encourage emptying of bladder q2-3h to prevent dispalcement and atony

vacuum-assisted delivery

involves the use of a cuplike suction device that is attached to the fetal head traction is applied during contractions to assist in the descent and birth of the head, after which, the vacuum cup is released and removed preceding delivery of the fetal body conditions for use: vertex presentation, absence of cephalopelvic disproportion, ruptured membranes associated risks: scalp lacterations, subdural hematoma of the neonate, cephalohematoma, maternal lacterations to the cervix, vagina or perineum provide support & education assist into lithotomy position to allow for sufficient traction of the vacuum cup assess FHR before and during assess for bladder distention use forceps if unsuccessful observe neonate for lacerations, cephalohematomas, subdural hematomas check neonate for caput succedaneum (swelling of the scalp in a newborn that disappears in ~3-5 days)

musculoskeletal system

joints return to prepregnant state & are completely restabilized by 6-8 wks, feet can remain larger permanently muscle tone begins to be restored w removal of progesterones effect rectus abdominis and the pubococcygeus muscle tone are restored following placental expulsion & return to prepregnant size 6 wks assess abdominal wall for diastasis recti (separation of rectus muscle) from 2-4 cm, usually resolves in 6 wks start w simple exercises then gradually progress postpone abdominal exercises until 4 wks if cesarean good body mechanics & proper posture

precipitous labor

labor that lasts 3 h or less from the onset of contractions to the time of delivery risk factors: -hypertonic uterine dysfunction: nonproductive, uncoordinated, painful, uterine contractions during labor that are too frequent and too long in duration and do not allow for relaxation of the uterine muscle between contractions; do not contribute to the progression of labor; can result in uteroplacental insufficiency leading to fetal hypoxia -oxytocin stimulation: administered to augment or induce labor by increasing intensity & duration of contractions, stimulation can lead to hypertonic contractions -multiparous client: can move through the stages of labor more rapidly expected findings: -low backache -abdominal pressure and cramping -increased or bloody vaginal discharge -palpable uterine contractions -progress of cervical dilation & effacement -diarrhea -fetal presentation, station & position -status of amniotic membranes assess maternal perineal area for indications of trauma or lacerations assess neonate's color for indications of hypoxia assess for indications of trauma to presenting part of neonate do not leave client unattended, provide reassurance & emotional support, prepare for emergency delivery encourage client to pant w open mouth between contractions to control the urge to push encourage side-lying position prepare for rupturing of membranes do not attempt to stop delivery control rapid delivery by applying light pressure to the perineal area & fetal head deliver the fetus between contractions assuring cord is not around neck; if it is, try and slip it off and if it won't, clamp and cut suction mucus from fetal mouth and nose when head appears delivery anterior shoulder located under maternal symphysis pubis, then posterior shoulder, then allow rest of body to slip out maternal complications: -cervical, vaginal, perineal lacerations -resultant tissue trauma secondary to rapid birth -uterine rupture -amniotic fluid embolism -postpartum hemorrhage fetal complications: -fetal hypoxia due to hypertonic contractions or umbilical cord around neck -intracranial hemorrhage due to head trauma from rapid birth

lacerations & hematomas

lacerations are the tearing of soft tissues in the birth canal & adjacent structures including the cervical, vaginal, vulvar, perineal and/or rectal areas episiotomy can extend & become a 3rd or 4th degree laceration hemotoma is a collection of 250-500 mL of clotted blood within tissues that can appear as bulging bluish masses can occur in the pelvic region or higher in the vagina pain, rather than noticeable bleeding risk for hemorrhage or infection risk factors: -operative vaginal birth -precipitous birth -cephalopelvic disproportion -size & abnormal presentation or position -prolonged pressure of fetal head on vaginal mucosa -previous scarring of birth canal from infection, injury, or operation -nulliparous -light skin, reddish hair laceration: sensation of oozing or trickling blood, excessive rubra lochia, vaginal bleeding even though the uterus is firm & contracted, continuous slow trickle of bright red blood from vagina, laceration or episiotomy hematoma: pain, pressure sensation in rectum or vagina, difficulty voiding, bulging, bluish mass or area of red-purple discoloration on vulva, perineum, or rectum assess pain visually or manually inspect vulva, perineum, & rectum assess episiotomy for extension evaluate lochia assess vitals & hemodynamic status identify source of bleeding assist provider w repairs use ice packs to treat small hematomas admin pain meds encourage sitz baths & frequent perineal hygiene repair & suturing of episiotomy or lacerations done by provider ligation of bleeding vessel or surgical incision for evacuation of clotted blood from hematoma done by provider

third stage of labor assessment

lasts from birth to placenta delivery BP, pulse, RR q15 min placental separation from the uterus as indicated by: -fundus firmly contracting -swift gush of dark blood from introitus -umbilical cord appears to lengthen as placenta descends -vaginal fullness on exam assignment of 1 & 5 min Apgar scores instruct client to push once findings of placental separation are present keep parents informed of progress of placental expulsion & perineal repair if appropriate administer oxytocics to stimulate the uterus to contract and prevent hemorrhage administer analgesics gently cleanse perineal area w warm water and apply a perineal pad or ice pack promote baby-friendly activities (skin to skin), allow private time, encourage breastfeeding

second stage of labor assessment

lasts from the time the cervix is fully dilated to the birth of the fetus BP, HR, and RR every 5-30 mins uterine contractions pushing efforts by client increase in bloody show shaking of extremities FHR every 15 mins & immediately following birth perineal lacerations assist in positioning for effective pushing assist in partner involvement w pushing efforts and in encouraging bearing down efforts during contractions promote rest between contractions provide comfort measures like a cold compress cleanse the client's perineum as needed if fecal material is expelled during pushing prepare for episiotomy provide feedback on labor progress to the client prepare for care of neonate check oxygen flow and tank on warmer preheat radiant warmer have resuscitation equipment in working order & emergency medications available check suction apparatus

nutritional needs for the newborn

loss of 5-10% after birth (regain 10-14 days after birth) is normal gain of 110-200 g/week for the first 3 months healthy newborns need a fluid intake of 100-140 mL/kg/day, don't need water, they get a sufficient amount of fluid from breastmilk or formula requires 110 kcal/kg/day for the first 3 months requires 100 kcal/kg/day for the next 3-6 months breast milk & formula provide 20 kcal/oz carbohydrates should make up 40-50% of the newborn's total caloric intake at least 15% of calories must come from fat (triglycerides), fat in breast milk is easier to digest than cow's milk 2.25-4 g/kg/day for protein intake newborns should receive 400 IU of vitamin D daily beginning in the first few days of life mothers who are vegetarians & don't eat meat, fish or dairy should also take vitamin B12 breast milk is adequate with the exception of iron & fluoride after 6 months, include iron-fortified cereal & other foods rich in iron-fortified until 12 months fluoride levels in breast milk & formula are low, supplement should be given after 6 months solids are not introduced until 6 months (if too early, food allergies can develop)

respiratory system changes in pregnancy

maternal oxygen needs increase during the last trimester, the size of the chest might enlarge, allowing for lung expansion, as the uterus pushes upward respiratory rate increases total lung capacity decreases

labor intraprocedures

maternal vital signs: check temp every 1-2 h if membranes are ruptured FHR: determine fetal well=being, can be performed by use of EFM or spiral electrode uterine labor contraction characteristics: by palpation or by use of external or internal monitoring; monitor for frequency (beginning of one to beginning of next), duration (time between the beginning of one contraction to the end of the same contraction), and intensity (strength at its peak); resting tone of uterine contractions is the tone of the uterine muscle in between contractions, a prolonged contraction duration (90+ s) or too frequent (5+ in 10 min) without sufficient time for relaxation (30 s) can reduce blood flow to placenta intrauterine pressure catheter: solid, sterile, water-filled intrauterine pressure catheter into the uterus to measure intrauterine pressure; displays uterine contraction patterns on monitor; requires membranes to be ruptured and cervix sufficiently dilated vaginal examination: assess for cervical dilation, effacement, descent of fetus through birth canal (station), fetal position, presenting part, lie, membranes intact or ruptured mechanisms of labor in vertex presentation: adaptations the fetus makes as it progresses through the birth canal (engagement, descent, flexion, internal rotation, extension, external rotation, birth by expulsion)

genetic counseling for infertility

may be recommended by the provider if there is a family hx of birth defects identify clients who are in need such as those with sickle cell trait or anemia or clients over 35 prenatal assessment of genetic disorders (amniocentesis) can pose potential risks to the fetus provide and clarify info pertaining to the risk of or the occurrence of genetic disorders within a family preceding, during, and following a session assist in the construction of family medical hx for several generations provide emotional support make referrals to support groups and provide follow-up

meconium-stained amniotic fluid

meconium passage in the amniotic fluid during the antepartum period prior to the start of labor fetus has had an episode of loss of sphincter control risk factors: after 38 wks, umbilical cord compression that results in fetal hypoxia and stimulates the vagal nerve in mature fetuses amniotic fluid can be black to greenish, yellow, brown; meconium stained is often green; consistency can be thick or thin often present in breech presentation, might not indicate fetal hypoxia present with no changes in FHR stained fluid accompanied by variable or late decelerations (ominous sign) electronic fetal monitoring notify neonatal resuscitation team to be present at birth & gather equipment needed suction mouth & nose using bulb syringe if respiratory efforts strong, muscle tone good, HR > 100 suction below the vocal chords before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and HR < 100

male infertility assessment

medical hx: mumps, endocrine disorders, genetic disorders, anomalies in reproductive system sexual hx: intercourse frequency, hx of STIs substance use: alcohol, tobacco, heroin, methadone occupational/environmental exposure risk assessment: exposure to hazardous teratogenic materials in home or work, exposure of scrotum to high temps

injectable progestins

medroxyprogesterone is an IM or SQ injection given every 11-13 weeks start of injections should be during first 5 days of menstrual cycle and every 11-13 weeks thereafter injections in postpartum nonbreastfeeding women should begin within 5 days after delivery if breastfeeding, injections should start 6 weeks postpartum maintain adequate intake of calcium and vitamin D very effective, only requires 4 injections/year doesn't impair lactation possible absence of periods and decrease in bleeding decreased risk of uterine cancer if used long-term ADE: decrease in bone mineral density, weight gain, increase in depression, and irregular vaginal spotting or bleeding no STI protection return to fertility can be delayed as long as up to 18 mos after discontinuation should only be used as a long-term method (2+ years) if other methods are inadequate avoid massaging injection site following administration contraindications: breast cancer, evidence of current cardiovascular disease, abnormal liver function, liver tumors, unexplained vaginal bleeding

nausea and vomiting education

might occur during 1st trimester eat crackers or dry toast 30 min to 1 hr before rising in the morning to relieve discomfort avoid having an empty stomach and ingesting spicy, greasy, or gas-forming foods encourage the client to drink fluids between meals

breast tenderness education

might occur during 1st trimester wear a bra that provides adequate support

constipation education

might occur during 2nd and 3rd trimesters drink plenty of fluids eat a diet high in fiber exercise regularly

hemorrhoids education

might occur during 2nd and 3rd trimesters warm sitz bath witch hazel pads application of topical ointments

heartburn education

might occur during the 2nd and 3rd trimesters eat small, frequent meals don't allow stomach to get too empty or too full sit up for 30 min after meals check with provider prior to using antacids

foods high in calcium

milk calcium-fortified soy milk fortified orange juice nuts legumes dark green leafy vegetables

newborn elimination

monitor elimination habits newborns should void once within 24 h of birth they should void 6-8x/day after day 4 meconium should be passed within the 1st 24-48 h after birth newborn will then continue to pass stool 3-4x/day depending on whether he is being breast- or bottle-fed the stools of newborns who are breastfed can be yellow and seedy, they should have at least 3 stools/day for the 1st mo, these stools are lighter in color & looser than the stools of newborns who are formula-fed monitor & document output keep perineal area clean & dry, the ammonia in urine is irritating to the skin & can cause diaper rash after each diaper change, cleanse perineal area w clear water or water w mild soap, diaper wipes w alcohol should be avoided, pat dry and apply triple antibiotic ointment, petroleum jelly, or zinc oxide, depending on facility protocol

postpartum assessment

monitor vitals, uterine firmness & location related to umbilicus, uterine position in relation to midline, amount of vaginal bleeding BP & HR every 15 mins for 2 hrs temp every 4 hrs for the 1st 8 hr then every 8 hrs Breasts Uterus: fundal height, uterine placement, consistency Bowel and GI function Bladder function Lochia: color, odor, consistency, amount Episiotomy: edema, ecchymosis, approximation CBC (Hgb, Hct, WBC, platelet) Rho(D) immune globulin within 72 hrs to women who are Rh- and gave birth to Rh+ baby Kleihauer-Betke test determines amount of fetal blood in maternal circulation (if 15+ mL, mother should receive increased Rho(D) immune globulin)

emergency oral contraceptive

morning-after pill that prevents fertilization from taking place taken within 72 h of unprotected sex take an OTC antiemetic 1 h prior to dose to counteract nausea be evaluated for pregnancy if no menstruation within 21 days not taken on a regular basis anyone can purchase at a pharmacy nausea, heavier menstrual bleeding, lower abdominal pain, fatigue, headache not for long-term contraception does not terminate an established pregnancy no STI protection contraindications: pregnancy, undiagnosed abnormal vaginal bleeding

human papilloma virus

most common STI some types can cause genital warts spread orally, vaginally, anally risk factors: multiple partners, unprotected sex bumps in the genital area that might not itch or hurt small warts or a group of warts that can have a cauliflower-like appearance abnormal changes to the cervix detected by a Pap test medications: client-applied cream, provider-administered therapy laser therapy or cone biopsy further treatment deferred until after birth

chlamydia

most commonly reported STI in American women difficult to diagnose bc it is often asymptomatic, if left untreated in women it can lead to PID and infertility risk factors: multiple partners, unprotected sex male: mucoid or watery urethral discharge, dysuria female: dysuria, urinary frequency, spotting or postcoital bleeding, mucopurulent endocervical discharge, easily induced endocervical bleeding urine culture for males endocervical culture preferred for females take entire prescription as prescribed and test again 3 weeks later azithromycin or amoxicillin (can decrease effectiveness of oral contraceptives) administer erythromycin to infants after birth

nonstress test

most widely used technique for fetal well-being 3rd tri noninvasive that monitors response of the the FHR to fetal movement mom presses a button when she feels fetal movement high rates of false nonreactive results due to fetal sleeping, fetal immaturity, maternal medications, nicotine use disorder potential diagnoses: assessing for an intact fetal CNS during 3rd tri, ruling out the risk for fetal death in clients with DM twice/week at 28-32 wweeks client presentation: decreased fetal movement, intrauterine growth restriction, postmaturity, gestational DM, gestational HTN, maternal chronic HTN, hx of previous fetal demise, advanced maternal age, sickle cell disease, isoimmunization 2 belts applied to abdomen if no fetal movements, vibroacoustic stimulation can be activated for 3 s to awaken sleeping fetus reactive: FHR normal baseline rate with moderate variability, accelerates at least 15 bpm (10 bpm before 32 weeks) for at least 15 s (10 s before 32 weeks) and occurs 2 or more times during a 20 min period nonreactive: doesn't demonstrate at least 2 accelerations in a 20 min period

feeding/elimination interventions

mothers who are breastfeeding should be seen by the lactation consultant every newborn should be seen & examined at the doctor's office within 72 hours (2-3 days) after discharge from the hospital newborn is offered the breast immediately after birth & frequently thereafter average of 15-20 minutes per breast, 30-40 minutes total feed on demand or every 2-3 hours formula feed every 3-4 hours don't adhere to specific timing of feedings is to be avoided parents should be instructed to recognize when the newborn has completed the feeding, no other fluids are offered to the newborn unless indicated by the provider mother's milk supple is equal to the demand of the newborn, the newborn will empty a breast within 5-10 min but can need to continue to suck to meet comfort needs frequent feedings (every 2 h) can be indicated & manual expression of milk to initiate flow most newborns spit up a small amount after feedings, keep newborn upright & quiet for a few mins after feedings breastfed newborns should have 3+ BMs/day, formula fed are less frequent breastfed newborns should have 6+ wet diapers/day, formula fed have a similar number

dietary complications during pregnancy

nausea: eat small amounts frequently (q2-3h), avoid large meals, avoid alcohol, caffeine, and fried, fatty or spicy foods, avoid consuming excessive amounts of fluid, do not take medication to control nausea, ginger may be helpful constipation: increase fluid consumption and include extra fiber in the diet (fruits, vegetables, whole grains) maternal phenylketonuria: resume the PKU diet at least 3 mos prior to pregnancy and continue throughout, avoid foods high in protein (fish, poultry, meat, eggs, nuts, dairy), avoid aspartame, monitor phenylalanine levels during pregnancy, interventions can prevent fetal complications such as mental retardation or behavioral problems diabetes mellitus: preexisting or gestational, monitor the amount of carbs in the diet and keep glucose levels within target, limit sweets and desserts, meet with dietician

positioning & holding of the newborn (head support) interventions

newborn has minimal head control head should be supported when lifted cradle hold: cradle the newborn's head in the bend of the elbow, this permits eye-to-eye contact & is a good position for feeding upright position: hold the newborn upright & face him toward the holder while supporting his head, upper back & buttocks football hold: support half of the newborn's body in the holder's forearm w the newborn's head & neck resting in the palm of the hand, this is a good position for resting in the palm of the hand, this is a good position for breastfeeding & when shampooing the newborn's hair colic hand: place the newborn face-down along the holder's forearm w the hand firmly between the newborn's legs, the newborn's cheek should be by the holder's elbow on the outside, the newborn should be able to see the ground, & the holder's arm should be close to the body, using it to brace & steady the newborn, a good position for quieting a fussy newborn

contraction stress test

nipple-stimulated contraction test: lightly brushing her palm across her nipple for 2 min causing the pituitary gland to release oxytocin then stopping the nipple stimulation when a contraction begins, analyzing the FHR to contractions determines how the fetus will tolerate the stress of labor, a pattern of at least 3 contractions within 10 mins with a duration of 40-60 s each must be obtained; hyperstimulation of the uterus (contraction longer than 90 s or 5+ in 10 min) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of both nipples oxytocin-stimulated contraction test: used if nipple stimulation fails, consists of IV admin of oxytocin to induce contractions, can be difficult to stop and can lead to preterm labor, contraindications include placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incision from C section, reduced cervical competence potential diagnosis: high-risk pregnancies (gestational DM, postterm pregnancy), nonreactive stress test client presentation: decreased fetal movement, intrauterine growth restriction, postmaturity, gestational DM, gestational HTN, maternal chronic HTN, hx of previous fetal demise, advanced maternal age, sickle-cell disease obtain baseline FHR, fetal movement, and contractions for 10-20 mins if there are contractions, complete assessment without artificial stimulation maintain bed rest during procedure monitor for contractions 90+ s, or occurring more frequently than every 2 mins observe for 30 mins after to be sure contractions have ceased negative cst (normal): no late decelerations of FHR in 10 mins with 3 contractions positive cst (abnormal): persistent and consistent late decelerations with 50% or more of the contractions, suggestive of uteroplacental insufficiency, variable deceleration can indicate cord compression, and early decelerations can indicate fetal head compression

amnioinfusion

normal saline or lactated ringer's instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid instillation reduces the severity of variable decelerations caused by cord compression indications: oligohydramnios (scant amount or absence of amniotic fluid) caused by uteroplacental insufficiency, PROM, or postmaturity of the fetus; fetal cord compression secondary to postmaturity of fetus (macrosomic, large body) which places the fetus at risk for variable deceleration from cord compression assist with amniotomy if membranes have not already ruptures, membranes must have ruptured to perform this warm fluid using a blood warmer prior to infusion perform nursing measures to maintain comfort & dryness monitor the client to prevent uterine overdistention and increased uterine tone, which can initiate, accelerate, or intensify uterine contractions & cause nonreassuring FHR changes continually assess intensity & frequency of uterine contractions monitor FHR monitor fluid output from vagina to prevent uterine overdistention

newborn nose assessment

nose should be midline, flat, and broad w lack of a bridge some mucus should be present, but w no drainage newborns are obligate nose breathers and do not develop the response of opening the mouth w a nasal obstruction until 3 wks a nasal blockage can result in flaring of nares, cyanosis, or asphyxia sneeze to clear nasal passages

parity

number of pregnancies in which the fetus or fetuses reach 20 weeks of pregnancy not the number of fetuses not effected whether the fetus is born stillborn or alive

therapeutic procedures for infertility

nutritional & dietary changes exercise, yoga, stress management herbal medications acupuncture ovarian stimulation-medications (clomiphene citrate, letrozole), metformin to support ovulation intrauterine insemination: procedure used to place prepared sperm in the uterus at the time of ovulation in vitro fertilization-embryo transfer (IVT-ET): collecting woman's eggs and fertilizing in a laboratory with sperm then transferring to the uterus gamete intrafallopian transfer: oocytes are retrieved & immediately places with prepared motile sperm, both placed together in catheter, gametes are then injected into fallopian tubes using laparoscopy donor oocyte: donates eggs are collected from a donor by IVF, eggs are inseminated, embryos are places into uterus, hormonal therapy prepared uterus donor embryo (embryo adoption): donated embryo is placed in recipient's uterus, which is hormonally prepared gestational carrier (embryo host): couple completes process of IVF with the embryo placed in another woman, contract agreement surrogate mother: a woman is inseminated with semen and carries the fetus until birth therapeutic donor insemination: donor sperm is used to inseminate a woman

iron-deficiency anemia

occurs due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron risk factors include < 2 yrs between pregnancies, heavy menses, diet low in iron, multifetal gestation, vomiting frequently expected findings include fatigue and weakness, irritability, headache, feeling dizzy or lightheaded, SOB with exertion, palpitations, craving unusual food (pica), pallor, brittle nails, SOB Hgb less than 11 mg/dL in the 1st and the 3rd trimesters and less than 10.5 mg/dL in the 2nd trimester Hct less than 3% recommended iron intake for pregnant women is 27 mg/day, prenatal vitamins contain 30 mg usually if maternal iron deficiency is present, increase dosages to 60-120 mg/day foods rich in iron: legumes, fruit, green leafy vegetables, meat ferrous sulfate iron supplements: take the supplement on an empty stomach and take w OJ to increase absorption. encourage a diet rich in vitamin C-containing foods, suggest that the client increase roughage & fluid intake in diet to assist with discomforts of constipation iron dextran: used in treatment of iron-deficiency anemia when oral iron supplements cannot be tolerated by the client who is pregnant

placenta previa

occurs when the placenta abnormally implants int he lower segment of the uterus near or over the cervical os instead of attaching to the fundus abnormal implantation results in bleeding during the 3rd trimester or pregnancy as the cervix begins to dilate and efface complete or total: cervical os is completely covered by placental attachment incomplete or partial: cervical os is only partially covered by the placental attachment marginal or low-lying: placenta is attached in the lower uterine segment but does not reach the cervical os risk factors: previous placenta previa, uterine scarring, maternal age greater than 35, multifetal gestation, multiple gestations or closely spaced pregnancies, smoking painless, bright red vaginal bleeding during the 2nd or 3rd trimester uterus soft, relaxed & nontender with normal tone fundal height greater than usually expected for gestational age fetus in a breech, oblique, or transverse position resassuring FHR vital signs WNL decreasing urinary output can be a better indicator of blood loss lab tests: Hct and Hgb, CBC, blood type, Rh, coagulation profile, Kleihauer-Betke test to detect fetal blood in maternal circulation diagnostic procedure: transabdominal or transvaginal ultrasound for placement of the placenta, fetal monitoring assess for bleeding, leakage, or contractions assess fundal height perform Leopold maneuvers refrain from performing vaginal exams administer IV fluids, blood products, and medications as prescribed corticosteroids promote fetal lung maturation if early delivery is anticipated (C section) have oxygen equipment available in case of fetal distress bed rest

first stage of labor assessment

onset of regular contractions to full effacement and dilation of cervix (latent, active, and transition phases) perform Leopold maneuvers perform vaginal exam as indicated (if no evidence of progress) to allow the examiner to assess whether client is in true labor & whether membranes have ruptured encourage client to take slow, deep breaths prior to vaginal exam monitor cervical dilation & effacement monitor station & fetal presentation prepare for impending delivery as the presenting part moves into positive stations & begins to push against the pelvic floor (crowning) when suspected ROM, first assess the FHR to ensure there is no fetal distress from possible umbilical cord prolapse verify presence of amniotic fluid using nitrazine paper (turns blue, pH 6.5-7.5) ferning test: sample of fluid obtained under a microscope and will make a fern-like pattern if its amniotic fluid assess amniotic fluid for color and odor, expected findings should be clear, straw color, and free of odor; abnormal findings include the presence of meconium, abnormal color (yellow or port wine), and a foul odor perform bladder palpation on a regular basis to prevent bladder distention, which can impede fetal descent through the birth canal and cause trauma to the bladder (clients may not feel the urge to void, encourage voiding frequently) temp assessment q4h (q1-2h if membranes have ruptured) teach about what to expect during labor teach relaxation methods: breathing (deep cleansing breaths help divert focus away from contractions), effleurage (gentle circular stroking of the abdomen in rhythm w breathing during contractions), diversional activities (distraction, concentration on a focal point, imagery) encourage upright positions, application of warm/cold packs, ambulation, or hydrotherapy if not contraindicated to promote comfort encourage voiding every 2 h ACTIVE PHASE: provide client/fetal monitoring encourage frequent position changes encourage voiding q2h encourage deep cleansing breaths before & after modified paced breathing encourage relaxation provide nonpharmacological and pharmacological comfort measures TRANSITION PHASE: encourage voiding q2h continue to monitor & support client & fetus encourage a rapid pant-pant-blow breathing pattern if the client has not learned a particular breathing pattern discourage pushing efforts until full dilation listen for client statements expressing the need to have a bowel movement, this sensation is normal of fetal descent and complete dilation prepare client for birth observe for perineal bulging or crowning (appearance of fetal head at perineum) encourage the client to begin bearing down w contractions once the cervix is fully dilated LATENT PHASE: BP, HR, RR every 30-60 mins contractions every 30-60 mins FHR monitoring every 30-60 mins ACTIVE PHASE: BP, HR, RR every 30 mins contractions every 15-30 mins FHR monitoring every 15-30 mins TRANSITIONAL PHASE: BP, HR, RR every 15-30 mins contractions every 10-15 mins FHR monitoring every 15-30 mins

breastfeeding

optimal source of nutrition recommended exclusively for 6 month breastfeed every 2-3 hours during the day and at least every 4 hours at night until gaining weight & feeding adequately should occur 8-12 times in a 24-hour window feed on demand first few days baby receives colostrum which is secreted from the mother's breasts during days 1-3, contains IgA which provides passive immunity practice of rooming-in (allowing mothers & newborns to to remain together) should be encouraged

progestin-only pills (Minipill)

oral progestins that provide the same action as combined oral contraceptives take at same time everyday, cannot miss a pill, need another form of birth control during first month of use fewer ADE when compared to combined safe while breastfeeding less effective in suppressing ovulation than combined increased occurrence of ovarian cysts no STI protection ADE: breakthrough. irregular, vaginal bleeding; headache; nausea; breast tenderness effectiveness decreases when taking medications that affect liver enzymes (anticonvulsants, some antibiotics) contraindications: bariatric surgery, lupus, severe cirrhosis, liver tumors, current or past breast cancer

ectopic pregnancy

ovum implants in the fallopian tubes or abdominal cavity due to the presence of endometrial tissue as ovum increases in size, fallopian tube can rupture, and extensive bleeding occurs, resulting in surgical removal of the damaged tube if identified prior to rupture of the tube, surgical removal of the products of conception may be performed, or methotrexate is prescribed to dissolve the pregnancy client faces increased risk of recurrence or infertility

gestational age assessment

performed within 48 h involves measurements NEW BALLARD SCALE: -assesses neuromuscular & physical maturity -each range of development within an assessment is assigned a # value from -1 to 5, totals are added to give a maturity rating in wks gestation Neuromuscular Maturity: -posture ranging from fully extended to fully flexed (0 to 4) -square window formation w neonate's wrist (-1 to 4) -arm recoil, where the neonate's arm is passively extended & spontaneously returns to flexion (0 to 4) -popliteal angle, which is the degree of the angle to which the newborn's knees can extend (0 to 4) -scarf sign, which is crossing the neonate's arm over the chest (-1 to 4) -heel to ear, which is how far the neonate's heels reach to her ears (-1 to 4) Physical Maturity: -skin texture, ranging from sticky to transparent, to leathery, cracked, and wrinkled (-1 to 5) -lanugo presence and amount, ranging from none, sparse, abundant, thinning, bald, or mostly bald (-1 to 4) -plantar surface creases, ranging from less than 40 mm to creases over the entire sole (-1 to 4) -breast tissue amount, ranging from imperceptible, to full areola with a 5-10 mm bud (-1 to 4) -eyes and ears for amount of eye opening and ear cartilage present (-1 to 4) -genitalia development, ranging from flat smooth scrotum to pendulous testes w deep rugae for males (-1 to 4) and prominent clitoris w flat labia to the labia majora covering the labia minora and clitoris for females (-1 to 4) CLASSIFICATION: -appropriate for gestational age (AGA): weight is between 10th-90th percentile -small for gestational age (SGA): weight is < 10th percentile -large for gestational age (LGA): weight is > 90th percentile -low birth weight (LBW): weight of 2500 g or less -intrauterine growth restriction (IUGR): growth rate foes not meet expected norms -term: birth between the beginning of week 37 & prior to the end of 42 weeks of gestation -preterm or premature: born prior to the completion of 37 weeks of gestation -postterm (postdate): born after the completion of 42 weeks of gestation -postmature: born after the completion of 42 weeks of gestation w evidence of placental insufficiency

Leopold maneuvers

performing external palpations of the maternal uterus through the abdominal wall to determine: -# of fetuses -presenting part -fetal lie -fetal attitude -degree of descent -location of fetus's back to auscultate fetal heart tones (vertex in which fetal heart tones should be assessed below mother's umbilicus in either RLQ or LLQ; breech in which fetal heart tones should be assessed above the mother's umbilicus in either the RUQ or LUQ) empty bladder before beginning place client supine w pillow under head and heave knees slightly flexed place small, roller towel under right or left hip to displace uterus off major blood vessels identify fetal part occupying the fundus, head should feel round firm and move freely, breech should feel irregular and soft to identify fetal lie and presenting part locate and palpate the smooth contour of the fetal back using palm of one hand and irregular small parts of the hands, feet & elbows using the palm of the other hand to validate presenting part determine part that is presenting over the true pelvis inlet by gently grasping the lower segment of the uterus between the thumbs and fingers, if head is presenting and not engaged, determine whether head is flexed or extended, identifies descent face feet and outline fetal head using the palmar surface of the fingertips on both heads to palpate the cephalic prominence to identify fetal attitude auscultate the FHR post-maneuvers to assess fetal tolerance to the procedure

anticipatory teaching for pregnancy and birth

physical & emotional changes and interventions to provide relief indications of complications to report birthing options available emotional lability to be expected with unpredictable mood changes and increased irritability, tearfulness, and anger alternating with feelings of joy and cheerfulness feelings of ambivalence toward the pregnancy that may occur early and resolve before 3rd trimester (conflicting feelings)

first trimester education

physical and psychosocial changes common discomforts of pregnancy and measures to provide relief lifestyle: exercise, stress, nutrition, sexual health, dental care, OTC and prescription medications, tobacco, alcohol, substance use, and STIs (encourage safe sex practices) possible complications and indications to report (preterm labor) fetal growth and development prenatal exercise expected lab testing

breast care education if lactating

place newborn skin-to-skin ASAP & initiate breastfeeding within 1st 1-2 hrs wear a well-fitting supportive bra emphasize importance of hand hygiene prior to breastfeeding completely empty breasts at each feeding allow infant to nurse on demand (8-12x/day) massage breasts during feeding to help w empyting apply cool compresses after feedings and apply warm compresses before for breast engorgement roll nipples between fingers before breastfeeding if flat or inverted, or use breast shield sore nipples--apply a small amount of breastmilk and allow it to airway apply breast creams as prescribed promote adequate fluid intake

nursing interventions for successful breastfeeding

place newborn skin-to-skin on mom's chest immediately initiate breastfeeding ASAP or within 30 mins following birth explain techniques to mother, have her wash hands, get comfortable, & have caffeine-free nonalcoholic fluids to drink during explain the let-down reflex (stimulation of maternal nipple releases oxytocin that causes let-down of milk) reassure that uterine cramps are normal when feeding & promote uterine involution express a few drops of colostrum & spread it over the nipple to lubricate & entice the newborn show mom proper latch-on position, support breast with one hand with the thumb on top & 4 fingers underneath, with mouth in front of the nipple, tickle newborn's lower lip w the tip of the nipple, pull newborn to the nipple w mouth covering areola as well explain that with proper latch, baby's nose, cheeks, & chin will be touching her breast hunger cues include hand to mouth or hand to hand movements, sucking motions, rooting reflex demonstrate the 4 basic positions: football hold, cradle, modified cradle, & side-lying encourage feeding at least 15-20 mins per breast to ensure that her newborn receives adequate fat & protein avoid educating moms regarding the duration of feedings, evaluate when the feeding is done, including slowing of newborn suckling, a softened breast, or sleeping both breasts should be offered explain that newborns will nurse on demand once a pattern is established show mother how to break suction prior to removing the newborn show mom how to burp when she alternates breasts, should be burped over the shoulder or in an upright position w his chin supported, mom should gently pat newborn tell mom to begin next feeding with the beast she stopped feeding him with in the previous tell mom how to tell if baby is receiving an adequate feeding (gaining weight, voiding 6-8 diapers per day, contentedness between feedings) explain to the mom that newborn can have loose, pale, or yellow stools & its normal tell mom to avoid nipple confusion by not offering supplemental formula, pacifiers, or soothers until 2-3 weeks supplementation can be provided via syringe if necessary tell mom to place baby on back after feedings promote rooming-in offer referral to support groups contact a lactation consultant herbal products can increase breast milk production

retained placenta

placenta or fragments remain in the uterus & prevent contractions can lead to uterine atony or subinvolution risk factors: -partial separation of normal placenta -entrapment of a partially or completely separated placenta by a constricting ring of uterus -excessive traction on umbilical cord prior to complete separation -placental tissue that is abnormally adherent to the uterine wall -preterm births between 20-24 wks uterine atony, subinvolution, inversion excessive bleeding or blood clots > a quarter return of lochia rubra once progressed to serosa or alba malodorous lochia or vaginal d/c elevated temp Hgb & Hct manual separation & removal of placenta by provider D&C if oxytocics are ineffective monitor fundal height, consistency, position monitor lochia monitor vitals maintain IV fluids provide O2 at 2-3 L/min per nasal cannula MEDICATIONS: oxytocin: -expel retained fragments -uterine stimulant -promotes uterine contractions -assess uterine tone & bleeding -monitor for ADE to water intoxication terbutaline: -tococlytic -relaxes uterus prior to D&C limit physical activity increase iron & protein intake

lochia postpartum

post-birth uterine discharge containing blood, mucus, and uterine tissue lochia rubra: bright red color, bloody consistency, fleshy odor, can contain small clots, transient flow increases during breastfeeding & upon rising; lasts 1-3 d after delivery lochia serosa: pinkish brownish color & serosanguineous consistency; lasts days 4-10 lochia alba: yellowish white creamy color, fleshy odor, lasts day 11 up to 4-8 wks assessed by the quantity of saturation on the perineal pad: -scant: <2.5 cm -light: 2.5-10 cm -moderate: 10+ cm -heavy: 1 pad in 2 hrs -excessive blood loss: one pad saturated within 15 mins, pooling of blood under buttocks assess for normal color, amount, consistency typically trickles from the vaginal opening but flows more steadily during uterine contractions massage uterus or ambulation can result in gush of lochia w clots and dark blood but should decrease back to a trickle of bright red lochia abnormal lochia: -excessive spurting of bright red blood from vagina, possibly indicating tear -numerous large clots & excessive blood loss which can indicate hemmorrhage -foul odor, which is suggestive of infection -persistent lochia rubra beyond day 3 (retained placental fragments) -continued flow of lochia serosa or alba beyond normal length of time (endometritis)

thermoregulation postpartum

postpartum chill can occur in 1st 2 hr, possibly related to a nervous system response, vasomotor changes, shift in fluids, and/or work of labor provide warm blankets & fluids assure client that these are self-limiting chills & a common occurrence

fetal distress

present when the FHR is <110 or >160, is shows decreased or no variability, &/or when there is fetal hyperactivity or no fetal activity nonreassuring FHR patterns w decreased or no variability monitor uterine contractions, FHR, findings of ultrasound & any other prescribed diagnostics risk factors: fetal anomalies, uterine anomalies, complications of labor & birth monitor vitals position client in left side-lying reclining position w legs elevated admin 8-10 L/min O2 w face mask discontinue oxytocin if being administerede increase IV fluid to treat hypotension if indicated prepare for emergency cesarean birth if necessary

newborn umbilical cord care

prevent/decrease risk for infection & hemorrhage cord clamp stays in place for 24-48 h includes cleaning the cord w water (using cleanser sparingly if needed to remove debris) during the initial bath assess stump & base of cord for erythema, edema & drainage w each diaper change newborn's diaper should be folded down and away from the umbilical stump bathing infant by submerging in water should not occur until the cord has fallen off most cords fall off within 10-14 d

assessment of family readiness for home care of the newborn

previous newborn experience & knowledge parent-newborn attachment adjustment to the parental role social support educational needs sibling rivalry issues readiness of the parents to have their home & lifestyle altered to accommodate their newborn parents' ability to verbalize & demonstrate newborn care following teaching

newborn family education

provide family education while performing all nursing care encourage family involvement, allowing mom and family to perform newborn care w direct supervision & support by the nurse encourage moms & family to hold newborn so they can experience eye-to-eye contact foster sibling interaction in newborn care

newborn thermoregulation

provides a neutral thermal environment that helps a newborn maintain a normal core temp w minimal O2 consumption and caloric expenditure has a relatively large surface-to-weight ratio, reduced metabolism per unit area, blood vessels close to the surface & small amounts of insulation newborn keeps warm by metabolizing brown fat, which is unique to newborns, but only within a very narrow temp range becoming chilled (cold stress) can increase the newborn's O2 demands & rapidly use up brown fat reserves monitor for hypothermia in the newborn (axillary temp < 36.5 C (97.7-98.6 F) heat loss occurs by: 1. CONDUCTION: loss of body heat resulting from direct contact w a cooler surface; preheat a radiant warmer, warm a stethoscope & other instruments, & pad a scale before weighing the newborn, newborn should be placed directly on the mother's chest & covered w a warm blanket 2. CONVECTION: flow of heat from the body surface to cooler environmental air, place bassinet out of the direct line of a fan or air conditioning vent, swaddle newborn in blanket, & keep head covered, any procedure done w the newborn uncovered should be performed under a radiant heat source, keep ambient temp of the nursery or mom's room 22-26 C (72-78 F) 3. EVAPORATION: loss of heat as surface liquid is converted to vapor, gently rub the newborn dry w a warm sterile blanket immediately after delivery, if thermoregulation is unstable postpone the initial bath until the newborn's skin temp is 36.5 C or 97.7 F), when bathing expose only 1 body part at a time washing & drying thoroughly 4. RADIATION: loss of heat from body surface to a cooler solid surface that is close to, but not in direct contact, keep the newborn & examining tables away from windows & air conditioners temp stabilizes at 37 C (98.6 F) within 4 h after birth if chilling prevented

advantages to breastfeeding

reduces the risk of infection by providing IgA antibodies, lysozomes, leukocytes, macrophages, & lactoferrin promotes rapid brain growth due to large amounts of lacose provides protein & nitrogen for neurological cell building & improves the newborn's ability to regulate calcium & phosphorus levels contains electrolytes & minerals easy to digest convenient & inexpensive reduces incidence of SIDS, allergies, childhood obesity promotes maternal-infant bonding & attachment newborn decreased risk of GI infections, celiac disease, asthma, lower respiratory tract infections, otitis media, SIDS, obesity in adolescence & adulthood, DM type 1 or 2, HTN, acute lymphocytic & myeloid leukemia mother decreased postpartum bleeding & more rapid uterine involution, decreased risk for ovarian & breast cancer, DM type 2, HTN, hypercholesterolemia, CVD, RA convenient, less expensive, reduces annual health care costs, reduces environmental burden related to disposal of formula packaging & equipment

postpartum exercises education

regain pelvic floor muscle control by performing Kegel exercises same muscles are used when starting & stopping the flow of urine have the client relax & contract the pelvic floor muscles 10 times 8x/day teach how to perform pelvic tilt exercises to strengthen back muscles and relieve strain on the lower back these exercises involve alternately arching and straightening the back

sleep-wake cycle interventions

reinforce that placing the newborn in the supine position for sleeping greatly decreases the risk of SIDS newborns sleep ~ 16-19 hours/day many parents believe that adding solid food will help w sleep patterns most newborns will sleep through the night without feeding by 4-5 months keep environment quiet & dark at night place the newborn in a crib or bassinet to sleep, the newborn should never sleep in the parent's bed most newborns get their days & nights mixed up, provide basic suggestions for helping the parents develop a predictable routine, bring newborn into center of action in the afternoon & keep him there for the rest of the evening bathe newborn right before bedtime give last feeding around 2300 & then place him into a crib & bassinet when awake, the newborn can be placed on abdomen to promote muscle development for nighttime feedings & diaper changes, keep a small night-light on to avoid having to turn on bright lights speak softly, & handle the newborn gently so that he goes back to sleep easily

client history

reproductive and obstetrical history: contraception use, gynecological diagnoses, obstetrical difficulties medical history: physical preexisting conditions, surgical procedures, any handicapping conditions, immune status (rubella, hepatitis B) nutritional history: complete dietary assessment (deficient practices, food allergies) family history: genetic disorders or conditions recurrent illnesses or infections current medications: substance use and alcohol consumption psychosocial history: a client's emotional response to pregnancy, adolescent pregnancy, spouse, support system, hx of depression, domestic violence any hazardous environmental exposures, current work conditions abuse history or risk: all forms of abuse (physical, sexual, or psychological abuse)

implantable progestin

requires a minor surgical procedure to subdermally implant and remove a single rod containing etonogestrel on the inner side of the upper aspect of the arm avoid trauma to area of implantation effective for 3 years can be inserted immediately after abortion, miscarriage, childbirth, and while breastfeeding reversible can be used by mothers who are breastfeeding after 4 weeks postpartum can cause irregular menstrual bleeding no STI protection ADE: irregular and unpredictable menstruation, mood changes, headache, acne, depression, decreased bone density, weight gain increased risk of ectopic pregnancy contraindications include unexplained vaginal bleeding, lupus, severe cirrhosis, liver tumors, breast cancer

uterine atony

results from the inability of the uterine muscle to contract adequately after birth can lead to postpartum hemorrhage risk factors: -retained placental fragments -prolonged labor -oxytocin induction or augmentation of labor -overdistention of the uterine muscle (multiparity, multiple gestations, polyhydramnios, macrosomic fetus) -precipitous labor -magnesium sulfate admin as a tocolytic -anesthesia & analgesia admin -trauma during labor & birth from operative delivery increased vaginal bleeding uterus that is larger than normal & boggy w possible lateral displacement prolonged lochial d/c irregular/excessive bleeding tachycardia, hypotension skin that is pale, cool, clammy w loss or turgor & pale mucous membranes bimanual compression or manual exploration of the uterine cavity for retained placental fragments; hysterectomy ensure bladder is empty monitor fundal height, consistency, location; lochia for quantity, color, consistency perform fundal massage express clots once uterus is firm, if not firm this can cause it to invert monitor vitals maintain IV fluids provide O2 at 2-3 L/min per nasal cannula medications: oxytocin, methylergonovine, misoprostol, carboprost tromethamine limit physical activity increase iron & protein intake

HIV/AIDS

retrovirus that attacks and causes destruction of T lymphocytes causes immunosuppression in a client testing is recommended in 3rd tri for clients at an increased risk avoid amniocentesis and episiotomy avoid use of internal fetal monitors, vacuum extraction, forceps no administration of injections/blood testing before infant's first bath risk factors: IV drug use, multiple partners, maternal history of multiple STIs, blood transfusion, men who have sex with men fatigue and influenza-like findings (fever, diarrhea, weight loss, lymphadenopathy and rash, anemia) antibody screening test to confirm positive results, rapid antibody test if in labor, screen for STIs, frequent viral loads and CD4 cell counts mental health consultation, legal assistance, financial resources use standard precautions administer antiviral prophylaxis, triple-medication antiviral, or highly active antiretroviral therapy encourage immunization against hep B, pneumococcal, haemophilus influenzae type B, viral influenza encourage use of condoms review plan for C section at 38 weeks if maternal viral load of 1,000 copies/mL infant should be bathed after birth before anything else retrovir: antiretroviral agent, administer at 14 weeks, throughout pregnancy, and before onset of labor or C section; administer to infant at delivery and for 6 weeks following birth do not breastfeed

immune system postpartum

review status of: rubella: titer < 1:8 receives a SQ of MMR & don't get pregnant for 1 mo after hepatitis B: newborns born to infected mom receive vaccine & immunoglobulin within 12 h Rh: Rh- moms w Rh+ baby receive Rho(D) IM within 72 h, test after 3 mos varicella: administered before d/c if no immunity, don't get pregnant for 1 mo, second dose given at 4-8 wks tetanus-diphtheria-acellular pertussis: not recommended for women who have not previously received it

continuous internal fetal monitoring

scalp electrode performed by attaching a small spiral electrode to the presenting part of the fetus to monitor the FHR electrode wires are then attached to a leg plate that is placed on the client's thigh and then attached to the fetal monitor can be used in conjunction w an intrauterine pressure catheter (IUPC) which is a solid or fluid-filled transducer placed inside the client's uterine cavity to monitor the frequency, duration, and intensity of contractions average pressure is usually 50-85 mmHg advantages: -early detection of abnormal FHR patterns suggestive of fetal distress -accurate assessment of FHR variability -accurate measurement of uterine contraction intensity -allows greater maternal freedom of movement bc tracing is not affected by fetal activity, maternal position changes, or obesity disadvantages: -membranes must have ruptured -cervix must be adequately dilated to a minimum of 2-3 cm -presenting part must have descended -potential risk of injury to fetus if not applied properly -must be specially trained to perform the procedure -potential risk of infection to the client and the fetus ensure that equipment is functioning properly use aseptic techniques monitor maternal vitals (temp every 1-2 h) encourage frequent repositioning of client, if supine use a wedge under one hip complications: -misinterpretation of FHR patterns -maternal or fetal infection -fetal trauma if fetal monitoring electrode or IUPC are inserted into the vagina improperly -supine hypotension secondary to internal monitor placement

breasts postpartum

secretion of colostrum (during pregnancy to 2-3 days postpartum) milk produced 3-5 days postpartum engorgement of breast tissue as a result of lymphatic circulation, milk production, temporary vein congestion redness & tenderness cracked nipples & indications of mastitis (infection in milk duct w flu-like manifestations) newborn latch ineffective newborn feeding patterns related to maternal dehydration, maternal discomfort, newborn positioning, difficulty latching encourage early breastgeeding try various positions (cradle, modified cradle, football hold, side-lying) newborn needs to take in areola and nipple, not just tip of nipple

continuous electronic fetal monitoring

securing an ultrasound transducer over the client's abdomen, which records the FHR pattern, & a tocotransducer on the fundus that records the uterine contractions advantages: -noninvasive & reduces risk for infection -membranes do not have to be ruptured -cervix does not have to be dilated -placement of transducers can be performed by the nurse -provides permanent record of FHR and uterine contraction tracing disadvantages: -contraction intensity is not measurable -movement of the client requires frequent repositioning of transducers -quality of recording is affected by client obesity & fetal position indications: -multiple gestations -oxytocin infusion -placenta previa -fetal bradycardia -maternal complications (GDM, gestational HTN, kidney disease) -intrauterine growth restriction -post-date gestation -active labor -meconium-stained amniotic fluid -abruptio placentae (suspected or actual) -abnormal NST or contraction stress test -abnormal uterine contractions -fetal distress palpate fundus to identify uterine activity for proper placement of tocotransducer to monitor uterine contractions encourage frequent maternal position changes, which can require adjustments of the transducers w position changes disconnect for mother to use the bathroom unless contraindicated (bedpan) normal FHR = 110-160 bpm should be moderate variability (absent or undetectable; minimal = <5/min; moderate = 6-25/min; marked = > 25/min) changes are episodic or periodic (episodic are not associated w uterine contractions, periodic occur w uterine contractions)

male diagnostic procedures for infertility

semen analysis: (in 40% of couples who are infertile, it is due to the male), less expensive and less invasive compared with female test ultrasonography: an ultrasound procedure is performed to visualize testes and abnormalities in the scrotum, a transrectal ultrasound procedure is performed to assess the ejaculatory ducts, seminal vesicles, and vas deferens

verifying pregnancy

serum and urine tests provide an accurate assessment for the presence of human chorionic gonadotropin (hCG) hCG production can start as early as the day of implantation and can be detected as early as 7-8 days after conception production of hCG begins with implantation, peaks at 60-70 days of gestation, declines until around 100-130 days and then gradually increases until term higher levels of hCG can indicate multifetal pregnancy, ectopic pregnancy, hydatidiform mole (gestational trophoblastic disease), or a genetic abnormality (Down syndrome) lower blood levels of hCG might suggest might suggest a miscarriage or ectopic pregnancy some medications (anticonvulsants, diuretics, tranquilizers) can cause false-positive or false-negative pregnancy results home pregnancy test: urine samples should be first-voided morning specimens and follow the directions for accuracy

sibling adaptation

siblings can experience a temporary separation from parents become aware of changes in the parents behavior assess for positive responses from the siblings (concern for the infant, increased independence) assess for adverse responses (signs of siblings rivalry and jealousy, regression in toileting and sleep habits, aggression toward the infant, increased attention-seeking behaviors and whining) take sibling on tour of the unit let sibling be one of the first to see the ingant provide gift from the infant to give the sibling arrange for 1 parent to spend time w sibling while other cares for infant allow older siblings to help provide care provide pre-school aged siblings w a doll to practice

cervical cap and spermicide

silicone rubber cap that fits snuggly around the base of the cervix three sizes can be inserted up to 6 hr before intercourse and needs to be left in place at least 6 hr after, no more than 48 hr at a time replaced every 2 years and refitted after and gynecological surgery, birth, or any major weight fluctuation should be washed with mild soap and warm water after each use possible risk of acquiring TSS risk of allergic rxn no STI protection not for women who have abnormal Pap test results or those who have history of TSS

wound infections

sites include cesarean incisions, episiotomies, lacerations, any trauma wounds present in the birth canal EXPECTED FINDINGS: -wound warmth, erythema, tenderness, pain, edema, seropurulent drainage, wound dehiscence or evisceration -temp > 100.4 (38 C) for 2+ consecutive days perform wound care admin IV antibiotics provide/encourage comfort measures (sitz baths, perineal care, warm/cold compresses) teach hand hygiene

newborn skin assessment

skin color should be pink or acrocyanotic w no jaundice present on the 1st day secondary to increased bilirubin, jaundice, can appear on the 3rd day of life, but then decrease spontaneously skin turgor should be present, showing that the newborn is well hydrated, skin should spring back immediately when pinched texture should be dry, soft, & smooth, showing good hydration cracks in hands & feet should be present in full term newborns, desquamation (peeling) occurs a few days after birth vernix caseosa (protective, thick, cheesy covering) amounts vary, w more present in creases & skin folds lanugo (fine downy hair) varies regarding the amount present, usually found on the pinnae of ears, forehead, and shoulders milia: small raised white spots on the nose, chin, and forehead can be present; disappear spontaneously w/o treatment, parents should not squeeze the spots mongolian spots: bluish purple spots of pigmentation, commonly noted on the shoulders, back & buttocks; frequently present on newborns who have dark skin; be sure the parents are aware of them and document location and presence telangiectatic nevi: stork bites, flat pink or red marks that easily blanch and are found on the back of the neck, nose, upper eyelids, and middle of forehead; usually fade by 2nd year of life nevus flammeus: port wine stain, a capillary angioma below the surface of the skin that is purple or red, varies in size & shape, is commonly seen on the face and does not blanch or disappear erythema toxicum: erythema neonatorum, pink rash that appears suddenly anywhere on the body of a term newborn during the 1st 3 weeks, frequently referred to as newborn rash, no treatment required

complications for newborn nutrition

sleepy newborns: -unwrap the newborn -change the newborn's diaper -hold newborn upright & turn from side to side -talk to the newborn -massage the newborn's back & rub his hands & feet -apply a cool cloth to newborn's face fussy newborns: -swaddle newborn -hold the newborn close, move, & rock gently -reduce newborn's environmental stimuli -place the newborn skin-to-skin

failure to thrive

slow weight gain below the 5th percentile on the growth chart evaluate positioning & latch-on during breastfeeding massage the breast during feeding determine feeding patterns & length of feedings if spitting up, newborn can have an allergy to dairy products, determine maternal intake of dairy products, mother can need to eliminate dairy from her diet, instruct her to consume other food sources high in calcium or calcium supplements

late deceleration of FHR

slowing of FHR after contraction has started w return of FHR to baseline well after contraction has ended causes/complications: -uteroplacental insufficiency causing inadequate fetal oxygenation -maternal hypotension, placenta previa, abruptio placentae, uterine hyperstimulation w oxytocin -preeclampsia -late or post-term pregnancy -maternal DM nursing interventions: -place client in side-lying position -insert an IV catheter if not in place, and increase rate of IV fluid administration -discontinue oxytocin if being infused -administer oxygen by mask at 8-10 L/min via nonrebreather face mask -elevate the clients legs -notify the provider -prepare for an assisted vaginal birth or cesarean birth

quieting technique interventions

swaddling close skin contact nonnutritive sucking with pacifier rhythmic noises to stimulate utero sounds movement (a car ride, vibrating chair, infant swing, rocking newborn) placing the newborn on his stomach across a holder's lap while gently bouncing legs en face position for eye contact (when parents & newborns faces are about 30 cm/12 in apart & on the same plane) stimulation

nutrition education

teach importance of eating a nutritious diet including all food groups encourage diet high in protein, which will aid in tissue repair consume 2-3 L encourage nonlactating clients to consume 1800-2200 calories instruct lactating client to increase caloric intake and include calcium-enriched foods: one source says increase 330 calories/day for first 6 mos of lactation, another says add 450-500 calories/day

basal body temperature

temp can drop slightly at time of ovulation measure oral temp prior to getting out of bed each morning to monitor ovulation inexpensive convenient no adverse effects reliability can be influenced by many variables (stress, fatigue, illness, alcohol, warmth of environment) no STI protection risk of pregnancy

ectopic pregnancy

the abnormal implantation of a fertilized ovum outside of the uterine cavity usually in the fallopian tube, which can result in a tubal rupture or fatal hemorrhage 2nd most frequent cause of bleeding in early pregnancy and a leading cause of infertility risk factors: any factor that compromises tubal patency (STIs, assisted reproductive technologies, tubal surgery, IUD) unilateral stabbing pain and tenderness in lower-abdominal quadrant delayed (1-2 weeks), lighter than usual, or irregular menses scant, dark red, or brown vaginal spotting 6-8 weeks after last normal menses red, vaginal bleeding if rupture has occurred referred shoulder pain due to blood in the peritoneal cavity irritating the diaphragm or phrenic nerve after tubal rupture report of indications of shock such as faintness & dizziness related to amount of bleeding in abdominal cavity clinical findings of hemorrhage and shock (hypotension, tachycardia, pallor) lab tests: serum levels of progesterone and hCG elevated rules out ectopic pregnancy transvaginal ultrasound shows an empty uterus use caution if vaginal and bimanual exam are used medical management if rupture has not occurred and tube preservation desired methotrexate inhibits cell division & embryo enlargement, dissolving the pregnancy (avoid alcohol and folic acid) salpingostomy is done to salvage the fallopian tube if not ruptures laparoscopic salpingectomy (removal of tube) is performed when ruptured replace fluids, maintain electrolyte balance obtain serum hCG and progesterone levels, liver and renal function studies, CBC, type and Rh

amniotomy

the artificial rupture of the amniotic membranes (AROM) by the provider using an Amnihook or other sharp instrument labor typically begins within 12 h after the membranes rupture & can decrease the duration of labor by up to 2 h the client is at an increased risk for cord prolapse or infection indicated when labor progression is too slow & augmentation or induction is indicated or when an amnioinfusion is indicated for cord compression ensure that the presenting part of the fetus is engaged prior to procedure to prevent cord prolapse monitor FHR prior to and immediately following AROM to assess for cord prolapse as evidenced by variable or late decelerations assess and document characteristics of amniotic fluid including color, odor, consistency document time of rupture obtain temperature q2h provide comfort measures (frequently change pads, perineal cleansing)

amniocentesis

the aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client's uterus and amniotic sac under direct ultrasound guidance locating the placenta and determining the position of the fetus may be performed after 14 weeks potential diagnoses: previous birth w chromosomal anomaly, carrier of chromosomal anomaly, family hx of neural tube defects, prenatal diagnosis of a genetic disorder or congenital anomaly of the fetus, alpha-fetoprotein level for fetal abnormalities, lung maturity assessment, fetal hemolytic disease, meconium in amniotic fluid empty bladder prior to procedure she will feel slight pressure as needle is inserted, continue breahting monitor for 30 mins after procedure, rest administer Rho(D) if she is Rh- report fever, chills, leakage of fluid, bleeding from insertion site, decreased fetal movement, vaginal bleeding, or uterine contractions drink plenty of liquids and rest for 24 hr AFP can be measures between 15-20 weeks (16-18 ideal) high levels of AFP: neural tube defects such as anencephaly (incomplete development of fetal skull and brain), spina bifida (open spine), omphalocele (abdominal wall defect), multifetal pregnancies low levels of AFP: associated with chromosomal disorders (Down syndrome), gestational trophoblastic disease (hydatidiform mole) if less than 37 weeks, fetal lung maturity can be assessed lecithin/sphingomyelin ratio: 2:1 indicates fetal lung maturity presence of phosphatidyglycerol: absence of PG is associated with respiratory distress complications: amniotic fluid emboli, hemorrhage, fetomaternal hemorrhage with Rh isoimmunization, infection, inadvertent fetal damage or anomalies involving limbs, fetal death, inadvertent maternal intestinal or bladder damage, miscarriage or preterm labor, PROM, leakage of amniotic fluid monitor vitals,FHR, contractions, vaginal discharge

induction of labor

the deliberate initiation of uterine contractions to stimulate labor before spontaneous onset to bring about the birth by chemical or mechanical means methods: -mechanical or chemical approaches -administration of IV oxytocin -nipple stimulation to trigger the release of endogenous oxytocin indications: 39+ wks, Bishop score of 8+ for multiparous and 10 for nulliparous, if it doesn't meet the criteria it can result in risk for infection, premature delivery, longer labor, & need for cesarean birth client presentation: -postterm pregnancy (42+ wk) -dystocia (prolonged, difficult labor) due to inadequate uterine contractions -prolonged rupture of membranes predisposes client & fetus to risk of infection -maternal medical conditions (Rh-isoimmunization, DM, pulmonary disease, gestational HTN) -fetal disease -chorioamnionitis prepare for cervical ripening: -obtain informed consent -obtain baseline data on fetal & maternal well-being -initiate oxytocin 6-12 h after admin of prostaglandin -monitor FHR & uterine activity -notify provider if hyperstimulation or fetal distress prepare for amniotomy or amniotic membrane stripping prepare for oxytocin -confirm that the fetus is engaged in the birth canal w a minimal station of 0 -use infusion port closest to client, piggyback to main IV line -IUPC may be used to monitor frequency, duration & intensity of contractions -maternal BP, HR & RR q 30-60 mins and w every change in dose -monitor FHR & contraction pattern q15 min & w every change in dose -assess I&O -Bishop score should be obtained prior to labor induction increase oxytocin as prescribed until desired contraction pattern is obtained & then maintain the dose if there is contraction frequency of 2-3 mins, duration of 60-90 s, intensity of 40-90 mmHg on IUPC, uterine resting tone of 10-15 mmHg on IUPC, cervical dilation of 1 cm/hr, reassuring FHR between 110-160 bpm discontinue if uterine hyperstimulation occurs: contraction frequency more than every 2 mins, duration longer than 90 s, intensity > 90 mmHg on IUPC, uterine resting tone > 20 mmHg between contractions, no relaxation of uterus between contractions complications: nonreassuring FHR (abnormal baseline < 110 or > 160 bpm, loss of variability, late or prolonged decelerations), notify provider, position into side-lying, keep IV line open and increase the rate of IV fluid admin to 200 mL/h unless contraindicated, administer O2 by a face mask at 8-10 L/min, admin tocolytic terbutaline 0.25 mg subcutaneously, monitor FHR & patterns w uterine activity, document responses to interventions, if unable to restore reassuring FHR prepare for cesarean birth

cesarean birth

the delivery of the fetus through a transabdominal incision of the uterus to preserve the life or health of the client & fetus when there is evidence of complications incisions are made horizontally into the lower segment of the uterus indications: -malpresentation, particularly breech -cephalopelvic disproportion -nonreassuring fetal heart tones -placental abnormalities -placenta previa -abruptio placentae -high-risk pregnancy (HIV+, hypertensive disorders, DM, active genital herpes lesions) -previous cesarean birth -dystocia -multiple gestations -umbilical cord prolapse assess FHR and vital signs assist w obtaining an ultrasound to determine whether a cesarean birth is indicated position client into supine position w a wedge under one hip insert indwelling urinary catheter obtain informed consent apply sequential compression device admin preop medications prepare surgical site insert IV and admin fluids determine whether client has been NPO since midnight ensure preop diagnostic tests are complete (Rh included) assist in positioning client on table continue to monitor FHR, vitals, IV fluids, urinary output instrument & sponge counts monitor for evidence of infection & excessive bleeding at incision site assess fundus for firmness & tenderness assess lochia assess for productive cough or chills (pneumonia) assess for indications of thrombophlebitis (tenderness, pain, heat on palpation) tender uterus & foul smelling lochia can be endometritis monitor I&O, vitals provide pain relief & antiemetics encourage client to turn, cough, and deep breathe to prevent pulmonary complications encourage splinting of incision w pillows encourage ambulation assess for burning & pain or urination (UTI) complications: -aspiration -amniotic fluid pulmonary embolism -wound infection -wound dehiscence -severe abdominal pain -thrombophlebitis -hemorrhage -UTI -injuries to bladder or bowel -anesthesia associated complications -premature birth of fetus if gestational age is incorrect -fetal injuries during surgery

abruptio placentae

the premature separation of the placenta from the uterus, can be partial or complete occurs after 20 weeks risk factors: maternal HTN, blunt external abdominal trauma, cocaine use resulting in vasoconstriction, previous incidents of abruptio placentae, cigarette smoking, PROM, multifetal pregnancy sudden onset of intense localized uterine pain with dark red vaginal bleeding area of uterine tenderness can be localized or diffuse over uterus and boardlike contractions w hypertonicity fetal distress clinical findings of hypovolemic shock lab tests: Hct & Hgb decreased, coagulation factors decreased, clotting defects, cross and type match for possible blood transfusions, Kleihauer-Betke test ultrasound for fetal well-being and placental assessment BPP to ascertain fetal well-being palpate uterus for tenderness and tone assess FHR pattern immediate birth is the management administer IV fluids, blood products, and medications administer oxygen 8-10 L/min via face mask monitor maternal vitals continuous fetal monitoring assess urinary output and monitor fluid balance

descent

the progress of the presenting part (preferably the occiput) through the pelvis measured by station during a vaginal exam as - or + in cm

gestational trophoblastic disease

the proliferation & degeneration of trophoblastic villi in the placenta that becomes swollen, fluid-filled, and takes on the appearance of grape-like clusters embryo fails to develop beyond a primitive state & these structures are associated with choriocarcinoma complete mole: all genetic material is paternally derived, ovum has no genetic material or its inactive, no fetus, placenta, amniotic membranes, or fluid, no placenta to receive maternal blood, hemorrhage into the uterine cavity occurs, ~20% of complete moles progress to choriocarcinoma partial mole: genetic material is maternal and paternal, normal ovum is fertilized by 2 sperm or 1 sperm in which meiosis or chromosome reduction and division did not occur, often contains abnormal embryonic or fetal parts, an amniotic sac, fetal blood but congenital anomalies are present, ~6% of partial moles progress to choriocarcinoma risk factors: prior molar pregnancy, clients in early teens or over age 40 excessive vomiting due to elevated hCG levels rapid uterine growth more than expected for the duration of the pregnancy due to the overproliferation of trophoblastic cells bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse & continues for a few days or intermittently for a few weeks anemia from blood loss clinical findings of preeclampsia that occur prior to 24 weeks serum level of hCG persistently high compared with expected decline after weeks 10-12 ultrasound reveals a dense growth with characteristic vesicles, but no fetus in utero suction curettage is done to aspirate and evacuate mole given Rho(D) if Rh- baseline pelvic exam and ultrasound after procedure serum hCG analysis following molar pregnancy to be done weekly for 3 weeks, then monthly for 6 mos up to a year to detect GTD measure fundal height assess vaginal bleeding & discharge assess GI status and appetite monitor for preeclampsia administer Rho(D) and/or chemotherapeutic meds advise client to save clots or tissue for evaluation instruct use of reliable contraception

augmentation of labor

the stimulation of hypotonic contractions once labor has spontaneously begun, but progress is inadequate some providers favor active management of labor to establish effective labor w the aggressive use of oxytocin or ROM administration procedures, nursing assessments, & possible complications are the same for labor induction

inversion of the uterus

the turning inside out of the uterus can be partial or complete emergency situation can result in hemorrhage risk factors: -retained placenta -uterine atony -vigorous fundal pressure -adbnormally adherent placental tissue -fundal implantation of the placenta -excessive traction applied to umbilical cord -short umbilical cord -prolonged labor pain in lower abdomen vaginal bleeding: complete inversion is large, red, rounded mass that protrudes 20-30 cm outside, partial is the palpation of a smooth mass through the dilated cervix dizziness, low BP, increased pulse, pallor manual replacement of the uterus into the uterine cavity & repositioning of the uterus by provider assess by visualizing introitus, performing pelvic exam maintain IV fluids, admin O2 stop oxytocin avoid excessive traction on umbilical cord anticipate surgery if nonsurgical interventions are unsuccessful terbutaline: -tocolytic -relaxes the uterus prior to provider's attempt at replacement of uterus into cavity and repositioning -closely observe client's response to treatment, assess for stabilization of hemodynamic status -avoid aggressive fundal massage -admin oxytocics -admin antibiotics for infection prophylaxis -inform client that a cesarean birth is necessary for subsequent pregnancies

male condom

thin rubber sheath a man wears on his penis during intercourse as a contraceptive or as protection against infection can be made of latex, rubber, polyurethane, or natural membrane place on the erect penis, leaving an empty space at the tip following ejaculation, withdraw while holding the rim of the condom to prevent any semen spillage can be used in conjunction with spermicidal gel or cream to increase effectiveness protects against STIs and involves the male in birth control no adverse effects readily accessible high rate of noncompliance can reduce spontaneity the penis must be erect to apply a condom withdrawing the penis while still erect can interfere with intercourse can rupture or leak, potentially resulting in pregnancy one-time usage, replacement cost latex-sensitive or allergies only water-soluble lubricants should be used with latex to avoid breakage

TORCH infection

toxoplasmosis, other (hepatitis), rubella virus, cytomegalovirus, herpes simplex can cross the placenta and have teratogenic effects on the fetus toxoplasmosis: caused by consumption of raw/undercooked meat or handling cat feces, manifestations are similar to influenza of lymphadenopathy (malaise, muscle aches, flu-like symptoms) other infections can include hepatitis A, B, syphilis, mumps, parvovirus B19, varicella-zoster rubella: contracted through children who have rashes or neonates who are born to women who had it during pregnancy, joint & muscle pains cytomegalovirus: transmitted by droplet infection from person to person, found in semen, vaginal and cervical secretions, breast milk, placental tissue, urine, feces, blood, asymptomatic or mononucleosis-like manifestations herpes simplex virus: spread by direct contact with oral or genital lesions, painful blisters and tender lymph nodes administer antibiotics as prescribed toxoplasmosis treatment includes sulfonamides or a combo of pyrimethamine and sulfadiazine

variable deceleration of FHR

transitory, abrupt slowing of FHR less than 110 bpm, variable in duration, intensity, & timing in relation to uterine contraction causes/complications: -umbilical cord compression -short cord -prolapsed cord -nuchal cord (around fetal neck) nursing interventions: -reposition client from side to side or into knee-chest -discontinue oxytocin if being infused -administer oxygen by mask at 8-10 L/min via nonrebreather face mask -perform or assist with a vaginal exam -assist with an amnioinfusion if prescribed

urinary system & bladder function postpartum

urinary retention secondary to loss of bladder elasticity and tone or loss of bladder sensation resulting from trauma, medications, anesthesia distended bladder as a result of urinary retention can cause uterine atony and displacement & ability to contract is lessened postpartal diuresis w increased urinary output occurs within 12 h of delivery assess ability to void q2-3h assess bladder elimination pattern, excessive urine is normal in first 2-3 d assess for evidence of distended bladder (fundal height above umbilicus or baseline, displaced from midline; bladder bulges over symphysis pubis; excessive lochia; bladder tenderness) frequent voiding of <150 mL is indicative of urinary retention w overflow measure 1st few voids to assess bladder emptying increase oral fluid intake catheterize if necessary

newborn identification

use 2 identifiers important safety measures to prevent newborn from being given to the wrong parents, switched, or abducted newborn, mom, and dad (or partner) are identified by plastic ID wristbands w permanent locks that must be cut to be removed ID should include newborn's name, sex, date, time of birth, and mother's health record number newborn should have 1 band placed on ankle & 1 on wrist newborn's footprints & moms thumb prints are taken ID band should be verified against mom's ID band every time newborn is given to parents all facility staff who assist in caring for the newborn are required to wear photo ID badges newborn is not to be given to anyone w/o a photo ID badge that distinguishes them as staff many facilities have locked units that require staff to permit entrance or exits

maternal serum alpha-fetoprotein (MSAFP)

used to detect neural tube defects clients who have abnormal findings should be referred for a quad marker screening, genetic counseling, ultrasound, and amniocentesis potential diagnoses: all pregnant clients, between 16-18 weeks draw blood sample high levels can indicate a neural tube defect or open abdominal defect low levels can indicate Down syndrome

biophysical profile

uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli combines FHR monitoring (nonstress test) and fetal ultrasound potential diagnoses: nonreactive stress test, suspected oligohydramnios or polyhydramnios, suspected fetal hypoxemia or hypoxia client presentation: premature rupture of membranes, maternal infection, decreased fetal movement, intrauterine growth restriction measures FHR, fetal breathing movements, gross body movements, fetal tone, qualitative amniotic fluid volume FHR: reactive (2) vs. nonreactive (0) fetal breathing movements: at least 1 episode of greater than 30 s in 30 min (2), absent or less than 30 s duration (0) gross body movements: at least 3 body or limb extensions with return in 30 min (2), less than 3 episodes (0) fetal tone: at least 1 episode of extension with return to flexion (2), low extension and flexion, lack of flexion or absent movement (0) qualitative amniotic fluid volume: at least 1 pocket of fluid that measures at least 2 cm in 2 perpendicular planes (2), pockets absent or less than 2 cm (0) 8-10 = normal 4-6 = abnormal, suspect chronic fetal asphyxia <4 = abnormal, strongly suspect chronic fetal asphyxia

intermittent auscultation & uterine contraction palpation

using a hand-held Doppler ultrasound device, ultrasound stethoscope, or fetoscope to assess FHR palpation of contractions at the fundus for frequency, intensity, duration & resting tone during latent phase: every 30-60 mins during active phase: every 15-30 mins during second stage: every 5-15 mins indications: -determine active labor -ROM, spontaneously or artifically -preceding & subsequent to ambulation -prior to & following admin of or a change in medication analgesia -at peak action of anesthesia -following vaginal exam -following expulsion of an enema -after urinary catheterization -abnormal/excessive uterine contractions auscultate FHR based on findings of Leopold maneuvers palpate uterine fundus to assess activity count FHR for 30-60 s between contractions to determine baseline auscultate FHR before, during, and after a contraction identify FHR patterns & characteristics of uterine contractions, implement nursing interventions, & report nonreassuring patterns or abnormal contractions consider cultural, emotional, educational, and comfort needs of mother normal FHR = 110-160 bpm w increases & decreases from baseline tachycardia = > 160 bpm for 10+ mins bradycardia = < 110 bpm for 10+ longer

forceps-assisted birth

using an instrument w 2 curved spoon-like blades to assist in the delivery of the fetal head traction is applied during contractions indications: prolonged 2nd stage of labor and need to shorten duration, fetal distress during labor, abnormal presentation or breech position requiring delivery of the head, arrest of rotation explain procedure assist to lithotomy position ensure that bladder is empty ensure that fetus is engaged & that membranes have ruptured assess FHR before, during, and after compression of the cord between the fetal head and forceps will cause a decrease in FHR, if this occurs, remove forceps and reapply observe neonate for bruises & abrasions at the site of forceps application after birth check for any possible injuries after birth (vaginal/cervical lacerations, urine retention resulting from bladder or urethral injuries, hematoma formation in the pelvic soft tissues) complications: lacerations of the cervix, lacerations of the vagina/perineum, injury to the bladder, facial nerve palsy of the neonate, facial bruising on the neonate

general postpartum changes

uterine involution, lochia flow, cervical involution, decrease in vaginal distention, alteration in ovarian function & menstruation, cardiovascular, urinary tract, breast & GI tract changes greatest risks: hemorrhage, shock, infection oxytocin released from the pituitary gland (occurs when breastfeeding afterpains hormones like estrogen, progesterone, and placental enzyme insulinase decrease, resulting in decreased blood glucose as well decreased estrogen = breast engorgement, diaphoresis, diuresis & excess extracellular fluid; diminishes vaginal lubrication (local dryness) decreased progesterone = increase in muscle tone decreased insulinase = reversal of diabetogenic effects of pregnancy (lowers blood glucose) lactating women: serum prolactin remain elevated and suppress ovulation; return of ovulation is affected by breastfeeding frequency, length, & use of supplementation nonlactating women: prolactin declines & reaches prepregnant levels by 3rd week postpartum; ovulation occurs 27-75 days postpartum; menses resume by 4-6 wks

female condom

vaginal sheath made of nitrile, a nonlatex synthetic rubber with flexible rings on both ends the closed end of the pouch is inserted into the vagina prior to intercourse and anchored around the cervix the open ring covers the labia removed and thrown away after intercourse STI protection

FHR accelerations

variable transitory increase in the FHR above baseline causes/complications: -healthy fetal/placental exchange -intact fetal CNS response to fetal movement -vaginal exam -uterine contractions -fundal pressure nursing interventions: -reassuring -no interventions required -indicate reactive NST

newborn physical assessment

vital signs check on admission/birth and every 30 min twice, every 1 hr twice, and then every 8 hr weight should be checked daily at the same time, using same scale inspect the umbilical cord, observe for bleeding from the cord, ensure that the cord is clamped securely to prevent hemorrhage in the first 6-8 h, observe for periods of reactivity: -1st period of reactivity: newborn is alert, exhibits exploring activity, makes sucking sounds, and has a rapid HR and RR; HR can be as high as 160-180 bpm, but will stabilize at a baseline of 100-120 bpm during a period that lasts 30 min after birth -period of relative inactivity: the newborn will become quiet & begin to rest & sleep, the HR and RR will decrease, & this period will last from 60-100 min after birth -2nd period of reactivity: the newborn reawakens, becomes responsive again, & often gags & chokes on mucus that has accumulated in his mouth; this period usually occurs 2-8 h after birth and can last 10 min to several hr conduct a pain assessment on the newborn every 8-12 h

breast education if nonlactating

wear a well-fitting, supportive bra for the first 72 h suppression of lactation is necessary for clients, avoid stimulation and running warm water for prolonged periods until no longer lactating for breast engorgement, apply cold compresses 15 min on and 45 min off; fresh, cold cabbage leaves can be placed inside the bra mild analgesics or anti=inflammatory medication can be taken

ongoing prenatal visits

weight, BP, urine for glucose, protein, and leukocytes monitor for presence of edema monitor fetal development FHR can be detected early by ultrasound and heard by Doppler late in the first trimester (listen at midline, right above the symphysis pubis by holding the Doppler firmly on the abdomen) measure fundal height starting in the 2nd trimester (weeks 18-30, fundal height in cm should be the same as # of weeks gestation) begin assessing for fetal movement between 16-20 weeks provide education for self-care to include management of common discomforts and concerns during pregnancy (n/v, fatigue, backache, varicosities, heartburn, activity, sexuality)

spontaneous abortions

when a pregnancy is terminated before 20 weeks or a fetal weight less than 500 g types include threatened, inevitable, incomplete, complete and missed risk factors: chromosomal abnormalities, maternal illness, advanced maternal age, premature cervical dilation, chronic maternal infections, maternal malnutrition, trauma or injury, anomalies in the fetus or placenta, substance use, antiphospholipid syndrome expected findings: backache and abdominal tenderness, rupture of membranes, dilation of the cervix, fever, signs and symptoms of hemorrhage (hypotension, tachycardia) lab tests: Hgb and Hct if considerable blood loss, clotting factors, WBC for suspected infection, hCG to confirm pregnancy ultrasound: determine presence of a viable or dead fetus examination of the cervix: open or closed dilation and curettage (D&C): dilate and scrape uterine walls to remove uterine contents for inevitable and incomplete abortions dilation and evacuation (D&E): dilate and evacuate uterine contents after 16 weeks prostaglandins and oxytocin: to augment or induce contractions and expulse products of conception observe color & amount of bleeding bed rest avoid vaginal exams save passed tissue for examination use term miscarriage instead of abortion medications: analgesics, sedatives, prostaglandin (vaginal suppository), oxytocin, broad-spectrum antibiotics (septic abortion), Rho(D) immune globulin, suppresses immune response if Rh- notify provider if heavy, bright red bleeding, elevated temp, foul-smelling discarge small amount of discharge is normal for 1-2 weeks refrain from tub baths, sexual intercourse, or anything in vagina for 2 weeks avoid pregnancy for 2 mos

pulmonary embolism

when fragments or an entire clot dislodges and moves into circulation a complication of DVT that occurs if the embolus moves into the pulmonary artery or 1 of its branches & lodges in a lung, occluding the vessel & obstructing blood flow to the lungs acute PE is an emergent situation risk factors: -pregnancy -cesarean birth -operative vaginal birth -varicosities -immobility -obesity -smoking -multiparity -age > 35 -hx of thromboembolism -DM expected findings: -apprehension -pleuritic chest pain -dyspnea -tachypnea -hemoptysis -peripheral edema -distended neck veins -elevated temp -hypotension -hypoxia ventilation/perfusion lung scan, chest radiographic study, radioisotope lung scan, pulmonary angiogram, embolectomy to surgically remove the embolus place client in semi-Fowler's position w HOB elevated to facilitate breathing admin O2 by mask heparin, warfarin thrombolytic therapy to break up blood clots: aletplase, streptokinase

vaginal birth after cesarean (VBAC)

when the client delivers vaginally after having had a previous cesarean birth indications: -no other uterine scars or hx of previous rupture -1 or 2 previous low transverse cesarean births -clinically adequate pelvis -providers immediately available throughout active labor capable of monitoring labor & performing an emergency cesarean birth if necessary -no current contraindications (large for gestational age, malpresentation, cephalopelvic disproportion, previous classical vertical uterine incision) assess FHR during labor assess contraction patterns for strength, duration, frequency assess for evidence of uterine rupture promote relaxation & breathing techniques provide analgesia

prolapsed umbilical cord

when the umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix results in cord compression & compromised fetal circulation risk factors: rupture of amniotic membranes, abnormal fetal presentation, transverse lie, small-for-gestational-age fetus, unusually long umbilical cord, multifetal pregnancy, unengaged presenting part, hydramnios or polyhydramnios client reports that she feels something coming through her vagina visualization/palpation of cord protruding FHR monitoring shows variable or prolonged deceleration excessive fetal activity followed by cessation of movement, suggestive of fetal hypoxia call for assistance, notify provider use a sterile-gloved hand, insert 2 fingers into vagina, apply finger pressure on either side of the cord to the fetal presenting part to elevate it off the cord reposition client in a knee-chest, Trendelenburg, or a side-lying position w something under a hip apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia administer O2 at 8-10 L/min via face mask initiate IV access and administer fluid bolus prepare for immediate vaginal birth if cervix is fully dilated or cesarean if its not

subinvolution of the uterus

when the uterus remains enlarged w continued lochial d/c & can result in hemorrhage risk factors: -pelvic infection and endometritis -retained placental fragments prolonged vaginal bleeding irregular/excessive bleeding uterus that is enlarged & higher than normal in the abdomen & boggy blood, intracervical & intrauterine bacterial cultures to check for infection dilation & curettage (D&C) is performed by provider to remove placental fragments if indicated monitor fundal position & consistency monitor lochia for color, amount, consistency, & odor monitor vitals encourage client to use activities that can enhance uterine involution (breastfeeding, early & frequent ambulation, frequent voiding) oxytocin, methylergonovine -uterine stimulants -promote uterine contractions & expel retained fragments of placenta -assess uterine tone & bleeding -ADE of water intoxication (lightheadedness, n/v, h/a, malaise) antibiotic therapy

coitus interruptus (withdrawal)

withdrawal of penis from vagina prior to ejaculation be aware of fluids leaking from the penis possible choice for monogamous couples who do not have another contraceptive available one of the least effective methods of contraception no protection against STIs influenced by male partner's control leakage of fluid that contains spermatozoa prior to ejaculation can be deposited in vagina risk of pregnancy