ADN 240 Exam 2 PP / Newborn MC
signs of nb respiratory distress
- nasal flaring - retractions of ribcage - grunting - cyanosis
The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartum blues? an 18-year-old mother who is currently holding her baby and looking face-to-face at the baby without saying a word a 29-year-old mother who has lots of family visiting, offering to help her with meals and cleaning for the next few months a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding a 38-year-old G1P1 who is constantly holding the baby and touching the baby's hands and fingers
a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding
how to identify a cervical laceration?
a slow trickle of bright red bleeding/oozing firm fundus
what is endometritis? s/s?
a uterine infection, most common pp infection, seen on day 2-5 - lochia serosa/alba >4-8 weeks - fever - pain - abdomen tenderness - loss of appetite
what is expected of a premature nb?
abundant lanugo - fine hair, esp on back decreased muscle tone abundant vernix
what should not be used on nb umbilical stump?
antimicrobials - can delay cord seperation
what are postmature nb at risk for?
anything after 42 weeks - meconium aspiration - hypoglycemia - nails extend over fingers/toes - dry/loose/peeling skin - damage to vaginal canal
how to assess nb hip dysplasia? how to fix?
asymmetrical gluteal folds, clicking when rotating hip in brace for 2-3mo breech baby may resolve naturally
what is cluster feeding?
baby feeding every hour for several hours in a row follow nb cues, feed 8-12 times a day
why are postmature nb at risk for hypoglycemia?
baby has already used up all glucose producing stores
what is expected in a nb with congenital diaphragmatic hernia?
barrel chest
what are premature nb at risk for?
before 37 weeks - thermoregulation - jaundice - insulin regulation - underweight -sids - breathing irregularities - organ development
when is phototherapy needed for nb?
bilirubin encepthalopathy,
what should you do if a nb temp is 96.9?
check blood glucose, probably high
proper breastfeeding technique and how often?
cheeseburger bite every 2-4 hrs, prn
when and how is mastitis developed?
clogged milk duct anywhere during 6 weeks pp
lochia assessment: COCA
color odor clarity amount
nursing intervention for DVT?
compression socks, anticoagulants, elevation
what does decreased abdominal movement mean in a nb?
decrease respirations - baby breath through stomach
what is a pku metabolic screen?
done at 24 hrs tests for pku, cystic fibrosis, hypothyroid - not diagnostic
what is the ballard scale?
done in first 48 hrs gives real gestational age based on neuromuscular and physical maturity sga: < 10th percentile lga: > 90th percentile aga: normal
homans sign
dorsiflexion of foot --> tender calf muscle, associated with deep vein thrombosis
What is evaporation and how do you prevent heat loss this way?
dry the baby immediately - wait to take their first bath if cold - bathe/expose one body part at a time
what should be done to pt in hypovolemic shock?
elevate legs 30 degrees - need to increase blood flow - decrease hypotn
nonpharmaceutical ways to treat pain on circumcised nb?
encourage nonnutritive sucking - pacifier
What is cold stress?
excessive heat loss requiring newborn to use compensatory mechanisms (nonshivering thermatogenesis & tachypnea) to maintain body temperature
what temp would be concerning for a pp client?
fever > 100.4 for 2 or more days
How is the gag reflex tested?
finger sweep into adulthood
how do we want fundus / uterus to feel pp
firm
how will a 24hr old nb act if mother was using drugs during preg?
flaccid irritable fussy
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? first degree second degree third degree fourth degree
fourth degree
pt has iv oxytocin pp, what should nurse assess to evaluate effectiveness?
fundal consistency causes uterine contraction, palpate fundus to determine
nursing intervention for subinvolution?
fundal massage
pt reports episiotomy is pulling and stinging, what should you do?
give sitz bath
What is macrosomia? Why did it probably happen? What are the risks?
growth beyond threshold abnormal large baby (>4000 grams) diabetic mom c-section normal risk for hypoglycemia
order of head/cold compress when breastfeeding?
head before feed ice after
normal head/chest/weight/length for nb
head circ: 33-37 cm (13-14 in) chest circ: 30-33 cm (12-13 in) weight: 5.5-8.5 lbs length: 45-55 cm (19-21 in)
how long does perineum take to heal pp
healing begins 2-3 weeks up to 6 mo
how is fundus measured? how much should it descend?
height / fingerbreadths +1 +2 +3 U -1 -2 -3 12hr pp: at level of umbilicus shrinks 1cm per day, slightly less for multiparous
what is #1 response to heavy bleeding?
massage the uterus
what is the first thing to do if uterus is boggy?
massage until firm check for bleeding
what can give baby thrush?
mastitis
what does mom have if she has redness, hard lump, red streaks, cracked nipples and flu like symptoms?
mastitis
What are the nursing implications of a subgaleal?
measure circumference of head, monitor for pain
what medication can promote uterine contractions?
methylergonovine
what does it mean if uterus is midline, right or left deviated?
midline = normal right = distended and full bladder left = distended bladder, bleeding, clots
what to assess for with epidural and why
monitor respirations can lead to placental fragmentation, relaxed uterus
how does a nb obtain a fractured clavicle from vaginal delivery?
more common w LGA - use of assistive devices - shoulder dystocia - preterm baby delivered too fast
when can a pt conceive after receiving the rubella vaccine?
must wait at least 1mo to avoid injury to fetus
what medication is given to nb to reverse respiratory depression from iv narcotics given to mother during labor?
naloxone
what mothers are at risk for a postterm birth?
no induction gestational diabetes
What is the Coombs test?
noninvasive mix mom/baby blood implications: jaundice, anemia (blood transfusion) Rh incompatibility
physiologic jaundice
normal newborn physiology, no other manifestations, appears after 24 hours-2 weeks baby needs colostrum or diuretic to poop
pt is only 32 hr pp with sore nipples, what do you do?
observe mom and be sure she is breastfeeding correctly
pathological jaundice
occurs before 24 hours and may indicate early hemolysis
breastfeeding jaundice
occurs during first week, due suboptimal milk intake, elevated bilirubin levels from reabsorption exacerbation of physiologic
what size/amount of blood is ok/concering?
ok: quarter sized concerning: golf ball sized, mid-day
what mothers are at risk for a preterm birth?
old/young mother diabetic genetic abnormalities environmental factors
What should your discharge instructions regarding jaundice be?
on head/upper body is normal especially if breast feeding expose skin to sunlight
what are the medications given to a newborn?
vit k: promotes bleeding/clotting, 1st priority bleeding hep b: vaccine at birth, need consent ees oinment: eyes for gonorrhea/chlamydia
medications for DVT
warfarin heparin scd's
What are the nursing implications of a caput succedaneum?
watch for jaundice due to bruising
pt developed hemorrhagic shock, what should nurse expect?
weak and irregular pulse
when should nb have first void?
within 24 hr
when will woman's blood volume return to normal?
within 24hrs
what allergy is contradicted with hep b vaccine?
yeast
What is bilirubin?
yellow pigment formed in the liver by the breakdown of old rbc and excreted in bile. helps digest food
discharge teaching regarding activity for pp client
- no heavy lifting for 3 weeks - nothing heavier than baby - limit stairs - c-sec, wait 6 weeks before strenuous exercise - no driving for 2 weeks or while taking opioids
nutrition discharge teachings for pp client
- high protein - 2-3 L of fluid per day - 1800-2000 cal/day for nonlactating - increase 330-500 cal/day when lactating
normal gu changes pp
- increase need to urinate - urine retention - encourage void every 2hr, lie on left side
what is metritis?
- inflammation of the wall of the uterus 2 day - 2 weeks - usually occurs w c-sec - sx lower abdominal pain
What does a premature baby look like?
- lanugo fine downy hair - vernix may be absent - fewer brown fat stores - low muscle tone -transparent, thin, smooth, shiny skin -low subQ fat -veins appear red -flaccid
What are special precautions for a circumcised newborn?
- no tub bath - add Vaseline & tight diaper
what is the puerperium period?
"4th trimester" process of woman returning to prepreg state, about 6 weeks
After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement? "If the symptoms last more than a few days, I need to call my doctor." "I might feel like laughing one minute and crying the next." "I'll need to take medication to treat the anxiety and sadness." "I should call this support line only if I hear voices."
"I might feel like laughing one minute and crying the next."
Upon entering the room of the newborn, the nurse notes the newborn is laying on the bed wearing only a diaper while the parents decide on an outfit for the newborn. What response by the nurse is of most importance? "Have you decided on which outfit you will put on the baby to go home?" "What questions do you have about fabrics that are close to the baby's skin?" "Let me show you how to swaddle the baby while you select the outfit." "I can see you are eager to find the perfect outfit for your baby."
"Let me show you how to swaddle the baby while you select the outfit."
What is radiation and how do you prevent heat loss this way?
- loss of heat from baby to cooler surface near to but not touching - keep away from window/AC- radiant warmer/double walled isolates
what adverse effects can an epidural cause?
- low bp - decreased blood to placenta - impair fetal oxygen
what factors place pp pt at risk for uterine atony?
- mag sulfate infusion - distended bladder - prolonged labor
What are the top two management measures for jaundice?
#1: breast feed early and often to excrete bilirubin in feces #2: blue light phototherapy
What do you need to know about a fractured clavicle of a newborn?
- LGA, maybe intentional due to shoulder being stuck during delivery - see turtle necking - split, assess lungs - implications: provider manipulates, mcroberts position, pubic pressure to get baby out
what are the nursing interventions for pp infections?
- avoid freq vag exams - hand hygiene - proper fluid intake - monitor wbc - assess placental integrity
what should a woman not breastfeeding do?
- avoid nipple stimulation - avoid heat - use ice - use cabbage leaves
how do you treat dvt?
- bed rest - elevate legs - warm compress - do NOT massage - scds - anticoagulants
Explain physiologic jaundice?
- common - occurs first 3 days usually - usually resolves itself by day 5 - breastfeeding helps
what is taking hold?
- day 2-3 - last 10 days - weeks - asks questions - improve competency - focused on baby - baby blues dependent - independent
normal abdominal changes pp
- diastasis recti, common w poor muscle tone and c-sec - slow to return to prepreg state
What is conduction and how do you prevent heat loss this way?
- direct contact - skin-to-skin (on mom with blanket) - prewarm blanket/hat/ stethoscope/instruments/pad scale
explain progression of pp uterus location
- end of 3rd stage labor: midline and 2cm below umbilicus - 1 hr after delivery: level of umbilicus - by day 6: halfway b/t pubis and umbilicus - 2 weeks: should be in pelvis, not able to palpate
what does a proper latch involve?
- erect nipple - areola and nipple - flanged lips
what to expect in nb with neonate abstinence syndrome?
- exaggerated reflexes - avoid eye contact during feedings to decrease stimulation
3 symptoms a pp mom should report immediately?
- fever > 100.4 - red streak in breast - sx of eclampsia (blurry vision, headache)
what is taking in?
- first 24-48 hrs - excited and talkative - focus on own needs - shivering is normal, don't fight - need to review birth experience - dependent
normal cervical changes pp
- flabby/floppy and bruised - external oz often torn, permanently changed after 1st birth - closes slowly
What is convection and how do you prevent heat loss this way?
- flow of heat from body to cooler air - no fan/draft swaddle and cover head - keep the room warm (72-78*)
what occurs pp that a mom is at risk for uterine atony?
- given mag sulfate during labor - distended bladder - long labor
What do you need to know about RBO incompatibility?
- hemolytic disease of the newborn - Rh factor/ ABO incompatibilities can lead to pathologic jaundice - can cause hyperbilirubinemia
Explain pathologic jaundice?
- occurs < 24 hours - related to RBC breakdown - can lead to toxic levels of bilirubin - move to brain & becomes kernicterus - often related to blood incompatibilities - positive DAT or coombs
what is common causes of pp hemorrhage?
- previous - bmi >35 - twins - placenta previa - preeclampsia - anemia - fibroids (growths) - blood thinners/clotting probs - urinary retention pp
how to care for a nb in drug withdrawl?
- promote feeding - administer small dose of substance to decrease s/s - possible separation from mom
normal vaginal changes pp
- size decrease 3-4 weeks - weak pelvic floor, do kegels - labia more flaccid
What does a postmature baby look like?
- skin folds, chubby, wrinkly - dry, cracked, loose, peeling, leathery skin - thick, cheesy, greasy, white vernix - after 42 weeks - unknown cause - overgrown nails - lots of scalp hair - very alert
What NB are at higher risk for hypoglycemia?
- small/large for gestation age - less than 37 wks gestation or greater than 42 weeks gestation. Blood glucose on these NB should be assessed within 2 hrs of life (30-45, but want in higher range)
What are the differences in lung sounds of nb vaginal delivery vs c-section?
- transient tachypnea fluid not squeezed out of lungs in c-section
what s/s need to be assessed to catch pp hemorrhage?
- uterine atony - > quarter sized clots - pad saturated in 15 min - oliguria - pale/cool/clammy - tachy - hypotension
name postpartum infections
- uterine infection w subinvolution (placental fragmentation) - csec infection - mastitis
normal pp cardiac changes
-heart returns to normal after delivery -bp returns to prepreg levels by 6 weeks -decrease in bp can suggest infection or uterine hemorrhage
normal gi changes pp
-hunger/thirst due to body replacing lost fluids from labor -decreased bowel mobility due to progesterone -fear of first bm pp, esp if had episiostomy -c-sec discomfort w gas common after abdominal surgery, peak on day 2-3, ambulating and gentle pressure can help
APGAR scoring
0-2 pts each, normal 8-10 Appearance - blue/pale, blue extremities, no cyanosis Pulse - <60, 60-100, >100 Grimace - no response, aggressive stim needed, cries easy on stim Activity (muscle tone) - absent/floppy, some flexion, flexes/resists Respiration - absent, weak/gasp, strong cry
How do you score APGAR?
0-3: distress 4-6 moderate difficulty 7-10 minimal or no difficulty Each five sign is scored from 0 - 2 (max 10 points). 0 = absent 1 = decreased 2 = strongly positive
when should breastfeeding occur after birth?
1-2 hrs, skin to skin
When does the umbilical cord fall off?
1-3 weeks
how much calcium should a breastfeed mom consume per day?
1000 mg
what classifies a pp hemorrhage?
1000+ mL pad saturated in < 1 hr
how much sleep does baby need?
18-20 hrs
when to preform maternal vitals pp
1st hr - every 15 min 2nd hr - every 30 min 24 hrs - every 4 hrs 24+ hr - every 8 hrs or PRN
when/how/why does mastitis occur?
2 day - 2 weeks pp caused by infrequent/inconsistent breastfeeding, incorrect latch, nipple trauma treat by emptying breast, control infection, increase freq of nursing (feed through it)
When does the Grasp reflex start? Disappear?
2 weeks 3-4 months for palmar 8 months for plantar
progression of milk production
2-3 days: colostrum 3-5 days: milk comes in 4 weeks: fully established
healing time of: cephalohematoma caput succedaneum
2-6 weeks 3-4 days
How long does it take a cephalohematoma to heal?
2-8 weeks
what is the lochia amount? pt has two 2.5 cm spots of lochia
2.5 = 25 cents - pt has 2 quarter sized amounts - still considered scant bc it is 5cm
fundus location in 3rd stage of labor? within 12 hr pp? 6th day pp? 2 weeks?
2cm below umbilicus rises 1cm above descends 1-2cm per day - about 6 cm not palpated in abdomen
what level should be reported w dtr?
3+
How long does a caput succedaneum last?
3-4 days
what is the expected location of the fundus 2 days pp?
3cm below umbilicus
when is maternal identity achieved?
4 mo
how do yo put an nb in a car seat?
45 degree angle
how long does placental attachment site take to heal?
6 weeks
what is moderate flow of lochia in cm?
7-12 cm
what blood glucose level should a nb be treated for hypoglycemia?
< 40-50
why should client report consistent abdominal pain?
> 1 week pp, could be retained placental fragments
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner? Normal birth length is usually 52 cm or above for a full-term newborn. A birth weight between 2200 and 3000 g is considered small for gestational age. A length between 48 and 50 cm plots out at the 95th percentile for length. A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn
When does the rooting reflex appear and disappear?
Appears: Birth Disappears: 4-6 mo
BUBBLEE HE assessment
Breast (size, engorgement) Uterus (fundal height, firm) Bowel (sounds, distention) Bladder (voiding) Lochia (amt, color, odor) Episiotomy (hematoma) Extremities Homan's Sign Emotional Status
What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? Epstein pearls milia stork bites congenital dermal melanocytosis
Epstein pearls
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Feed the baby at least every two or three hours. Provide the infant oral nystatin. Apply cold compresses to the breasts. Dry the nipples following feedings.
Feed the baby at least every two or three hours.
The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism?
Group B beta-hemolytic streptococci
what are newborn vitals
HR 110 - 160, 180 at birth BP 60/40 - 80/50 RR 30 - 60, 15 sec apnea T 97.5 - 99.5 Blood Glucose 30-45 Fronteal: open and flat
explain the main role of surfactant in the neonate?
Helps the lungs remain expanded after the initiation of breathing, lubricant
A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem? Inspect the clamp to insure that it is tightly closed and applied correctly. Clean the cord with soap and water, as oozing of blood is a common finding. Notify the doctor to come suture the site of the bleeding. Remove the clamp and replace with another one just above the old one.
Inspect the clamp to insure that it is tightly closed and applied correctly.
A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding? This is an abnormal finding and needs to be reported immediately. If the fontanel (fontanelle) feels full, then this is normal. This finding is normal if the pulsation can also be palpated in the posterior fontanel (fontanelle). It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).
It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).
What is the problem with non-shivering thermogenesis in newborns?
It uses up their energy - may even lose weight It can lead to respiratory problems due to metabolism effects and acidosis May cause hypoglycemia (low blood sugar) due to increased glucose consumption
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?
Jaundice within the first 24 hours of life, pathologic Nb will have + coombs test
How do newborns attempt to thermoregulate?
Non-shivering thermogenesis: cold induced heat production that is not associated with the muscle activity of shivering; located in brown fat and controlled by sympathetic nervous supply
what are the medications given for pp hemorrhage? Oh My Hemorrhage
Oxytocin - natural uterus contraction Methergine - firms/contracts uterus Hemabate - promotes clotting
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize? Notify a health care provider. Apply a warm washcloth. Place an ice pack. Put on a witch hazel pad.
Place an ice pack.
What is RDS in a newborn?
Respiratory Distress Syndrome
hypervolemic shock
Shock due to a rise in the volume of blood in circulation
A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What sign of distress would validate the nurse's concerns? Respiratory rate of 40 breaths/min Erythema toxicum Heart rate of 152 beats/min Temperature instability
Temperature instability
The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn? Newborn makes stepping motion. Newborn throws arms outward and flexes knees. Toes fan out when sole of foot is stroked. Newborn's toes curl over the nurse's finger.
Toes fan out when sole of foot is stroked.
what are the 3 priority pp maternal assessments?
VS uterine firmness/location amount of bleeding
A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Apply warm compresses. Wear a well-fitting bra. Express milk frequently. Apply hydrogel dressing.
Wear a well-fitting bra.
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening? infection hemorrhage fluid volume overload pulmonary emboli
hemorrhage
what are the 3 greatest risk factors pp
hemorrhage, shock, infection
what should you never do for dvt?
homans sign - can detect dvt but can dislodge clot
pp with cardiac disease: what should the nurse assess?
i/o high fiber diet daily weight bedrest w head of bed elevated
what are nursing interventions for perineal discomfort?
ice packs sitz bath/whirlpool topicals
when and why is oxytocin (pitocin) given pp
if bleeding cannot be stopped
what should be reported w a 24hr post of circumcision nb?
if nb has only urinatied once since op - nb should void 2-6x a day in first 24-48 hr after birth - 6-8 times a day on 3rd day
how to care for a nb with fractured clavicle?
immobilize hold baby like football
what is expected with a premature nb?
intraventricular hemorrhage - blood vessels are fragile
Involution vs subinvolution
involution: uterus returns to prepreg state sub: uterus is not decreasing in size, infection, retained fragments
Why would a newborn have a subgaleal? What is it?
it is a rupture of veins that contains 260 ml/ 1/4 blood volume of nb vacuum delivery or excessive pulling
nursing intervention for pp hemorrhage?
iv fluids, meds, fundal massage, indwelling cath, nonrebreather mask 10mL
what is a vacuum assisted nb at a higher risk for?
jaundice
what is decidua?
lochia: spongy layer of uterus that sheds pp
normal respiratory changes pp
lung size returns to prepreg after delivery
how to prevent cold stress in nb? what does can it cause?
maintain temp of 97.5-99.5 respiratory depression
what chemical is released while breastfeeding? what does is cause?
oxytocin uterine contractions vaginal dryness
what is done for nb with decreases bilirubin levels?
phototherapy
what should you do to nb who is receiving phototherapy?
place a mask of nb eyes
When palpating for fundal height on a postpartum woman, which technique is preferable? placing one hand at the base of the uterus, one on the fundus resting both hands on the fundus placing one hand on the fundus, one on the perineum palpating the fundus with only fingertip pressure
placing one hand at the base of the uterus, one on the fundus
The nurse notes the listed assessment findings in a newborn. Which finding correlates with a glucose level for a newborn is 39 mg/dl (2.16 mmol/l). poor feeding heart rate of 142 beats/min strong cry elevated temperature
poor feeding
when will nb have dry, cracked, wrinkled skin?
post mature birth
why can a pp mom shiver?
pp chill; normal 1st 2hrs pp
risks of subinvolution
pp hemorrhage prolonged lochia discharge boggy uterus infection
mom and nb with increased risks
premature postmature older 35+/younger mom substance abuse lack of prenatal care previous c-sec lack of activity/obesity
how to preform a fundal massage?
pt on back, place hand above pubis, other hand above fundus, rotate upper hand to massage, use downward pressure
A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing: mitral valve collapse. thrombophlebitis. pulmonary embolism. upper respiratory infection.
pulmonary embolism
what can a dislodged DVT cause?
pulmonary embolism
what are the 4 types of nb heat loss?
radiation - heat lost to cold surface, not in direct contact conduction - heat lost to direct contact with cold surface convection - heat lost to cold air evaporation - heat lost from not drying
A nurse is conducting an in-service program for a group of nurses newly hired to work in the labor and birth unit. Part of the program focuses on the neonate and the various mechanisms of heat loss that can occur. Place the mechanisms below in the order that the nurse would describe them as accounting for heat loss from greatest to least. conduction radiation convection evaporation
radiation convection evaporation conduction
how/time length of cephalohematoma healing?
resolves naturally 2-6 weeks
order to assess nb vitals
respirations pulse bp temp
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
respirations pulse temp least to most invasive
mom received mag sulfate during labor, what would indicate nb toxicity from the med?
respiratory depression
what is a potential comp of nb on oxygen therapy?
retinopathy: retinal blood vessels are underdeveloped in preterm baby
normal musculoskeletal changes pp
return to prepreg state, except for feet
what does moms temp do pp
rises until 24hr pp
what day does each stage of lochia occur pp? color?
rubra: 3-4 days pp dark red serosa: 3-10 days pp pink alba: 10-14 days to 3-6 weeks white/yellow if bad odor; infection
when to perform vitals on nb?
same as maternal 1st hr - every 15 min 2nd hr - every 30 min 24 hrs - every 4 hrs 24+ hr - every 8 hrs or PRN
what are the amounts of lochia discharge?
scant: < 10 mL small: 10-25 mL moderate: 25-25 mL large: saturated pad within an hour
A client gave birth 1 day ago and the nurse is monitoring the client's blood pressure. In which position will the nurse place the client to get the most accurate reading? lying flat in the bed on the back lying on the right side for 5 minutes standing next to the bed after 3 minutes sitting on the side of the bed for 2 minutes
sitting on the side of the bed for 2 minutes
what are nursing interventions for hemorrhoids?
sitz bath/whirlpool topicals suppositories side lying stool softeners
what is number one caused of mastisis?
staph aureus
what is the moro reflex?
startle reflex starts after birth, last 3-6 mo
in what order is nb secretions managed?
suctioning mouth before nose
what vaccines are appropriate/inappropriate for mom?
tdap and flu mmr and varicella
cephalohematoma
the collection of blood b/t skull and periosteum due to suction/forceps does NOT break suture lines
caput succedaneum
the swelling of tissue over the presenting part of scalp due to pressure natural delivery DOES break suture lines
2nd priority of delivery
thermoregulation
what is a blood clot assessed at a 26 week pp c-sec delivery?
thromboembolic disease (DVT)
what is the babinski reflex?
toe flare stroking the sole of the foot causes toes to hyper extend - disappears after age of 1
TSB and SBR
total serum bilirubin serum bilirubin
what should be reported in a nb with opioid withdrawls?
tremors
The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition? loss of pelvic muscle tone increased urine output stress incontinence urinary tract infection
urinary tract infection
What is the Ortolani maneuver?
used to screen for hip dysplasia (congenital) 1) supine & flex hips/knees to 90* at hip 2) grasp inner aspect of thigh and abduct to approx. 180* while applying upward pressure 3) Listen; no "click" or "click" If positive, hip dysplasia may be present
what does a displaced/not midline fundus mean?
usually distended bladder excessive bleeding, uterine atony
most common cause of pp fever
uti
when should follow up appointment be for pp client?
vag: 4-6 weeks c-sec: 2 weeks
