ATI: MATERNAL

A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced to the right, and there is uterine atony. The nurse should identify which condition as the cause of the uterine atony? A) Poor involution B) Urinary retention C) Hemorrhage D) Infection

B) Urinary retention

A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A) Apply cold compresses to the affected extremity B) Massage the affected extremity C) Allow client to ambulate D) Measure leg circumference

D) Measure leg circumference

A nurse is caring for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition? A) No alteration in menses B) Transvaginal ultrasound indicating a fetus in the uterus C) Blood progesterone greater than expected range D) Report of severe shoulder pain

D) Report of severe shoulder pain

Prenatal Care: Birth Plan:

- A nurse ascertains what a client's goals are for the birthing process - The nurse should discuss birthing methods, such as Lamaze, and pain control options (epidural, natural birth)

Nursing Care Of Newborns: Complications: Hemorrhage:

- Due to improper cord care of placement of clamp Nursing Action: - Ensure that clamp is right. If seepage of blood is noted, secondary clamp should be applied - Notify provider if bleeding continues

Bottle Feeding: Human/Donor Milk:

- If parent is not able to produce breast milk, recommended to get donor milk from a milk bank (obtain informed consent). - Donor milk might be prescribed for infants who have some disorders - Caution the client against purchasing donor milk from individuals due to risk of contamination

A nurse is caring for a client who is pregnant and undergoing a non-stress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? A) "It is used to stimulate uterine contractions." B) "It will decrease the incidence of uterine contractions." C) "It lulls the fetus to sleep." D) "It awakens a sleeping fetus."

D) "It awakens a sleeping fetus."

A nurse is carting for a client who is at 42 weeks gestation and in labor. The client asks the nurse what to expect bc the baby is postmature. Which of the following statements should the nurse make? A) "Your baby will have excess body fat." B) "Your baby will have flat areola without breast buds." C) "Your baby's heels will easily move to his ears." D) "Your baby's skin will have a leathery appearance."

D) "Your baby's skin will have a leathery appearance."

Physiological Status Of Pregnant Client: Respiratory:

- Maternal oxygen needs increase - During the last trimester, the size of chest might enlarge, allowing for lung expansion, as the uterus pushes upwards - Respiratory rate increases and total lung capacity decreases

Intermittent Auscultation & Uterine Contraction Palpation: Considerations: Interpretations Of Findings:

- Normal FHR is 110-160/min with increases and decreases from baseline - Tachycardia is FHR greater than 160/min for 10 min. or longer - Bradycardia is a FHR less than 110/min for 10 min. or longer

Interventions For Home Care Of Newborn: Swaddling:

- Parents should be shown how to swaddle - Swaddling newborn snugly in a receiving blanket helps them feel secure - Swaddling brings newborn's extremities in closer to the trunk, which is similar to intrauterine position

Interventions For Home Care Of Newborn: Manifestations Of Illness To Report:

- Temp. greater than 38C (100.4F) or less than 36.5C (97.9F) - Poor feeding or little interest in food - Forceful vomiting or frequent vomiting - Decreased urination - Diarrhea or decreased bowel movements - Labored breathing with flared nostrils or absence of breathing for greater than 15 seconds - Jaundice - Cyanosis - Lethargy - Inconsolable crying - Difficulty waking - Bleeding or purulent drainage around umbilical cord or circumcision - Drainage developing in eyes

Pre-term Labor:

- Birth occurs after 20 weeks and before completion of 37 weeks - A late preterm birth occurs from 34 - 3 weeks - A early preterm birth occurs from 37 - 38 weeks - Preterm newborns are at risk of complications due to immature organ systems Decreased risk for complications closer the newborn is to 40 weeks: - Goals include meeting newborn's growth and development needs, anticipating/managing associated complications (RDS, sepsis) - Main priority in treating newborn who are preterm is supporting cardiac/respiratory systems. Most newborns who are preterm are cared for in NICU. Meticulous care/observation in NICU is necessary until newborn can receive oral feedings, maintain body temperature, weighs approx 2 kg (4.4 lb) Complications: - Respiratory distress syndrome: Decreased surfactant in alveoli occurs regardless of newborn's birth weight - Bronchopulmonary dysplasia (BPD): Causes the lungs to become stiff and noncompliant, requiring a newborn to receive mechanical ventilation and oxygen. BPD is also commonly caused by mechanical ventilation. It is sometimes difficult to remove newborn from ventilation and oxygen after initial placement - Aspiration: Result of a newborn who is premature not having an intact gag reflex or ability to effectively suck/swallow - Apnea of prematurity: Result of immature neurological and chemical mechanisms - Intraventricular hemorrhage: Bleeding in or around ventricles of brain - Retinopathy of prematurity: Disease caused by abnormal growth of retina blood vessels and is complication associated with oxygen administration to newborn; can cause mild to severe eye/vision problems - Patent ductus arteriosus: Occurs when ductus arteriosus reopens after birth due to neonatal hypoxia or when it does not close after birth - Necrotizing enterocolitis: An inflammatory disease in GI mucosa due to ischemia. It results in necrosis and perforation of bowel. (Short-gut syndrome can be result secondary to removal of most or part of small intestine due to necrosis) - Additional complications: Infection, hyperbilirubinemia, anemia, hypoglycemia, delayed growth/development Risk Factors: - Maternal gestational hypertension - Multiple pregnancies that are closely spaced - Adolescent pregnancy - Lack of prenatal care - Maternal substance use, smoking - Previous history of preterm delivery - Abnormalities of uterus - Cervical incompetence - Placenta previa - Preterm labor - Preterm premature rupture of membranes Expected Findings: - Ballard assessment showing physical/neurological assessment totaling less than 37 weeks of gestation - Periodic breathing consisting of 5-10 second respiratory pauses followed by 10-15 second compensatory rapid respirations - Manifestations of increased respiratory effort and/or respiratory distress including nasal flaring or retractions of chest wall during inspirations, expiratory grunting, tachypnea - Apnea: Pause in respirations 20 seconds or greater - Low birth weight - Minimal subcutaneous fat deposits - Head that is large in comparison with body and small fontanels - Wrinkled features with abundance of lanugo covering back, forearms, forehead, sides of face and few or no creases on soles of feet - Skull/rib cage that feel soft - Eyes closed if newborn is born at 22-24 weeks - Weak grasp reflex - Inability to coordinate suck/swallow; weak or absent gag, suck, cough reflex; weak swallow - Hypotonic muscles, decreased level of activity, and weak cry for more than 24 hr - Lethargy, tachycardia, poor weight gain Lab Tests: - CBC showing decreased Hgb and Hct as result of slow production of RBCs - Urinalysis/specific gravity - Increased PT and aPTT time with an increased tendency to bleed - Serum glucose - Calcium - Bilirubin - ABGs Diagnostic Procedures: - Chest xray - Head ultrasounds - Echocardiography - Eye exams Nursing Care: - Perform rapid initial assessment - Perform resuscitative measures if needed - Monitor vitals - Assess newborn's ability to consume/digest nutrients. Before feeding by breast/nipple, newborn must have intact gag reflex and be able to suck/swallow to prevent aspiration - Monitor I/O and daily weights - Monitor newborn for bleeding from puncture sites and GI tract - Ensure and maintain thermoregulation in newborn who is preterm by using radiant heat warmer - Administer respiratory support measures like surfactant and/or oxygen - Administer parental or enteral nutrition and fluids as prescribed - Minimize stimulation - Position newborn in neutral flexion with extremities close to body to conserve body heat. Prone/side-lying positions are preferred to supine with body containment using blanket rolls and swaddling, but only in nursery under supervision - Perform skin assessment daily - Encourage skin-to-skin contact - Protect newborn against infection by enforcing hand hygiene and growing procedures: - Equipment should not be shared with other newborns - Evidence of infection: Temperature instability, lethargy, irritability, cyanosis, bradycardia, tachycardia, apnea or tachypnea, feeding intolerance, glucose instability Dehydration: - Urine output less than 1 ml/kg/hr - Urine-specific gravity greater than 1.015 - Weight loss - Dry mucous membranes - Absent skin turgor - Depressed fontanel Overhydration: - Urine output greater than 3 mL/kg/hr - Urine-specific gravity less than 1.001 - Edema - Increased weight gain - Crackles in lungs - Intake greater than output

Nursing Care Of Newborns: Patient-Centered Care: Feeding:

- Can be started immediately after birth - Breastfeeding initiated ASAP after birth - Formula feeding usually is started at about 2-4 hr of age: newborn is fed on demand which is normally every 3-4 hr for bottle-fed newborns and more frequent for breastfed newborns. Monitor/document feedings.

Patent Ductus Arteriosus:

- Educate parents about surgical treatment

Respiratory Distress Syndrome, Asphyxia, Meconium Aspiration:

- RDS occurs as result of surfactant deficiency in lungs and is characterized by poor gas exchange and ventilatory failure - Surfactant is phospholipid that assists in alveoli expansion. Surfactant keeps alveoli from collapsing and allows gas exchange to occur - Atelectasis (collapsing of a portion of lung) increases the work of breathing. As result, respiratory acidosis and hypoxemia can develop - Birth weight alone is not indicator of fetal lung maturity Complications from RDS are related to oxygen therapy and mechanical ventilation: - Pneumothorax - Pneumomediastinum - Retinopathy of prematurity - Bronchopulmonary dysplasia - Infection - Intraventricular hemorrhage Risk Factors: - Preterm gestation - Perinatal asphyxia (meconium staining, cord prolapse, nuchal cord) - Maternal diabetes mellitus - Premature rupture of membranes - Maternal use of barbiturates or narcotics close to birth - Maternal hypotension - C-section without labor - Hydrops fetalis (massive edema of fetus caused by hyperbilirubinemia) - Maternal bleeding during third trimester - Hypovolemia - Genetics: white males Expected Findings: - Tachypnea (respiratory rate greater than 60/min) - Nasal flaring - Expiratory grunting - Retractions - Labored breathing with prolonged expiration - Fine crackles on auscultation - Cyanosis - Unresponsiveness, flaccidity, apnea with decreased breath sounds (manifestations of worsened RDS) Lab Tests: - ABGs - CBC with differential - Culture and sensitivity of blood, urine, cerebrospinal fluid - Blood glucose Diagnostic Procedures: - Chest x-ray Nursing Care: - Suction newborn's mouth, trachea, nose as needed - Maintain thermoregulation - Provide mouth/skin care - Correct respiratory acidosis with ventilatory support - Correct metabolic acidosis by administering sodium bicarbonate - Maintain adequate oxygenation, prevent lactic acidosis, and avoid toxic effects of oxygen - Monitor pulse oximetry - Provide parenteral nutrition as prescribed - Monitor lab results, I/O, weight to evaluate hydration status - Decrease stimuli Medications: - Beractant, calfactant, lucinactant - Lung surfactants - Intended effect: Restores surfactant and improves respiratory compliance for newborns who are premature and have RDS Nursing Actions: - Perform respiratory assessment including ABGs, respiratory rhythm, rate and skin color before and after administration of agent - Provide suction to newborn prior to administration of medication - Assess endotracheal tube placement - Avoid suctioning of the endotracheal tube for 1 hr after administration of medication

Passageway:

- The birth canal that is composed of bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening) - The size and shape of bony pelvis must be adequate to allow the fetus to pass through it. - The cervix must dilate and efface in response to contractions and fetal descent

A nurse is providing care for a client who is in preterm labor at 32 weeks. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A) Calcium gluconate B) Indomethacin C) Nifedipine D) Betamethasone

D) Betamethasone

GTPAL Acronym:

Gravidity Term births (38 weeks or more) Preterm births (from viability to 37 weeks) Abortions/miscarriages (prior to viability) Living children

Expected Vital Signs Of Pregnant Clients: Pulse:

- Increases 10-15/min around 32 weeks of gestation and remains elevated throughout the remainder of pregnancy

Congenital Anomalies:

- Can affect all systems - Anomalies are diagnosed prenatally - Nurse should provide emotional support to parents - Congenital Heart Disease (CHD): Atrial septal defects, ventricular septal defects, coarctation of aorta, tetralogy of Fallot, transposition of greater vessels, stenosis, atresia of valves - Neurological Defects: Neural tube defects, hydrocephalus, anencephaly, encephalocele, meningocele, myelomeningocele - GI Problems: Cleft lip/palate, diaphragmatic hernia, imperforate anus, tracheosophageal fistula/esophageal atresia (EA), duodenal atresia, omphalocele, gastroschisis, umbilical hernia, intestinal obstruction - Musculoskeletal Deformities: Clubfoot, polydactyly, developmental dysplasia of hip - Genitourinary Deformities: Hypospadias, epispadias, exstrophy of bladdery, ambiguous genitalia - Metabolic Disorders: Phenylketonuria, galactosemia, hypothyroidism - Chromosomal abnormalities Congenital anomalies are generally identified soon after birth Apgar scoring and brief assessment indicating need for further investigation. Once identified, congenital anomalies are treated in pediatric setting: - Cleft lip/palate: Failure of lip or hard or soft palate to fuse - Tracheoseophageal Atresia: Failure of the esophagus to connect to stomach - Phenylketonuria (PKU): Inability to metabolize amino acid phenylalanine - Galactosemia: Inability to metabolize galactose into glucose - Hypothyroidism: Slow metabolism caused by maternal iodine deficiency or maternal antithyroid medications during pregnancy - Neurologic Anomalies (Spina Bifida): Neural tube defect in which the vertebral arch fails to close - Hydrocephalus: Excessive spinal fluid accumulation in the ventricles of brain - Patent ductus arteriosus: A non-cyanotic heart defect in which ductus arteriosus connecting the pulmonary artery the aorta fails to close after birth - Tetralogy Of Fallot: Cyanotic heart defect characterized by a ventricular septal defect, aorta is positioned over ventricular septal defect, stenosis of pulmonary valve, hypertrophy of right ventricle - Down Syndrome: Trisomy 21, which is the most common trisomic abnormality with 47 chromosomes in each cell Risk Fractors: Genetic And/Or Environmental Factors: - Maternal age greater than 40 - Chromosom abnormalities, like Down syndrome - Viral infections like Rubella - Excessive body heat exposure during the first trimester (neural tube defects) - Medications/substance use during pregnancy - Maternal obesity - Radiation exposure - Maternal metabolic disorders (phenylketonuria, diabetes mellitus) - Poor maternal nutrition such as folic acid deficiency (neural tube defects) - Newborns who are preterm - Newborns who are SGA - Oligohydramnios or polyhydramnios Expected Findings: - Cleft lip/palate - Tracheosophageal atresia - Duodenal atresia - PKU - Galactosemia - Hypothyroidism - Neurologic anomalies (spina bifida) - Hydrocephalus - Patent ductus arteriosus - Tetralogy of fallot - Down syndrome Nursing Assessment: - Newborn's ability to take in adequate nourishment - Newborn's ability to eliminate waste products - Vitals and axillary temp - Newborn-parental bonding, observing the parent's response to diagnosis of a congenital defect, encouraging parents to verbalize concerns Diagnostic & Therapeutic Procedures: - Prenatal screening for congenital anomalies can be done by ultrasound and multiple-marker screening (triple and quad screen) - Confirmation of diagnosis depends on anomaly - Prenatal diagnosis or confirmation of congenital anomalies is often made by amniocentesis, chorionic villi sampling, or ultrasound - Pulse oximetry reading for CHD Routine testing of newborns for metabolic disorders (inborn errors of metabolism): - A Guthrie test for PKU is done to show elevations of phenylalanine in blood/urine. It's not reliable until newborn has ingested sufficient amounts of protein - Monitor blood and urine levels of galactose (galactosemia) - Measure thyroxine (hypothyroidsim) - Cytologic studies (karyotyping of chromosomes) such as buccal smear, uses cells scraped from mucosa from inside newborn's mouth Nursing Care: - Establish and maintain adequate respiratory status, extrauterine circulation, adequate thermoregulation - Administer meds. as prescribed, such as thyroid replacement for hypothyroidism - Educate parents regarding pre-op and post-op treatments - Encourage parents to hold, touch, talk to newborn - Ensure parents provide consistent care to newborn - Provide parents with info about parent groups or support systems

Gonorrhea:

- Neisseria gonorrhoeae is the causative agent of gonorrhea. - It's a bacterial infection that is primarily spread by genital-to-genital or oral-to-genital contact. - It can also be transmitted to newborns during delivery - Females frequently have no manifestations. If left untreated in females, it can cause tubal scarring and can lead to PID which can cause infertility - CDC recommends yearly screenings - All pregnant clients at risk should be screened at first prenatal visit - If left untreated, neonate experiences opthalmia neonatorum, which can cause blindness Risk Factors: - Multiple sexual partners - Unprotected sex - Age younger than 25 (if sexually active) Expected Findings: - If anal lesions present: Anal itching or irritation, rectal bleeding, diarrhea, painful defecation - If oral lesions present: Ulcerations of lips, tender gums, pharyngitis Male: - Dysuria - Testicular edema or pain - Penile discharge (white, green, yellow, or clear), sometimes profuse Female: - Often no manifestations, but can experience: dysuria, vaginal bleeding between periods, dysmenorrhea - Yellowish-green vaginal discharge - Easily induced endocervical bleeding Lab Tests: - Endocervical culture preferred for females - Urine cultures - Anal or oral cultures Nursing Care: - Provide client education regarding disease transmission - Identify and treat all sexual partners - Administer erythromycin to all infants following delivery - All states have reportable disease list. Gonorrhea is one of them. Provider's responsibility to do this. Medications: - CDC recommends treatment of chlamydia as well for those who test positive for gonorrhea - Pregnancy: Celtriaxone IM and azithromycin PO Client Education: - Take all medications as prescribed - Repeat the culture within 3-4 weeks to assess for medication effectiveness - There is possibility of decreasing effectiveness of oral contraceptives - Adhere to safe sex Complications: - Peritoneal complications if left untreated - Premature rupture of membranes (PROM) - Preterm birth - Postpartum sepsis and endometritis - Chorioamnionitis - Neonatal sepsis

Hyperbilirubinemia:

- Elevation of serum bilirubin levels resulting in jaundice. Jaundice normally appears on heat (especially the sclera and mucous membranes) then progresses down thorax, abdomen, extremities Jaundice can be physiologic or pathologic: - Physiologic Jaundice: Considered benign (resulting from normal newborn physiology of increased bilirubin production due to shortened lifespan and breakdown of fetal RBCs and liver immaturity). The newborn who has this exhibits an increase in unconjugated bilirubin levels 72-120 hr after birth with a rapid decline to 3 mg/dL 5-10 days after birth - Pathologic Jaundice: Result of an underlying disease. Appears before 24 hr of age or is persistent after day 14. In term newborn, bilirubin levels increase more than 0.5 mg/dL/hr, peaks at greater than 12.9 mg/dL or is associated with anemia and hepatosplenomegaly. This jaundice is usually caused by a blood group incompatibility or infection, but can be result of RBC disorders Acute Bilirubin Encephalopathy: When the bilirubin is deposited in brain. This occurs once all of binding sites for bilirubin are used within body, resulting in necrosis of neurons. Bilirubin levels higher than 25 mg/dL place the newborn at risk. This can result in permanent damage including dystonia and athetosis, upward gaze, hearing loss, cognitive impairments Kernicterus: Irreversible, chronic result of bilirubin toxicity. Newborn demonstrates many of the same manifestations of bilirubin encephalopathy with hypotonia, severe cognitive impairments, spastic quadriplegia Risk Factor: - Increased RBC production or breakdown - Rh or ABO incompatibility - Decreased liver function - Maternal ingestion of diazepam, salicylates, or sulfonamides close to birth - Maternal diabetes - Oxytocin during labor - Neontal hypoerthyroidism - Ecchymosis or hemangioma - Cephalohematomas - Prematurity Expected Findings: - Yellowish tent to skin, sclera, mucous membranes - To verify jaundice, press newborn's skin on cheek or abdomen lightly with one finger. Then, release pressure, observe newborn's skin color for yellowish tint as skin is blanched - Note the time of jaundice onset - Assess underlying cause by reviewing maternal prenatal, family, newborn history - Hypoxia, hypothermia, hypoglycemia, metabolic acidosis can occur as a result of hyperbilirubinemia and can increase risk of brain damage Lab Tests: - Elevated serum bilirubin level can occur (direct/indirect bilirubin). Monitor newborn's bilirubin levels every 4 hr until level returns to normal - Assess maternal newborn blood type to determine whether there is ABO incompatibility. This occurs if newborn has blood type A or B, and parent is type O. - Review Hgb and Hct - A direct Coombs' test reveals presence of antibody-coated (sensitized) Rh-positive RBCs in the newborn - Check electrolyte levels for dehydration from phototherapy Diagnostic Procedures: - Transcutaneous bilirubin level is non-invasive method to measure newborn's bilirubin level Nursing Care: - Observe skin and mucous membranes for jaundice - Monitor vitals Set up phototherapy if prescribed: - Maintain eye mask over newborn's eyes for protection of corneas and retinas - Keep newborn undressed. For male newborn, a surgical mask should be placed (like a bikini) over genitalia to prevent possible testicular damage from heat and light waves. Be sure to remove the metal strip from the mask to prevent burning - Avoid applying lotions or ointments to skin bc they absorb heat and can cause burns - Remove the newborn from phototherapy every 4 hr, unmask the newborn's eyes, checking for inflammation or injury - Reposition newborn every 2 hr to expose all of body surfaces to the phototherapy lights and prevent pressure sores - Check the lamp energy with a photometer per protocol - Turn off phototherapy lights before drawing blood for testing Observe newborn for effects of phototherapy: - Bronze discoloration: not a serious complication - Maculopapular skin rash: not a serious complication - Development of pressure areas - Dehydration: poor skin turgor, dry mucous membranes, decreased urinary output - Elevated temperature - Encourage parents to hold/interact with the newborn who phototherapy lights are off - Monitor elimination/daily weights, watching for evidence of dehydration - Check newborn's axillary temperature every 4 hr during phototherapy bc temperature can become elevated - Feed newborn early and frequently, every 3-4 hr. This will promote bilirubin excretion in stools - Encourage continued breastfeeding of newborn. Supplementation with formula can be prescribed. - Maintain adequate fluid intake to prevent dehydration - Reassure parents that most newborns experience some degree of jaundice - Explain hyperbilirubinemia, its causes, diagnostic tests, treatment to parents - Explain newborn's stool contains some bile that will be loose and green - Administer an exchange transfusion for newborns who are at risk for kernicterus Therapeutic Procedures: Phototherapy: Newborn's bilirubin should start to decrease within 4-6 hr after starting treatment Client Education: Discharge Instructions: - Remember to adhere to newborn's plan of care - Infant who have low to moderate risk of hyperbilirubinemia should receive follow up care within 2 days. Infants at higher risk should be seen within 24 hr

A nurse is caring for a client who is pregnant and reviewing manifestations of complications the client should promptly report to the provider. Which of the following should the nurse include? A) Vaginal bleeding B) Swelling of ankles C) Heartburn after eating D) Lightheadedness when lying on back

A) Vaginal bleeding

A nurse is completing an admission assessment for a client who is at 39 weeks of gestation and reports fluid leaking from vagina for 2 days. Which of the following conditions is the client at risk for developing? A) Cord prolapse B) Infection C) Postpartum hemorrhage D) Hydramnios

B) Infection

A nurse is reviewing discharge teaching with a client who has a UTI. Which of the following statements by the client indicates understanding of the teaching? SATA A) "I will perform perineal care and apply a perineal pad in back-to-front direction." B) "I will drink grape fruit juice to make my urine more acidic." C) "I will drink large amounts of fluids to flush the bacteria from my urinary tract." D) "I will go back to breastfeeding after I have finished taking the antibiotic." E) "I will take Tylenol for any discomfort."

C) "I will drink large amounts of fluids to flush the bacteria from my urinary tract." E) "I will take Tylenol for any discomfort."

Signs Of Pregnancy: Probable Signs:

Changes that make the examiner suspect a client is pregnant: - Abdominal enlargement: related to changes in uterine size, shape, position - Hegar's sign: softening and compressibility of lower uterus - Chadwick's sign: deepened violet-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: felt by examiner

A nurse is completing an assessment. Which of the following indicate the newborn is adapting to extrauterine life? SATA A) Expiratory grunting B) Inspiratory nasal flaring C) Apnea for 10 second periods D) Obligatory nose breathing E) Crackles and wheezing

C) Apnea for 10 second periods D) Obligatory nose breathing

Complications For Newborn Nutrition:

Newborns Who Are Sleepy: - Unwrap newborn - Change diaper - Hold upright and turn them from side to side - Talk to them - Massage their backs and rub the hands/feet - Apply a cool cloth to newborn's face Newborns Who Are Fussy: - Swaddle - Hold them close, move, rock them gently - Reduce newborn's environmental stimuli - Place newborn skin-to-skin

Non-Pharmacological Pain Management: Cognitive Strategies:

- Childbirth education - Childbirth preparation methods (Lamaze, patterned breathing) promote relaxation and pain management - Doulas can assist using methods of non-pharmacological pain - Assessing for findings of hyperventilation (caused by low blood vessels of PCO2, from blowing off too much CO2), such as lightheadedness, tingling of fingers (if this happens then have client breathe into a paper bag) - Hypnosis - Biofeedback

Pain Relief Measures During Labor: Cesarean Birth:

- Epidural (block) anesthesia - Spinal (block) anesthesia - General anesthesia

Newborn Infection, Sepsis (Sepsis Neonatorum):

- Infection can be contracted by newborn before, during, after delivery. Newborns are more susceptible to micro-organisms due to their limited immunity and inability to localize infection. Infection can spread rapidly in bloodstream. - Newborn sepsis is presence of micro-organisms or their toxins in blood or tissues of newborn during first month after birth. Manifestations of sepsis are subtle and can resemble other diseases; nurse often notices them during routine care of newborn - Organisms frequently responsible for newborn infections include Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, Haemophilus influenzae, streptococcus beta-hemolytic, Group B. - Prevention of infection and newborn sepsis starts perinatally with. maternal screening for infections, prophylactic interventions, use of sterile/aseptic techniques during delivery - Prophylactic antibiotic treatment of eyes of all newborns and appropriate umbilical cord care also help prevent newborn infection/sepsis Risk Factors: - Premature rupture of membranes - Prolonged labor - Toxoplasmosis, rubella, cytomegalovirus, herpes (TORCH) - Chorioamnionitis - Preterm birth - Low birth weight - Maternal substance use - Maternal urinary tract infection - Meconium aspiration - HIV transmitted from parent to newborn perinatally through placenta and postnatally through breast milk Expected Findings: - Temperature instability - Suspicious drainage (eyes, umbilical stump) - Poor feeding pattern (weak suck, decreased intake) - Vomiting/diarrhea - Hypoglycemia, hyperglycemia - Abdominal distention - Apnea, retractions, grunting, nasal flaring - Decreased oxygen saturation - Color changes (pallor, jaundice, petechiae) - Tachycardia or bradycardia - Tachypnea - Low blood pressure - Irritability and seizure activity - Poor muscle tone and lethargy Lab Tests: - CBC with differential, C-reactive protein - Blood, urine, cerebrospinal fluid cultures and sensitivities - Chemical profile to show a fluid and electrolyte imbalance Nursing Care: - Assess infection risks - Monitor for clinical findings of opportunistic infection - Monitor vitals continuously - Monitor I/O and daily weight - Monitor fluid and electrolyte status - Obtain specimens (blood, urine, stool) to assist in identifying causative organism - Initiate/maintain IV therapy as prescribed to administer electrolyte replacements, fluids, meds. - Isolate precautions as indicated - Administer meds as prescribed (antibiotics, antivirals, antifungals) - Initiate/maintain respiratory support as needed - Assess IV site for evidence/infection - Provide newborn care to maintain temperature - Clean/sterilize all equipment to be used - Provide emotional support to family Client Education: Discharge Instructions: - Understand/adhere to infection control - Use clean bottles/nipples each feeding - Discard any unused formula - Perform proper hand hygiene - Promote adequate rest for newborn, decrease physical stimulation

Preeclampsia:

- Is gestational hypertension with addition of proteinuria of greater than or equal to 1+. - Report of transient headaches might occur along with episodes of irritability. - Edema can be present.

Psychological Response:

- Maternal stress, tension, and anxiety can produce physiological changes that impair the progress of labor

Prenatal Routine Lab Tests:

Blood type, Rh factor, presence of irregular antibodies: Determines risk for maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbiliruibinemia. Indirect Coombs' test identifies clients sensitized to Rh-positive blood. For clients who are Rh-negative and not sensitized, the indirect Coombs' test is repeated between 24 and 28 weeks of gestation CBC with differential, Hgb, Hct: Detects infection and anemia Hgb electrophoresis: Identifies hemoglobinopathies (sickle cell anemia and thalassemia) Rubella titer: Determines immunity to rubella Hepatitis B screen: Identifies carries 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 exam of pH, specific gravity, color, sediment, protein, glucose, albumin, RBCs, WBCs, casts, acetone, human chorionic gonadotropin: Identifies pregnancy, diabetes mellitus, gestational hypertension, renal disease, infection 1 hour glucose tolerance (oral ingestion with venous sample taken 1 hour later): Fasting not necessary. Identifies hyperglycemia, done at initial visit for at-risk clients and at 24-28 weeks of gestation for all pregnant clients (greater than 140 = requires follow-up) 3 hour glucose tolerance (fasting overnight prior to oral ingestion or IV administration of concentrated glucose with a venous sample taken 1,2, 3 hours later): Used in clients who have elevated 1-hr glucose test as a screening tool for diabetes mellitus. A diagnosis of gestational diabetes requires two elevated blood-glucose readings Papanicolaou (Pap) Test: Used as a screening tool for cervical cancer, herpes simplex type 2, and/or human papillomavirus (HPB) Vaginal/cervical culture: Detects streptococcus beta-hemolytic, bacterial vaginosis, or STI (gonorrhea/chlamydia) PPD (tuberculosis screening), chest x-ray after 20 weeks of gestation with PPD test: Identifies exposure to tuberculosis Venereal disease research laboratory (VDRL): Syphilis screening mandated by law HIV: Detects HIV infection (Centers for disease control and prevention and the American college of obstetrician and gynecologists recommends testing all clients who are pregnant unless they refuse) Toxoplasmosis, other infections, rubella, cytomegalovirus, herpes virus (TORCH) screening when indicated: Screening for a group of infections capable of crossing the placenta and adversely affecting fetal development Maternal serum alpha-fetoprotein (MSAFP): Screening occurs between 15-22 weeks of gestation. Used to rule out Down syndrome (low level) and neural tube defects (high levels). The provider might decide to use a more reliable indicator and opt for the Quad screen instead of the MSAFP at 16-18 weeks of gestation. This includes AFP, inhibin-A, a combination analysis of human chorionic gonadotropin and estriol

Pharmacological Pain Management: Analgesia: Metoclopramide:

Can control nausea/anxiety. Does not relieve pain and is used as an adjunct with opioids. Adverse Effects: - Dry mouth - Sedation Nursing Actions: - Provide ice chips or mouth swabs - Provide safety measures

A nurse is reviewing breastfeeding positions with the parent of a newborn. Which position should the nurse discuss? A) Over-the-shoulder B) Supine C) Chin-supported D) Cradle

D) Cradle

Causes Of Bleeding During Pregnancy: Second Trimester:

Gestational Trophoblastic Disease: Uterine size increasing abnormally fast, abnormally high levels of hCG, nausea and increased emesis, no fetus present on ultrasound, and scant or profuse dark-brown or red vaginal bleeding

Spontaneous Abortion Lab Tests:

Hgb and Hct: If considerable blood loss Clotting factors: Monitored for disseminated intravascular coagulopathy (DIC): a complication with retained products of conception. WBC: For suspected infection Serum human chorionic gonadotropin (hCG): levels to confirm pregnancy

Risk Factors For Impaired Newborn Nutrition:

Newborn Factors: - Inadequate breastfeeding - Illness/infection - Malabsorption - Other conditions that increase energy needs Maternal Factors: - Inadequate or slow milk production - Inadequate emptying of breast - Inappropriate timing of feeding - Inadequate breast tissue - Pain with feeding - Hemorrhage - Illness/infection

Labor & Delivery: Intraprocedure:

Nursing Actions: - Assess maternal vital signs: Per agency protocol. Check maternal temp every 2 hr. if membranes are ruptured - Assess FHR: To determine fetal well-being. This can be performed by use of EFM or spiral electrode that is applied to fetal scalp. Prior to electrode placement, cervical dilation and rupture of membranes must occur. Assess uterine labor contraction characteristics: By palpation (placing hand over fundus to assess contraction frequency, duration, and intensity) or by the use of external or internal monitoring - Frequency: Established from beginning of one contraction to beginning of next - Duration: Time between beginning of one contraction to end of that same contraction - Intensity: Strength of contraction at its peak described as mild (slightly tense, like pressing finger to tip of nose), moderate (firm, like pressing finger to chin), or strong (rigid, like pressing finger to forehead) - Resting tone of uterine contractions: Tone of uterine muscle in between contractions. A prolonged contraction duration (greater than 90 seconds) or too frequent contractions (more than 5 in 10 min.) without sufficient time for uterine relaxation (less than 30 seconds) in between can reduce blood flow to the placenta. This can result in fetal hypoxia and decreased FHR - Intrauterine pressure catheter: Insert a sterile solid or fluid-filled intrauterine pressure catheter inside uterus to measure intrauterine pressure: Displays uterine contraction patterns on monitor, Requires the membranes to be ruptured and cervix to be sufficiently dilated Vaginal Exam: Performed digitally by provider or qualified nurse to assess for: - Cervical dilation (stretching of cervical os adequate to allow fetal passage) and effacement (cervical thinning and shortening) - Descent of fetus through birth canal as measured by fetal station in cm - Fetal position, presenting part, and lie - Membranes that are intact or ruptured Mechanism of labor in vertex presentation: The adaptations the fetus makes as it progresses through the birth canal during birthing process - Engagement: Occurs when presenting part, usually biparietal (largest) diameter of fetal head phases the pelvic inlet at level of ischial spines, referred to as station 0 - Descent: Progress of presenting part (preferable the occiput) through pelvis. Measured by station during a vaginal exam as either negative station measured in cm if superior to station 0 and not yet engaged, or positive station measured in cm if inferior to station 0 - Flexion: When the fetal head meets resistance of cervix, pelvic wall, or pelvic floor. The head flexes bringing the chin close to the chest, presenting a smaller diameter to pass through pelvis - Internal rotation: Fetal occiput ideally rotates to a lateral anterior position as it progresses from ischial spines to lower pelvis in a corkscrew motion to pass through pelvis - Extension: Fetal occiput passes under symphysis pubis, then head is deflected anteriorly and is born by extension of chin away from fetal chest - External rotation (restitution): After head is born, it rotates to position it occupied as it entered the pelvic inlet (restitution) in alignment with fetal body and completes a quarter turn to face transverse as anterior shoulder passes under symphysis - Birth by expulsion: After birth of head and shoulders, the trunk of neonate is born by flexing it toward the symphysis pubis

Sources Of Pain During Labor: Fourth Stage:

Pain is caused by distention and stretching of the vagina and perineum incurred during second stage with a splitting, burning, tearing sensation

Sources Of Pain During Labor: Second Stage:

Pain that is somatic and occurs with fetal descent/expulsion Pain Causes: - Pressure/distention of vagina and perineum, described by client as burning, splitting, tearing - Pressure/pulling on pelvic structures (ligaments, fallopian tubes, ovaries, bladder, peritoneum) - Lacerations of soft tissues (cervix, vagina, perineum)

Sources Of Pain During Labor: Third Stage:

Pain with expulsion of the placenta is similar to pain experienced during first stage of labor Pain Causes: - Uterine contractions - Pressure/pulling of pelvic structures

Postpartum Cardiovascular System & Fluid & Hematologic Status:

Physical Changes: In the cardiovascular system during postpartum: The cardiovascular system undergoes a decrease in blood volume related to: - Blood loss during birth (average blood loss is 300-500 mL = 10% of blood volume) in an uncomplicated vaginal delivery and 500-1,000 mL (15%-30% of blood volume) for c-section - Diaphoresis and diuresis occur within first 2-5 days after delivery and rid the body of excess fluid accumulated during last part of pregnancy - Weight loss (due to lochia, delivery, diuresis of about 19 lb during first 5 days after delivery Hypovolemic shock does not usually occur in response to normal blood loss of labor and birth bc of expanded blood volume of pregnancy and the readjustment in maternal vasculature which occurs in response to: - Elimination of placenta - Rapid reduction in size of uterus, putting more blood into maternal systemic circulation In blood values, coagulation factors, fibrinogen levels during the puerperium: - Hematocrit levels drop moderately for 3-4 days then begin to increase and reach non-pregnant levels by 8 week postpartum - During first 4-7 days after birth, WBC values between 20,000-25,000 mm are common. This is called postpartum leukocytosis and it's how the body prevents infection and aids in healing - Coagulation factors and fibrinogen levels increase during pregnancy and remain elevated in immediate postpartum period. Hypercoagulability predisposes the postpartum client to thrombus formation and thromboembolism Vital Sign Changes: - Blood pressure usually unchanged w/ uncomplicated pregnancy but can have an insignificant slight transient increase. Significant decrease from baseline could indicate bleeding. Significant increase could indicate postpartum hypertension - Possible orthostatic hypotension within first 48 hr. postpartum can occur immediately after standing up with manifestations of faintness or dizziness resulting from splanchnic (viscera/internal organs) engorgement that can occur after birth. Encourage client to sit on side of bed prior to standing up - Elevation of pulse, stroke volume, cardiac output for first hour postpartum occurs then gradually decreases to pre-pregnant state baseline by 6-8 weeks. Due to elevation in stroke volume during first 2 days after delivery, the heart rate can be as low as 40/min. This is called puerperal bradycardia and this is common finding. Tachycardia in postpartum should be evaluated. - Elevation of temp. to 100.4F resulting from dehydration after labor during first 24 hr can occur but should return to normal after 24 hr postpartum. Elevation after 24 hr or that persists after 2 days could indicate infection. Assessment: - Assess for cardiovascular and vital sign changes and monitor blood component changes. Compare with baseline pregnancy vitals - Assess pedal pulses, skin turgor, and legs/feet for edema - Inspect legs for redness, swelling, warmth which are additional indications of venous thrombosis Patient-Centered Care: - Encourage adequate fluid intake - Encourage early ambulation to prevent venous stasis and thrombosis - Apply antiembolism stockings to lower extremities if client is at high risk for developing venous stasis and thrombosis. Remove stockings as soon as client is ambulating - Administer meds. as prescribed

Gestational Trophoblastic Disease Assessment:

Risk Factors: - Prior molar pregnancy - Clients in early teenage years or older than 40 Expected Findings: - Excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels - Rapid uterine growth more than expected for the duration of the pregnancy due to over-proliferation of trophoblastic cells - Bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues for a few days or intermittently for a few weeks and can be accompanied by passage of vesicles - Anemia from blood loss - Clinical findings of preeclampsia that occur prior to 24 weeks of gestation Lab Tests: - Serum level of hCG is persistently high compared with expected decline after week 10-12 of pregnancy Diagnosis/Therapeutic Procedures: - An ultrasound reveals a dense growth with characteristic vesicles, but no fetus in utero - Suction curettage is done to aspirate and evacuate the mole - Post-surgery, Rh-negative clients are given Rho(D) immune globulin - Following mole evacuation, the client should undergo a baseline pelvic exam and ultrasound scan of the abdomen - Serum hCG analysis following molar pregnancy to be done weekly for 3 weeks and then monthly for 6 months up to 1 year to detect GTD

Fourth Stage Of Labor:

- 1-2 hr - Delivery of placenta - Maternal stabilization of vitals - Achievement of vital sign homeostasis - Lochia scant to moderate rubra

5 P's:

- 5 factors that affect/define labor and birth process - Passenger (fetus and placenta) - Passageway (birth canal) - Powers (contractions) - Position (of the woman) - Psychological response

Preterm Labor Medication: Nifedipine:

- A calcium channel blocker that is used to suppress contractions by inhibiting calcium from entering smooth muscles. Nursing Action: - Monitor for headache, flushing, dizziness, nausea. These usually are related to orthostatic hypotension that occurs with administration. - Should not be administered concurrently with magnesium sulfate, or with or immediately following a beta-adrenergic agonist. Client Education: - Slowly change positions from supine to upright, and sit until dizziness disappears. - Maintain adequate hydration to counter hypotension.

Chlamydia:

- A bacterial infection caused by Chlamydia trachomatis and is most commonly reported STI in American women - Infection can be difficult to diagnose bc the client rarely has manifestations. If left untreated in females, it can lead to pelvic inflammatory disease (PID) which can cause infertility and ectopic pregnancy - CDC recommends yearly screenings - If not treated during pregnancy, chlamydia can cause premature rupture of membranes, preterm labor, postpartum endometritis - If transmitted to neonate, it can cause conjunctivitis and pneumonia after delivery Risk Factors: - Multiple sexual partners - Unprotected sex Male: - Penile discharge - Dysuria - Testicular edema or pain Female: - Dysuria - Urinary frequency - Spotting or postcoital bleeding - Vulvar itching - Gray-white discharge - Mucopurulent endocervical discharge - Easily induced endocervical bleeding Lab Tests: - Endocervical swab culture of cervical discharge - Urine culture specimen as alternative Nursing Care: - Instruct client to take entire prescription as prescribed - Identify and treat all exposed sexual partners - Client who are pregnant should be retested 3 weeks after completing the prescribed regimen Medications: - Doxycycline: Used as a treatment, but contraindicated during pregnancy - Azithromycin or amoxicillin: Prescribed during pregnancy - Erythromycin: Administered to all infants following delivery. This is medication of choice for ophthalmia neonatorum. This antibiotic is both bacteriostatic and bactericidal and so provides prophylaxis against Neisseria gonorrhoeae and chlamydia trachomatis Client Education: - Doxycycline might reduce effectiveness of oral contraceptives - If continued sexual activity is desired, be aware of sexually transmitted infection status of any sexual partners, and use a barrier contraceptive each time - All states have reportable disease list. Chlamydia is commonly reported. Provider's responsibility to do this.

Spontaneous Abortion Expected Findings:

- Abdominal cramping or pain - Rupture of membranes - Dilation of cervix - Fever - Manifestations of hemorrhage (hypotension, tachycardia)

Amniocentesis Complications:

- Amniotic fluid emboli - Maternal or fetal hemorrhage - Fetomaternal hemorrhage with Rh isoimmunization - Maternal or fetal infection - Inadvertent fetal damage or anomalies involving limbs - Fetal death - Inadvertent maternal intestinal or bladder damage - Miscarriage or preterm labor - Premature rupture of membranes - Leakage of amniotic fluid

Client Education About Nutrition: Increase Calories:

- An increase of 340 calories/day is recommended during second trimester - An increase of 452 calories/day is recommended during the third trimester - If client is breastfeeding during postpartum period, additional calories is advised (450-500 calories/day)

Nursing Care Of Newborns: Patient-Centered Care: Bathing:

- Can begin once newborn's temp has stabilized (at least 36.5C = 97.7F). A complete sponged bath should be postponed until stabilized - Gloves should be worn until newborn's first bath to avoid exposure to body secretions

Postpartum Blues:

- Can occur in up to 85% of clients during first few days after birth and generally continues for up to 10 days. - Characterized by mood swings, tearfulness, insomnia, lack of appetite, feeling of letdown. - Parent can experience an intense fear, anxiety, anger, inability to cope with slightest problems and become despondent. - Typically it's resolved in 10 days without intervention Expected Findings: - Feelings of sadness - Lack of appetite - Sleep pattern disturbances - Feeling of inadequencies - Crying easily for no reason - Restlessness, insomnia, fatigue - Headache - Anxiety, anger, sadness - CRYING

Third Trimester Client Education:

- Childbirth classes or birth plan - Coping methods - Breathing and relaxation techniques - Use of effleurage and counter pressure - Application fo heat/cold, touch and massage, water therapy - Use of transcutaneous electrical nerve stimulation (TENS) - Acupressure and acupuncture - Music and aromatherapy - Discussion regarding pain management during labor and birth (natural or epidural) - Use of a doula during labor - Indications of preterm labor and labor - Labor process - Infant care - Postpartum care

Interventions For Home Care Of Newborn: Clothing:

- Choose flame-retardant fabrics - Wash clothes separately with mild detergent/hot water - Dress newborns lightly for indoors and on hot days. Too many layers of clothing or blankets can make newborn too hot - On cold days, cover newborn's head when outdoors - A general rule is to dress newborn as parents would dress themselves

Spontaneous Abortion Risk Factors:

- Chromosomal abnormalities (account for 25%) - Maternal illness, such as type 1 diabetes mellitus - Advanced maternal age - Premature cervical dilation - Chronic maternal infections - Maternal malnutrition - Trauma or injury - Anomalies in the fetus or placenta - Substance use - Antiphospholipid syndrome

Nursing Care: First Stage:

- Lasts from onset of regular uterine contractions to full effacement and dilation of cervix (longer than second/third stage combined) Assessment: - Perform Leopold maneuvers Perform vaginal exam as indicated (if no evidence of progress) to allow examiner to assess whether client is in true labor and whether membranes ruptured: - Encourage client to take slow, deep breaths prior to vaginal exam - Monitor cervical dilation and effacement - Monitor station and fetal presentation - Prepare for impending delivery as the presenting part moves into positive stations and begins to push against the pelvic floor (crowning) Assessment related to possible rupture of membranes: - When this is suspected, first assess the FHR to ensure there is no fetal distress from possible umbilical cord prolapse which can occur with gust of amniotic fluid - Verify presence of alkaline amniotic fluid using nitrazine paper (turns blue, pH 6.5-7.5) - A sample of fluid can be obtained and viewed under a microscope. Amniotic fluid will exhibit a fond-like ferning pattern. Assess the amniotic fluid for color/odor (expected findings are clear, color of water, free or odor) (Abnormal findings are presence of meconium, abnormal color of yellow, green, and foul odor) - Perform bladder palpation on regular basis to prevent bladder distention which can impede fetal descent through birth canal and cause trauma to bladder (clients might not feel the urge to void secondary to labor process or anesthesia) (Encourage client to void frequently) - Perform a temperature assessment every 4 hr (every 3 hr if membranes ruptured) Nursing Actions: - Teach client and their partner about what to expect during labor and implementing relaxation techniques: breathing (deep cleansing breaths help divert focus away from contractions), effleurage (gentle circular stroking of abdomen in rhythm with breathing during contractions), diversional activities (distraction, concentration on a focal point, imagery) - Encourage upright positions, applications of warm/cold packs, ambulation, or hydrotherapy if not contraindicated to promote comfort - Encourage voiding every 2 hr During Active Phase: - Provide client/fetal monitoring - Encourage frequent position changes - Encourage deep cleansing breaths before/after modified paced breathing - Encourage relaxation - Provide non-pharm comfort measures - Provide pharm pain relief as prescribed During Transition Phase: - Continue to encourage voiding every 2 hr - Continue to monitor and support client/fetus - Encourage a rapid pant-pant-blow breathing pattern if client has not learned a particular breathing pattern - Discourage pushing efforts until cervix is fully dilated - Listen for client statements expressing need to have a bowel movement. This sensation is a finding of complete dilation and fetal descent - Prepare client for birth - Observe for perineal bulging or crowning (appearance of fetal head at perineum) - Encourage client to begin bearing down with contractions once the cervix is fully dilated

Pain Relief Measures During Labor: First Stage:

- Opioid agonist analgesics - Opioid agonist-antagonist analgesics - Epidural (block) analgesia - Combined spinal-epidural (CSE) analgesia - Nitrous oxide

Breastfeeding Nursing Interventions:

- Place newborn skin-to-skin on parent's chest immediately after birth. Initiate breastfeeding ASAP or within first 30 min - Explain breastfeeding techniques to parent. Have parent wash their hand, get comfortable, have caffeine-free nonalcoholic fluids to drink during breastfeeding - Explain let-down reflex (stimulation of maternal nipples releases oxytocin that causes the let-down of milk) - Express a few drops of colostrum or milk and spread it over nipple to lubricate nipple and entice newborn - Show parent proper latch-on position. Have them support breast in one hand with thumb on top and four fingers underneath. With newborn's mouth in front of nipple, newborn can be stimulated to open their mouth by tickling lower lip with tip of nipples. Parent pulls newborn to nipple with newborn's mouth covering all or as much of areola as possible, as well as the nipple - Demonstrate the four basic breastfeeding positions: football hold (under the arm), cradle (most common), modified cradle (across lap), side-lying - Teach parents to observe infant for cues of fullness rather than being concerned about time the feeding takes - To prevent nipple trauma, show parent how to insert a finger in side of newborn's mouth to break suction from nipple prior to removing newborn from breast - Promote rooming-in efforts - Offer referral to breastfeeding support groups - Contact a lactation consult to offer additional recommendation/support, especially to parents who have concerns about adequate breast milk or parents who have been unsuccessful with breastfeeding in the past. Client Education: - Uterine cramps are normal during breastfeeding resulting from oxytocin and promote uterine involution - When newborn is latched on correctly, the nose, cheeks, chin will be touching breast - Hunger cues include hand to mouth or hand to hand movements, sucking motions, rooting reflex. Newborns will nurse on demand after a pattern is established - Breastfeed at least 15-20 min per breast to ensure that newborn receives adequate fat/protein, which is richest in breast milk as it empties the breast. Newborns need to be breastfed at least 8-12 times in 24 hr - Observe for indications that newborn has completed feeding (slowing of sucking, softened breast, sleeping). offer both breasts to ensure breast receives equal stimulation/emptying - Burp newborn when alternating breasts. Newborn should be burped either over shoulder or in upright position with chin supported. Gently pat newborn on back. - Begin newborn's next feeding with breast you stopped feeding with in previous feeding - Newborn is receiving adequate feeding if they're gaining weight, voiding 6-8 diapers per day, content between feedings - Loose, pale, and/or yellow stools are normal during breastfeeding - Avoid nipple confusion in newborn by not offering supplemental formula, pacifier, or soothers until breastfeeding is established (usually 3-4 weeks). Supplementation can be provided using supplemental device/syringe feeding if needed. If supplementation is necessary, expressed breast milk is best - Always place newborn on back after feedings - Herbal products (fenugreek, blessed thistle) have been reported to increase breast milk production. There is insufficient data to deny this effect. Check with provider before taking any OTC Breast milk can be expressed using hand expression or a pump so newborn can be fed using bottle or supplemental device: - Breast pumps can be manual, electric, battery-operated and pumped directly into a bottle/freezer bag - One or both breasts can be pumped, and suction is adjustable for comfort Breast milk must be stored according to guidelines for proper containers, labeling, refrigerating, freezing: - Breast milk can be stored at room temperature under very clean conditions for up to 8 hr. It can be refrigerated in sterile bottles for use within 8 days, or can be frozen in sterile containers in freezer for up to 6 months. Breast milk can be stored in a deep freezer for 12 months - Thawing a milk in refrigerator for 24 hr is best way to preserve immunoglobulin present in it. It also can be thawed by holding container under running lukewarm water or place it in a container of it. The bottle should be rotated often, but not shaken when thawing it this way. - Thawing by microwave is contraindicated bc it destroys some of the immune factors and lysozymes contained in milk. Microwave thawing also leads to development of hot spots in milk bc of uneven heating, which can burn newborns - Do not refreeze thawed milk - Unused portions of breast milk must be discarded after thawing or warming.

A nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn. Which of the following responses should the nurse make to newborn's parents regarding why this medication is given? A) "It assists with blood clotting." B) "It promotes maturation of the bowel." C) "It is a preventative vaccine." D) "It provides immunity."

A) "It assists with blood clotting."

A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which of the following manifestations could indicate postpartum depression? SATA A) Fatigue B) Insomnia C) Euphoria D) Flat affect E) Delusions

A) Fatigue B) Insomnia D) Flat affect

A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? (SATA) A) Fetal distress B) Preterm labor C) Vaginal bleeding D) Cervical dilation greater than 6 cm E) Severe gestational hypertension

A) Fetal distress C) Vaginal bleeding D) Cervical dilation greater than 6 cm

A nurse is caring for a client having contractions every 8 min that are 30-40 seconds in duration. Client's cervix is 2 cm dilated, 50% effaced and fetus is at a -2 station with a FHR around 140/min. Which of the following states and phases of labor is the client experiencing? A) First stage, latent phase B) First stage, active phase C) First stage, transition phase D) Second stage of labor

A) First stage, latent phase

A nurse is caring for a client who is in labor. The nurse should identify which of the following infections can be treated during labor or immediately following birth? (SATA) A) Gonorrhea B) Chlamydia C) HIV D) Group B streptococcus beta-hemolytic E) TORCH infection

A) Gonorrhea B) Chlamydia C) HIV D) Group B streptococcus beta-hemolytic

A nurse is called to the birthing room to assist with the assessment of a newborn who was at 32 weeks of gestation. The newborn's birth weight is 1,100 g. Which of the following are expected findings in this newborn? SATA A) Lanugo B) Long nails C) Weak grasp refulx D) Translucent skin E) Plump face

A) Lanugo C) Weak grasp refulx D) Translucent skin

A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? SATA A) Precipitous delivery B) Obesity C) Inversion of the uterus D) Oligohydramnios E) Retained placental fragments

A) Precipitous delivery C) Inversion of the uterus E) Retained placental fragments

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is at risk for this condition? A) Preeclampsia B) Thrombophelbitis C) Placenta previa D) Hyperemesis gravidarum

A) Preeclampsia

A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent? A) Staphylococcus aureus B) Chlamydia trachomatis C) Klebsiella pneumonia D) Clostridium perfringens

A) Staphylococcus aureus

A nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. Which of the following info should the nurse include? SATA A) Use a perineal squeeze bottle to cleanse perineum B) Sit on the perineum while resting in bed C) Apply a topical anesthetic cream or spray to perineum D) Wipe perineum thoroughly with a back-forth motion E) Apply cold or ice packs to the perineum

A) Use a perineal squeeze bottle to cleanse perineum C) Apply a topical anesthetic cream or spray to perineum E) Apply cold or ice packs to the perineum

A nurse is reviewing findings of a client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (SATA) A) Fetal weight B) Fetal breathing movement C) Fetal tone D) Fetal position E) Amniotic fluid volume

B) Fetal breathing movement C) Fetal tone E) Amniotic fluid volume

Non-Pharmacological Pain Management: Sensory Stimulation Strategies:

Based on the gate control theory to promote relaxation and pain relief - Aromatherapy - Breathing techniques - Imagery - Music - Use of focal points - Subdued lighting

A nurse is teaching a client who is breastfeeding and has mastitis Which of the following responses should the nurse make? A) "Limit the amount of time the infant nurses on each breast." B) "Nurse the infant only on the unaffected breast until resolved." C) "Completely empty each breast at each feeding or use a pump." D) "Wear a tight fitting bra until lactation has ceased."

C) "Completely empty each breast at each feeding or use a pump."

A nurse is instructing a client who is taking an oral contraceptive about manifestations to report to the provider. Which of the following manifestations should the nurse include? A) Reduced menstrual flow B) Breast tenderness C) Shortness of breath D) Increased appetite

C) Shortness of breath

A nurse in a clinic receives a phone call from a client who would like to be tested in the clinic to confirm a pregnancy. Which of the following information should the nurse provide to the client? A) "You should wait 4 weeks after conception to be tested." B) "You should be off any medications for 24 hours prior to the test." C) "You should be NPO for at least 8 hours prior to the test." D) "You should collect urine from the first morning void."

D) "You should collect urine from the first morning void."

A nurse is caring for a client who is in second stage of labor. The client's labor has been progressing, and a vaginal delivery is expected in 20 min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know which of the following types of regional block is to be administered? A) Pudendal B) Epidural C) Spinal D) Paracervical

A) Pudendal

A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? A) "Obtain an immunization against rubella early in pregnancy." B) "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy." C) "A client should avoid crowded places during pregnancy." D) "A client should avoid consuming undercooked meat while pregnant."

D) "A client should avoid consuming undercooked meat while pregnant."

A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hr. Which of the following statements should the nurse make? A) "A full bladder increases the risk for fetal trauma." B) "A full bladder increases the risk for bladder infections." C) "A distended bladder will be traumatized by frequent pelvic exams." D) "A distended bladder reduces pelvic space needed for birth."

D) "A distended bladder reduces pelvic space needed for birth."

A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of fingers. Which of the following actions should the nurse take? A) Administer oxygen via nasal cannula at 2 L/min B) Apply a warm blanket C) Assist the client to a side-lying position D) Place an oxygen mask over the client't nose and mouth

D) Place an oxygen mask over the client't nose and mouth

Interpretation Of Alpha-Fetoprotein Findings:

High Levels: - Associated with neural tube defects, such as anencephaly (incomplete development of fetal skull and brain), spina bifida (open spine), or omphalocele (abdominal wall defect) - High AFP levels also can be present with normal multifetal pregnancies Low Levels: - Associated with chromosomal disorders (Down syndrome) or gestational trophoblastic disease (hydatidiform mole)

Fetal Distress:

Is present when: - FHR is below 110/min or above 160/min - FHR shows decreased or no variability - There is fetal hyperactivity or no fetal activity. Additional manifestations are late decelerations associated with absent or minimal variability, recurrent variables, prolonged decelerations Expected Findings: - Nonreassuring FHR pattern with decreased or no variability Diagnostic Procedures: - Monitor uterine contractions - Monitor FHR - Monitor findings of ultrasound and any other prescribed diagnostics Risk Factors: - Fetal anomalies - Uterine anomalies - Complications of labor and birth Nursing Care: - Monitor vitals and FHR - Position client in a left side-lying position (or knee-chest, Trendelenburg) - Administer 8-10 L/min of oxygen via face mask - Discontinue oxytocin if being given - Increase IV fluid rate to treat hypotension if indicated - Prepare client for an emergency cesarean birth if indicated

Premature Rupture Of Membranes & Preterm Premature Rupture Of Membranes:

Premature rupture of membranes (PROM): Is the spontaneous rupture of amniotic membranes prior to onset of true labor. For most clients, PROM = onset of true labor if gestational duration is at term Preterm premature rupture of membranes (PPROM): Is the premature spontaneous rupture of membranes after 20 weeks and prior to 37 weeks. Risk Factors: - Infection - Prior preterm birth - Shortening of cervix - Second/third trimester bleeding - Pulmonary or connective tissue disorders - Low BMI - Cooper or ascorbic acid deficiencies - Tobacco or substance use Expected Findings: - Client reports a gush or leakage of clear fluid from vagina - Presence of clear fluid - Assess for prolapsed umbilical cord: abrupt FHR variable or prolonged deceleration, visible or palpable cord at the introitus Lab Tests: - Positive nitrazine paper test (blue, pH 6.5-7.5) or positive ferning test is conducted on amniotic fluid to verify rupture of membranes Nursing Care: - Depends on gestational duration, if there is evidence of infection, indication of fetal or maternal compromise - Prepare for birth if indicated - Obtain vaginal/rectal cultures for streptococcus beta-hemolytic - Obtain vaginal cultures for chlamydia and Neisseria gonorrhoeae - Limit vaginal exams - Provide reassurance to reduce anxiety - Assess vitals every 2 hr. Notify provider of temp. greater than 100F - Monitor FHR and uterine contractions - Encourage hydration - Obtain a CBC - Anticipate a prescription for 7-day course of broad spectrum antibiotics Client Education: - Perform daily fetal kick counts and notify nurse of uterine contractions - Adhere to bed rest with bathroom privileges Medications: Ampicillin: - An antibiotic used to treat infection. It's commonly used to treat chorioamnionitis. - Obtain vaginal, urine, blood cultures prior to administration. Betamethasone: - A glucocorticoid administered IM in 2 injections 24 hrs apart and requires 24 hr to be effective. The action is to enhance fetal lung maturity and surfactant production. - Single dose is given with PROM at 24-34 weeks to reduce risk of perinatal mortality, respiratory distress syndrome, and other morbidities. - It's given to PROM and PPROM clients between 24-34 weeks to reduce risk of distress syndrome. Complications: Infection: - Particularly chorioamnionitis is most common complication of PPROM. Other complication: - Placental abruption, umbilical cord compression or prolapse, fetal pulmonary hypoplasia and death. Client Education: - Depending on gestational age, treatment is conservative, hospitalization can prolong pregnancy while monitoring for risk factors (infection, vaginal bleeding, fetal complications) - Adhere to limited activity with bathroom privileges - Hydrate - Conduct self-assessment for uterine contractions - Record daily kick counts for fetal movement - Monitor for foul-smelling vaginal discharge - Refrain from inserting anything into vagina - Abstain from intercourse - Avoid tub baths - Wipe perineal area from front to back after voiding and fecal elimination - Take temp. every 4 hr. when awake and report temp. higher than 100F.

Spontaneous Abortion Diagnostic/Therapeutic Procedures:

Ultrasound: To determine the presence of a viable or dead fetus, or partial or complete products of conception within uterine cavity Examination of the cervix: To observe whether it is opened or closed Dilation and curettage (D&C): To dilate and scrape the uterine walls to remove uterine contents for inevitable and incomplete abortions Dilation and evacuation (D&E): To dilate and evacuate uterine contents after 16 weeks of gestation Postaglandins and oxytocin: To augment or induce uterine contractions and expulse the products of conception.

Prenatal Assessment:

- Begins with an initial assessment (within first 12 weeks) and continues throughout pregnancy - In an uneventful pregnancy, prenatal visits are scheduled monthly for weeks 16-28, every 2 weeks from 29-36 weeks, and every week from 36-until birth

Physiological Status Of Pregnant Client: Cardiovascular:

- Cardiac output increases (30-50%) and blood volume increases (30-45% at term) to meet the greater metabolic needs - Heart rate increases during pregnancy beginning around week 5 and reaches a peak (10-15/min above pro-pregnancy rate) around 32 weeks of pregnancy

Indications For An Ultrasound (Potential Diagnosis):

- Confirming pregnancy - Confirming gestational age by biparietal diameter (side-to-side) measurement - Identifying multifetal pregnancy - Determining site of fetal implantation (uterine, ectopic) - Assessing fetal growth and development - Assessing maternal structures - Confirming fetal viability or death - Ruling out or verifying fetal abnormalities - Locating the site of placental attachment - Determining amniotic fluid volume - Observing fetal movement (fetal heartbeat, breathing, and activity) - Assessing fetal position - Placental grading (evaluation placental maturation) - Adjunct for other procedures (amniocentesis, biophysical profile)

Initial Prenatal Visit:

- Determine the estimated date of birth base don last menstrual period - Obtain medical and nursing history to include social supports and review of systems (to determine risk factors) - Perform a physical assessment to include a client's baseline weight, vital signs, pelvic exam - Obtain initial lab tests: hemoglobin, hematocrit, WBC, blood type and Rh, rubella titer, urinalysis, renal function test, pap test, cervical cultures, HIV antibody, hepatitis B surface antigen, toxoplasmosis, and RPR or VDRL

Client Education About Nutrition: Increasing Protein Intake:

- Essential for basic growth

Indications For An Ultrasound (Client Presentation):

- Vaginal bleeding evaluation - Questionable fundal height measurement in relationship to gestational weeks - Reports of decreased fetal movements - Preterm labor - Questionable rupture of membranes

Contraceptive Methods: Coitus Interruptus:

- Withdrawal ("pull out") - One of the least effective methods - Possible pregnancy

Expected Vital Signs Of Pregnant Clients: Blood Pressure:

- Within the pre-pregnancy range during the first trimester - Systolic: slight or no increase from pre-pregnancy levels - Diastolic: Slight decrease around 24-32 weeks and will gradually return to pre-pregnancy level by the end of pregnancy - The position of the pregnant client may affect blood pressure. - In supine position the blood pressure might appear to be lower due to the weight and pressure of the gravid uterus on the vena cava, which decreases venous blood flow to the heart - Maternal hypotension and fetal hypoxia might occur, which is referred to as supine hypotensive syndrome or supine vena cava syndrome. Manifestations include: dizziness, lightheadedness, pallor, clammy skin - Encourage the client to engage in maternal positioning on the left-lateral side, semi-fowler's position or if supine, with a wedge placed under one hip to alleviate pressure to the vena cava

A nurse is teaching a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? (SATA) A) Avoid any lifting B) Perform Kegel exercises twice a day C) Perform the pelvic rock exercise every day D) Use proper body mechanics E) Avoid constrictive clothing

C) Perform the pelvic rock exercise every day D) Use proper body mechanics

Nursing Actions For Abdominal Ultrasound:

Client Preparation: - Explain the procedure and that it presents no known risk to self or fetus - Advice client to drink 1 quart of water prior to the ultrasound to fill the bladder, lift and stabilize the uterus, displace the bowel, and act as an echolucent to better reflect sound waves to obtain a better image of the fetus. - Assist the client into a supine position with a small pillow under their head and knees. Ongoing care: - Apply an ultrasound/transducer gel to the client's abdomen before the transducer is moved over the skin to obtain a better fetal image, ensuring that the gel is at room temperature or warmer. - Allow the client to empty bladder at the end of procedure. - Provide a washcloth or tissue to wipe away gel after procedure.

A nurse is reviewing a new prescription for iron supplements with a client who is at 8 weeks of gestation and has iron deficiency anemia. Which of the following beverages should the nurse instruct the client to take the iron supplements with? A) Ice water B) Low-fat or whole milk C) Tea or coffee D) Orange juice

D) Orange juice

Signs Of Pregnancy: Positive Signs:

Those that can be explained only by pregnancy: - Fetal heart sounds - Visualization of fetus by ultrasound - Fetal movement: palpated by an experienced examiner

Amniocentesis Indications Potential Diagnosis:

- Previous birth with a chromosomal anomaly - A parent who is a carrier of a chromosomal anomaly - A family history of neural tube defects - Prenatal diagnosis of a genetic disorder of congenital anomaly of the fetus - Alpha-fetoprotein level for fetal abnormalities - Lung maturity assessment - Fetal hemolytic disease

Preterm Labor Medication: Magnesium Sulfate:

- A commonly used tocolytic that is a CNS depressant and relaxes smooth muscles = inhibiting uterine activity by suppressing contractions Nursing Actions: - Contraindications for tocolysis include active vaginal bleeding, dilation of cervix greater than 6 cm, chorioamnionitis, greater than 34 weeks of gestation, acute fetal distress. Do not use concurrently with nifedipine. Do not give to clients who have myasthenia gravis. - Monitor client closely. Discontinue tocolytic therapy immediately if client exhibits manifestations of pulmonary edema, which includes chest pain, shortness of breath, respiratory distress, audible wheezing and crackles, and a productive cough containing blood-tingled sputum. - Monitor for adverse effects (hot flashes, diaphoresis, burning at IV site, nausea, vomiting, drowsiness, blurred vision, headache, non-reactive non-stress test, reduced fetal heart rate variability) - Monitor for magnesium sulfate toxicity and discontinue if these adverse effects occur: loss of deep tendon reflexes, urinary output less than 30 ml/hr or 100 ml/4hr, respirations less than 12/min, pulmonary edema, severe hypotension or chest pain - Administer calcium gluconate or calcium chloride as an antidote for magnesium sulfate toxicity. Client Education: - Notify nurse of blurred vision, headache, nausea, vomiting, or difficulty breathing.

Episiotomy:

- An incision made into perineum to enlarge vaginal opening to facilitate birth and minimize soft tissue damage Indications: - Shorten the second stage of labor - Facilitate forceps-assisted or vacuum-assisted birth - Prevent cerebral hemorrhage in fragile preterm fetus - Facilitate birth of a macrosomic (large) infant Median (midline) episiotomy: Extends from vaginal outlet toward rectum and is most commonly used - Effective - Easily repaired - Generally less painful - Associated w/ higher incidence of third-and fourth-degree lacerations Mediolateral episiotomy: Extends from vaginal outlet posteriolateral, either to the left or right of midline and is used when posterior extension is likely - Third-degree laceration can occur - Blood loss is greater and the repair is more difficult and painful - Local anesthetic is administered to perineum prior to incision Ongoing Care: - Encourage alternative labor positions to reduce pressure on perineum and promote perineal stretching to reduce necessity for an episiotomy

Labor & Delivery Process Assessment:

- An intrapartum nurse should collect assessment data on maternal and fetal well-being during labor, the progress of labor, and psychosocial and cultural factors that affect labor.

Syphilis:

- An STI caused by the bacterium Treponema pallidum. - It can have long-term complications if not adequately treated - Has 3 stages - Can be transmitted through oral, vagina, anal sex as well as to unborn child. - More cases of congenital syphilis are reported in US than cases of perinatal HIV infection - All pregnant clients should be screened at first prenatal visit and re-screened in third trimester if at high risk (lives in area with higher syphilis rate or had positive test in first trimester) Risk Factors: - Multiple partners - Unprotected sex Expected Findings: Primary Stage: Client can notice a chancre, which is a painless papular lesion at site of infection. Chancres can progress to an ulcerated area. Female report of inguinal lymph node edema can indicate internal lesions (vaginal or cervical) Secondary Stage: Client can notice skin rashes, such as a maculopapular rash on the palmar surface of hands and soles of feet Tertiary Stage: Damage to internal organs can occur where clients can notice the manifestations including difficulty coordinating muscle movements and blindness Lab Tests: - Serology Tests: Non-treponemal (VDRI, and rapid plasma region) and treponemal (enzyme immunoassay) - Non-treponemal tests are often used for screening then treponemal tests for detecting antibodies specific for syphilis to confirm diagnosis. - This sequence of non-treponemal then treponemal tests is considered standard for testing. - Microscopic: Examination of primary lesions Medications: - Penicillin G IM in a single dose. If duration of syphilis is unknown, 3 doses are recommended. Safe during pregnancy - Doxycycline or tetracycline orally if allergic to penicillin as alternative therapy. Do not give this if pregnant Client Education: - Abstain from sexual contact until sores are completely healed - Partners need to be tested/treated - Adhere to safe sex - Report this disease. - After treatment, report headache, fever, tachycardia, myalgia. This could indicate Jarisch-Herxheimer reaction and should be reported Complications: - If left untreated/undiagnosed can be transmitted to neonate and cause stillborn birth or congenital abnormalities - Infection of eyes (leading to blindness) or nervous system (headache, numbness, paralysis, dementia)

Newborn Assessment: Physical Head-To-Toe Exam: Anogenital:

- Anus should be present, patent, and not covered by a membrane - Meconium should be passed within 24-48 hr after birth - Genitalia of a male newborn should include rugae on scrotum - Testes should be present in scrotum - Male urinary meatus should be located at penile tip - Genitalia of a female should include labia majora covering the labia minora and clitoris and are usually edematous - Vaginal blood-tinged discharge can occur in female newborns which is caused by maternal pregnancy hormones (expected finding) - A hymenal tag should be present - Urine should be passed within 24 hr after birth. Uric acid crystals will produce a rust color in urine the first couple days of life

Non-Pharmacological Pain Management: Gate-Control Theory Of Pain:

- Based on concept that sensory nerve pathway that pain sensations use to travel to the brain will allow only a limited number of sensations to travel at any time - By sending alternative signals through these pathways, the pain signals can be blocked from ascending the neurologic pathway and inhibit the brain's perception/sensation of pain - Assists in understanding of how non-pharmacological pain techniques can work to relieve pain

Continuous Electronic Fetal Monitoring: Interpretation Of Findings: Category I:

- Baseline fetal heart rate of 110-160/min - Baseline fetal heart rate variability: Moderate - Accelerations: Present or absent - Early decelerations: Present or absent - Variable or late decelerations: Absent

Nursing Care: Fourth Stage:

- Begins with delivery of placenta and includes at least the first 2 hr after birth Assessment: - Maternal vitals - Fundus - Lochia - Urinary output - Baby-friendly activities of family Nursing Actions: - Assess maternal blood pressure and pulse every 15 min for first 2 hr and determine temperature at beginning of recovery period, then assess every 4 hr for first 8 hr after birth, then at least every 8 hr. - Assess fundus and lochia every 15 min for first hour and then according to facility protocol - Encourage voiding to prevent bladder distention - Assess episiotomy or laceration repair for erythema - Promote opportunity for parental-newborn bonding - After they've had a chance to bond with their baby and eat, most new mothers are ready for a nap or least some quiet period of rest.

Indications Of Pain:

- Behavioral manifestations (crying, moaning, screaming, gesturing, writhing, avoidance, withdrawal, inability to follow instructions) - Increasing blood pressure, tachycardia, hyperventilation - Nausea/vomiting with an increase in gastric acidity

High-Risk Pregnancy: Quad Marker Screening:

- Blood test that ascertains information about likelihood of fetal birth defects - It does not diagnosis the actual defect - Can be performed instead of maternal AFP blood level yielding more reliable findings. It includes a test for: - Human chorionic gonadotropin (hCG): A hormone produced by placenta - Alpha-fetoprotein (AFP): A protein produced by fetus - Estriol: A protein produced by the fetus and placenta - Inhibin A: A protein produced by ovaries and placenta Client Presentation: - Preferred at 16-18 weeks of gestation - Risk for giving birth to a neonate who has a genetic chromosomal abnormality Interpretation Of Findings: - Low levels of AFP can indicate risk for Down Syndrome - High levels of AFP can indicate a risk for neural tube defects - Levels higher than expected range for hCG and inhibin A indicates a risk for Down Syndrome - Lower levels than expected range of estriol can indicate risk for Down Syndrome

Severe Preeclampsia:

- Consists of blood pressure that is 160/110 mmHg or greater, proteinuria greater than 3+, oliguria, elevated blood creatinine greater than 1.1 mg/dL, cerebral or visual disturbances (headache and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and right upper-quadrant pain, and thrombocytopenia.

False Labor:

- Contractions are painless, irregular, intermittent - Decreases in frequency, duration, intensity with walking or position changes - Felt in lower back or abdomen above umbilicus - Often stop with sleep or comfort measures (oral hydration, emptying of bladder) - Cervix (assessed by vaginal exam) - No significant change in dilation or effacement - Often remains in posterior position - No significant bloody show - Fetus: Presenting part is not engaged in pelvis

Decrease Or Loss Of FHR Variability:

- Decrease or loss of irregular fluctuations in baseline of FHR Causes/Complications: - Medications that depress the CNS (barbiturates, tranquilizers, general anesthetics) - Fetal hypoxemia and metabolic acidemia - Fetal sleep cycle (minimal variability sleep cycles usually don't last longer than 30 min.) - Congenital abnormalities Nursing Interventions: - Stimulate fetal scalp - Assist provider with application of scalp electrode - Place client in left-lateral position

Nutritional Needs For The Newborn:

- Desirable growth/development is enhanced by good nutrition - Feeding newborn provides nutritional needs/bonding Normal newborn weight loss immediately after birth and subsequent weight gain should be as follows: - Loss of 5% - 10% after birth (regain 10-14 days after birth) - Gain of 110 - 200 g/week for first 3 months - During first 2 days of life, healthy newborn needs fluid intake of 60-80 mL/kg/24 hr. From 3-7 days, fluid requirement is 100-150 mL/kg/24 hr - Adequate caloric intake is essential to provide energy for growth, digestion, metabolic needs, activity. For first 3 months the newborn requires 110 kcal/kg/day. From 3-6 months the requirement decreases to 100 kcal/kg/day. Both breast milk and formula provide 20 kcal/oz. - Carbs should make up 40% - 50% of newborn's total caloric intake. Most abundant carb in breast milk or formula is lactose - At least 15% calories must come from fat (triclycerides). The fat in breast milk is easier to digest than the fat in cow's milk - For adequate growth/development, newborn should receive 9 g per day of protein from birth to 6 months of age - Breast milk contains vitamins necessary to provide adequate newborn nutrition. - There's Vitamin D in breast milk and supplements needed for formula. - Parents breastfeeding who do not consume meat, fish, dairy should provide Vitamin B12 supplements to newborns Mineral content of commercial newborn formula/breast milk is adequate with exception of iron and fluoride: - Iron is low in all forms of milk but is absorbed better from breast milk. Newborns who only breastfeed should be given iron supplements at 4 months, and until they're able to consume iron-containing foods. Newborns who are formula fed should receive iron-fortified newborn formula until 12 months - Fluoride levels in breast milk and formulas are low. Fluoride supplement should be considered after 6 months, depending on water supply - Solids are not introduced until 6 months. If introduced too early, food allergies can develop

Pain Relief Measures During Labor: Second Stage:

- Epidural (block) analgesia - Combined spinal-epidural (CSE) analgesia - Nitrous oxide - Local infiltration anesthesia - Pudendal block - Spinal (block) anesthesia

Baby-Friendly Care: Nursing Actions:

- Facilitate the bonding process by placing the infant skin-to-skin or in en face position with client immediately after birth - Promote rooming-in as a quiet private environment that enhances the family bonding process - Promote early initiation of breastfeeding and encourage client to recognize infant readiness cues. Offer assistance if needed. - Teach client about infant care to facilitate bonding as client's confidence improves - Encourage parents to bond with infant through cuddling, bathing, feeding, diapering, watching infant - Provide frequent praise, support, reassurance to the client as they move toward independence in caring for infant and adjusting to their parental role - Encourage parents to express feelings, fears, anxieties about caring for the infant

Hydrocephalus:

- Frequently reposition newborn's head to prevent sores - Measure newborn's head circumference daily - Assess for manifestations of increased intracranial pressure (vomiting, shrill cry

Bottle Feeding: Formula:

- Formula can be adequate source of nutrition - Newborn should be fed every 3-4 hr Parents should awaken newborn to feed at least every 3 hr during the day and every 4 hr during the night until newborn is feeding well. Then a feed-on-demand schedule: Nursing Actions: - Teach parents how to prepare formula, bottles, nipples. Review importance of hand hygiene prior to formula prep - Teach parents about different forms of formula (ready-to-feed, concentrated, powder) and how to prepare each correctly Client Education: - Bottles/accessories can be put in dishwasher, boiled, or washed by hand in soapy water using a good bottle and nipple brush - Wash lid of a can of formula with hot soapy water, and shake before opening it - Use tap water to mix concentrated or powder formula. If water sources are questionable, tap water should be boiled first - Prepared formula can be refrigerated for up to 48 hr - Check flow of formula from bottle to ensure it's not coming out too slow/too fast - Do not use formula past expiration date - Cradle newborn in arms in semi-upright position. Newborn should not be placed in supine position during bottle feeding bc of danger of aspiration. Newborns who bottle feed do best when held close and at 45 degree angle - Place nipple on top of newborn's tongue - Keep nipple filled with formula to prevent newborn from swallowing air - Always hold bottle and never prop bottle for feeding - Give newborn opportunities to burp several times during feeding - Place newborn on back after feeding - Discard any unused formula remaining in bottles when newborn is finished Newborn is adequately fed if they are gaining weight, bowel movement is yellow, soft, formed and they're satisfied between feedings: - Infants usually have 6 or more wet diapers a day - Infants who consume breast milk usually have 3 or more bowel movements a day; infants receiving formula have less frequent bowel movements

HIV/AIDS Nursing Care:

- Goal is to keep CD4 cell count greater than 500 cells/mm - Provide counseling prior to and after testing - Refer client for mental health consult, legal assistance, finance resources - Use standard precautions - Administer antiretroviral prophylaxis, triple-medication antiretroviral (ART), or highly active antiretroviral therapy (HAART) as prescribed - Encourage immunization against hepatitis B, pneumococcal infection, Haemophilus influenzae type B, and viral influenza - Encourage use of condoms to minimize exposure if partner is source of infection - Review plan for scheduled cesarean birth at 38 weeks for maternal viral load of more than 1,000 copies/mL - Vaginal birth can be an option for a client who has a viral load less than 1,000 copies/mL at 36 weeks - Wear gloves when caring for newborn delivery - Infant should be bathed after birth before remaining with mother

Nursing Interventions For Postpartum Care: Contraception:

- If breastfeeding do not take oral contraceptives until milk production is well established (usually 6 weeks) - Menses for non-lactating clients might not resume until around 4-10 weeks. Ovulation can occur as early as 1 month after delivery - Menses for lactating patients might not resume for 6 months or until cessation of breastfeeding

Nursing Care Of Newborns: Complications: Cold Stress:

- Ineffective thermoregulation can lead to hypoxia, acidosis, hypoglycemia. Newborns who have respiratory distress are at higher risk for hypothermia Nursing Actions: - Monitor for manifestations (skin pallor with mottling and cyanotic trunk, tachypnea) - Newborn should be warmed slowly over period of 2-4 hr. Correct hypoxia by administering oxygen. Correct acidosis and hypoglycemia

Assessing A Client's Knowledge Of Postpartum Care:

- Inquire about client's current knowledge regarding self-care - Assess client's home support system and who will be there to assist. Include support persons in educational process - Determine client's readiness for learning and their ability to verbalize or demonstrate the information that has been given

Non-Stress Test Interpretations Of Findings:

- Is interpreted as reactive if FHR accelerates at least 15/min (10/min prior to 32 weeks) for at least 15 seconds (10 seconds prior to 32 weeks) and occurs two or more times during a 20-minute period. - Non-reactive NST is a test that does not demonstrate at least two qualifying accelerations in a 20-min window. If this is so, a further assessment such as a contraction stress test or BPP is indicated.

TORCH Nursing Care:

- Monitor fetal well-being - For rubella, immunization of clients who are pregnant is contraindicated bc rubella infection can develop. These clients should avoid large crowds and young children. Clients who have low titers prior to pregnancy should receive immunizations: - Rubella vaccination is received postpartum due to effects on fetus in utero. Clients should avoid pregnancy for 4 weeks (28 days) after receiving this vaccine. - Discuss safe sexual relations - Provide emotional support Medications: - Administer antibiotics as prescribed - Treatment of toxoplasmosis includes sulfonamides or a combination of pyrimethamine and sulfadiazine (potentially harmful to the fetus, but parasitic treatment is essential) Client Education: - Adhere to prevention practices, including correct hand hygiene and cooking meat properly. Avoid contact with contaminated cat litter - Bc no treatment for cytomegalovirus exists, prevent exposure by frequent hand hygiene before eating and after handling infant diapers and toys - A cesarean section is recommended for all clients in labor who have active genital herpes lesions or early findings of impending outbreak (vulvar pain, itching)

Interventions For Home Care Of Newborn: Positioning & Holding Of Newborn (Head Support):

- Newborn has minimal head control - Head should be supported when newborn is lifted bc head is larger and heavier than rest of the body Basic Ways To Hold A Newborn: - Cradle hold: Cradle newborn's head in bend of elbow. This permits eye-to-eye contact and is a good position for feeding - Upright position: Hold newborn upright, and face them toward the holder while supporting the head, upper back, buttocks - Football Hold: Support half the newborn's body in holder's forearm with newborn's head/neck resting in palm of hand. This is good position for breastfeeding and when shampooing newborn's hair

Placenta Previa:

- Occurs when placenta abnormally implants in lower segment of uterus near or over cervical instead of attaching to fundus. - The abnormal implantation results in bleeding during third trimester as cervix os begins to dilate and efface Complete or Total: Cervical os is completely covered by the placental attachment Incomplete or Partial: Cervical os is only partially covered by placental attachment Marginal: Placenta is attached in lower uterine segment but does not reach cervical os Low-lying: Exact relationship of the placenta to the internal os has not been determined

Breastfeeding:

- Optimal source of nutrition for newborns - Recommended exclusively for first 6 months - Newborns should be breastfed every 2-3 hr - Parents should awaken newborn to feed at least every 3 hr during day and at least every 4 hr during night until newborn is feeding well and gaining weight. Breastfeeding should occur 8-12 times within 24 hr then a feed-on-demand schedule: - For first few days after birth, baby receives colostrum (early milk). It's secreted from postpartum client's breast during postpartum days 1-3. It contains immunoglobulin A (IgA) which provides passive immunity to newborn - Nursing interventions can help new parent be successful. Including provision of adequate calories and fluids to support breastfeeding. Practice of rooming-in (allowing clients and newborns to remain together) should be encouraged. Lactation consults can improve success in breastfeeding. Encourage breastfeeding through first 12 months of life.

Neurologic Anomalies (Spina Bifida):

- Protect membrane with a sterile covering and plastic to prevent drying - Observe for leakage of cerebrospinal fluid - Handle newborn gently by positioning them prone to prevent trauma - Prevent infection by keeping area free from contamination by urine and feces - Measure circumference of newborn's heat to identify hydrocephalus - Assess the newborn for increased intracranial pressure

Eclampsia:

- Severe preeclampsia manifestations with onset of seizure activity or coma. - Usually preceded by headache, severe epigastric pain, hyperreflexia, hemoconcentrations, which are warning manifestations of probable convulsions.

Newborn Assessment: Physical Head-To-Toe Exam: Spine:

- Should be straight, flat, midline, easily flexed

Interpretation Of Fetal Lung Maturity Findings:

- Tests for fetal lung maturity can be performed if gestation is less than 37 weeks, in the event of a rupture of membranes, for preterm labor, or for a complication indicating a cesarean birth. - Amniotic fluid is tested to determine whether the fetal lungs are mature enough to adapt to extrauterine life, or if the fetus will likely have respiratory distress. - Determination is made whether the fetus should be removed immediately or if the fetus requires more time in utero with the administration of glucocorticoids to promote fetal lung maturity. Lethin/Sphingomyelin (L/S) Ratio: - 2:1 ratio indicates fetal lung maturity (2.5:1 or 3:1 for a client who has diabetes mellitus) Phosphatidylglycerol (PG): - Absence of PG is associated with respiratory distress

Nursing Care Of Newborns: Therapeutic Procedures: Circumcision:

- Surgical removal of foreskin of penis - Newborn's family makes choice regarding this. - Should not be performed immediately following birth bc newborn's level of vitamin K is at a low point and newborn would be at risk for hemorrhage and also at increased risk for cold stress - Circumcision is usually performed within first few days of life Health Benefits: - Easier hygiene - Decreased risk of STIs - Decreased risk of penile cancer and cervical cacner Possible Risks: - Hemorrhage - Infection - Inflammation of stenosis of urinary meatus - Urethral fistula - Adhesion or dehiscence of skin - Concealed penis Contraindications: - Hypospadias (abnormal positioning of urethra on ventral under-surface of penis) and episadias (urethral canal terminates on dorsum of penis) bc the prepuce skin can be needed for surgical repair of defect - Family history of bleeding disorders - Newborns who do not receive Vitamin K making them more likely to experience bleeding at circumcision site Pre-Procedure Nursing Assessment: - Family history of bleeding tendencies (hemophilia, clotting disorders) - Hypospadias or epispadias - Ambiguous genitalia (can include male and female) - Illness/infection Nursing Actions: - Obtained signed informed consent - Gather/prepare supplies - Administer meds. Assist with procedure: - Place newborn on restraining board and provide a radiant heat source to prevent cold stress. Do not leave unattended. Have bulb syringe readily available - Comfort newborn as needed - Document time/type of circumcision, amount of bleeding, newborn voiding following procedure Intraprocedure: - Anesthesia: Is required. Can be ring block, dorsal-penile nerve block, topical anesthetic (eutectic mixture of local anesthetics) and concentrated oral sucrose. Non-pharmacological Methods: Swaddling, non-nutritive sucking can be used to enhance pain management Equipment: Gomco (Yellen) or Mogen clamp, or Plastibell device: - Provider applies the Gomco (Yellen) or Mongen clamp to penis, loosens foreskin, inserts the cone under foreskin to provide a cutting surface for removal of foreskin and to protect penis. Using the clamp reduces the amount of blood lost. The wound is covered with sterile petroleum gauze to prevent infection and control bleeding - Provider slides the Plastibell device between the foreskin and glans of the penis. Provider ties a suture tightly around foreskin at coronal edge of the glans. This applies pressure as the excess foreskin is removed from penis. After 5-7 days the Plastibell drops off leaving a clean, healed excision. No petroleum is used for circumcision with the Plastibell Post-Procedure: Nursing Assessment: - Bleeding (assess every 15-30 min for first hour then hourly for the next 4-6 hr) - The first voiding Nursing Actions: - Remove newborn from restraining board and swaddle to comfort - Monitor for bleeding/voiding. Apply gauze lightly to penis if bleeding/oozing happens - Fan-fold diapers to prevent pressure on circumcision area - Liquid acetaminophen 10-15 mg/kg can be administered orally after procedure and repeated every 4-6 hr as prescribed for a max. of 30-45 mg/kg/day - Provide discharge instructions to parents about manifestations of infection, comfort measures, meds., when to notify provider Client Education: - Signed informed consent is needed - Newborn will not be able to be bottle fed for up to 2-3 hr prior to procedure to prevent vomiting and aspiration based. Newborns can be breastfed up until procedure - Newborn is restrained on a board during the procedure - Keep area clean. Change newborn's diaper at least every 4 hr and clean penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after circumcision to keep diaper from adhering to penis. - Avoid wrapping penis to tight gauze, which can impair circulation of glans - Do not give a tub bath until circumcision healed. Until then, trickle warm water gently over penis - Notify provider if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from newborn - A film of yellowish mucus can form over glans by day two. Do not wash off - Avoid using pre-moistened towelettes to clean penis bc they contain alcohol - Newborn can be fussy or can sleep several hours after. - Circumcision should heal completely within a couple weeks - Report any frank bleeding, foul-smelling drainage, or lack of voiding to provider Complications: Hemorrhage: - Monitor for bleeding - Provide gentle pressure on penis using small gauze square. Gelfoam powder or sponge can be applied to stop bleeding. If bleeding persists, notify provider that a blood vessel might need to be ligated. Have a nurse continue to hold pressure until provider arrived while another nurse prepares circumcision tray and suture material. Cold Stress/Hypoglycemia: - Monitor for excessive loss of heat resulting in increased respirations and lowered body temp. - Swaddle and feed the newborn as soon as procedure is over

Powers:

- Uterine contractions cause effacement (shortening and thinning of cervix) during first stage of labor and dilation of cervix (enlargement or widening of cervical opening and canal) that occurs once labor has begin and fetus is descending. - Involuntary urge to push and voluntary bearing down in the second stage of labor helps in the expulsion of the fetus

Monitoring Newborn For Adequate Growth:

- Weights are done in newborn nursery. Every newborn should be seen/examined at provider's office within 3-5 days after discharge from hospital and again at 2 weeks. Growth is assessed by placing newborn's weight on a growth chart. Adequate growth should be within the 10th-90th percentile. Poor weight gain is below 10th percentile and too much weight gain is above 90th percentile. - newborn's length and head circumference are also routinely monitored - Assess parent's ability to feed newborn (breast or bottle) - Calculate newborn's 24 hr I/O if indicated to ensure adequate nutrition Assessment Of Newborn Nutrition: - Begins during pregnancy and continues after birth Newborn: - Maturity level - History of labor/delivery - Birth traua - Congenital defects - Physical stability - State of alertness - Presence of bowel sounds Parent: - Previous experience with breastfeeding - Knowledge about breastfeeding - Cultural factors - Feelings about breastfeeding - Physical features of breasts - Physical/psychological readiness - Support of family/significant others

Newborn Assessment: Gestational Age Assessment: New Ballard Score:

A newborn maturity rating score used to assess neuromuscular and physical maturity: - Each individual assessment parameter displays at least 6 ranges of development along a continuum - Each range of development within an assessment is assigned a number value from -1 to 5. The totals are added to give a maturity rating in weeks gestation (EX: a score of 35 indicates 38 weeks of gestation) Neuromuscular Maturity: - Posture ranging from fully extended to fully flexed (0-4) - Square window formation with neonate's wrist (-1 to 4) - Arm recoil, where neonate's arm is passively extended and spontaneously returns to flexion (0-4) - Popliteal angle, which is degree of angle to which newborn's knees can extend (-1 to 5) - Scarf sign which is crossing neonate's arm over chest (-1 to 4) - Heel to ear which is how far neonate's heels reach their ears (-1 to 4) Physical Maturity: - Skin texture ranging from sticky to transparent to leathery, cracked, wrinkled (-1 to 5) - Lanugo presence and amount ranging from none, sparse, abundant, thinning, bald, mostly bald (-1 to 4) - Plantar surface creases ranging from less than 40 mm to creases over entire sole (-1 to 4) - Breast tissue amount ranging from imperceptible to full areola with a 5 to 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 with deep rugae for males (-1 to 4) and prominent clitoris with flat labia to the labia majora covering the labia minora and clitoris for females (-1 to 4)

A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? A) "Apply cold compresses between feedings." B) "Take a warm shower right after feedings." C) "Apply breast milk to the nipples and allow them to air dry." D) "Use the various infant positions for feedings."

A) "Apply cold compresses between feedings."

A nurse education in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? A) "They are tablets administered vaginally." B) "They act by absorbing fluid from tissues." C) "They promote dilation of the os." D) "They include an amniotomy."

A) "They are tablets administered vaginally."

A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across newborn's lower back. The nurse should include which of the following in the teaching? A) "This is more commonly seen in newborns who have dark skin." B) "This is a finding indicating hyperbilirubinemia." C) "This is a forcep mark from an operative delivery." D) "This is related to prolonged birth or trauma during delivery."

A) "This is more commonly seen in newborns who have dark skin."

A nurse is providing discharge teaching for a non-lactating client. Which of these instructions should the nurse include in the teaching? A) "Wear a supportive bra continuously for first 72 hours." B) "Pump your breast every 4 hours to relieve discomfort." C) "Use breast shells throughout the day to decrease milk supply." D) "Apply warm compresses until milk suppression occurs."

A) "Wear a supportive bra continuously for first 72 hours."

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A) Assist client into left-lateral position B) Apply a fetal scalp electrode C) Insert an IV catheter D) Perform a vaginal exam

A) Assist client into left-lateral position

A nurse is caring for a client who is at 32 weeks of gestation and has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following medications should the nurse expect the provider will prescribe? A) Betamethasome B) Indomethacin C) Nifedipine D) Methylergonovine

A) Betamethasome

A nurse on the postpartum unit is assessing a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse expect? SATA A) Calf tenderness to palpation B) Mottling of the affected extremity C) Elevated temperature D) Area of warmth E) Report of nausea

A) Calf tenderness to palpation C) Elevated temperature D) Area of warmth

A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A) A client who has an episiotomy that is erythematous and has extended into a third-degree laceration B) A client who does not wash their hands between perineal care and breastfeeding C) A client who is not breastfeeding and is using measures to suppress lactation D) A client who has a cesarean incision that is well-approximated with no drainage

B) A client who does not wash their hands between perineal care and breastfeeding

Newborn Assessment: Complications:

Airway Obstruction Related To Mucus: Nursing Action: Suction mouth and then nose with a bulb syringe. Mouth should be suctioned first to prevent aspiration as nose is suctioned. Hypothermia: Nursing Action: - Monitor axillary temp. Healthy newborn temp averages (37C) 98.6F with a range of (36.5C - 37.5C) 97.7-99.5F - If temp. is unstable, place newborn in radiant warmer and maintain skin temp. at approx. 36.5C (97.7F). Ideal method for promoting warmth and maintaining neonate's body temp. for a stable newborn is easily skin-to-skin contact with parents. If infant does not remain skin-to-skin with parent during first 1-2 hr after birth, place thoroughly dried infant under radiant warmer or a warm incubator until body temp. stabilizes - Assess axillary temp. every hour until stable - All exams and assessments should be performed while newborn is under a radiant warmer during skin-to-skin contact with parent Inadequate Oxygen Supply: - Related to obstructed airway, poorly functioning cardiopulmonary system, or hypothermia Nursing Action: - Monitor respirations and for indication of cyanosis (changes in skin, mucous membrane color) - Stabilize the body temp. or clear airway as indicated, administer oxygen, and if needed prepare for resuscitation

A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? A) A client who experienced a precipitous labor less than 3 hr in duration B) A client who had premature rupture of membranes and prolonged labor C) A client who delivered a large for gestational age infant D) A client who had a boggy uterus that was not well-contracted

B) A client who had premature rupture of membranes and prolonged labor

Newborn Assessment: Physical Assessment Of Newborn Following Birth:

Apgar Scoring: And a brief physical exam is done immediately following birth to rule out abnormalities Equipment For Newborn Assessment: - Bulb syringe: Used for suctioning excess mucus from mouth/nose - Stethoscope w/ pediatric head: Used to evaluate heart rate, breath sounds, bowel sounds - Axillary thermometer: Used to monitor temperature and prevent hypothermia. Rectal temps. are avoided bc they can injure the delicate rectal mucosa; an initial rectal temp. can be obtained to evaluate for anal abnormalities - Blood pressure cuff: Electronic method. Blood pressure can be done in all 4 extremities if evaluating newborn for cardiac problems - Scale with protective cover in place: Scale should be at 0; weight should include pounds, ounces, grams - Tape measure in cm: Measure from crown to heel of foot for length. Measure head circumference at greatest diameter (occipital to frontal). Measure chest circumference beginning at nipple line, and abdominal circumference above umbilicus - Clean gloves: Worn for all physical assessment until discharge

A nurse is caring for a newborn who was born 38 weeks of gestation, weights 3,200 g, and is in 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which? A) Low birth weight B) Appropriate for gestational age C) Small for gestational age D) Large for gestational age

B) Appropriate for gestational age

Dietary Complications During Pregnancy: Diabetes Mellitus:

Both pre-existing and gestational are complications that require nutritional interventions. - Monitor amount of carbohydrates in the diet and keep glucose levels within target range - Limit amount of sweets and desserts, which typically have large amounts of carbohydrates - Meet with a registered dietitian

A nurse is reviewing a new prescription for ferrous sulfate with a client who is 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? A) "I will take this pill with my breakfast." B) "I will take this medication with a glass of milk." C) "I plan to drink more orange juice while taking this pill." D) "I plan to add more calcium-rich foods to my diet while taking this medication."

C) "I plan to drink more orange juice while taking this pill."

A nurse is caring for a client following administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about purpose of IV fluids. Which of the following statements should the nurse make? A) "It's needed to promote increased urine output." B) "It's needed to counteract respiratory depression." C) "It's needed to counteract hypotension." D) "It's needed to prevent oligohydramnios."

C) "It's needed to counteract hypotension."

Leopold Maneuvers:

Consist of performing external palpations of maternal uterus through abdominal wall to determine the following: - Presenting part, fetal lie, fetal attitude - Degree of descent of representing part into the pelvis - Location of fetus's back to assess for fetal heart tones: --Vertex Presentations: Fetal heart tones should be assessed below client's umbilicus in either the right or lower-left quadrant of abdomen -- Breech Presentation: Fetal heart tones should be assessed above the client's umbilicus in either the right or left-upper quadrant of the abdomen

A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A) Nifedipine B) Pyridoxine C) Ferrous sulfate D) Calcium gluconate

D) Calcium gluconate

Neonatal Substance Withdrawal: Assessments:

Expected Findings: - CNS: High-pitched, shrill cry; incessant crying; irritability; tremors; hyperactivity with increased Moro reflex; increased deep-tendon reflexes; increased muscle tone; disturbed sleep pattern; hypertonicity; convulsions - Metabolic, vasomotor, respiratory findings: Nasal congestion with flaring, frequent yawning, skin mottling, retractions, apnea, tachypnea greater than 60/min, sweating, temperature greater than 37.2C (99F) - Gastrointestinal: Poor feeding, regurgitation (projectile vomiting); diarrhea; excessive, uncoordinated, constant sucking Opiate Withdrawal: Manifestations of neonatal abstinence syndrome Heroin Withdrawal: - Low birth weight - Small for gestational age - Manifestations of neonatal abstinence syndrome - Increased risk of sudden infant death syndrome (SIDS) Methadone Withdrawal: Manifestations of neonatal abstinence syndrome: - Increased incidence of seizures, sleep pattern disturbances, stillbirth, SID, higher birth weights (compared to heroin exposure) Marijuana Withdrawal: - Preterm birth, intrauterine growth restriction - Long-term effects such as deficits in attention, cognition, memory, motor skills Amphetamine Withdrawal: - Preterm or SGA, drowsiness, jitteriness, sleep pattern disturbances, respiratory distress, frequent infections, poor weight gain, emotional disturbances, delayed growth and development Alcohol Withdrawal: - Jitteriness, irritability, increased tone and reflex responses, seizures Fetal Alcohol Syndrome: - Facial anomalies: small eyes, flat midface, smooth philtrum, thin upper lip, eyes with wide-spaced appearance, epicanthal folds, strabismus, ptosis, poor suck, small teeth, cleft lip or palate - Many vital organ anomalies such as heart defects, including atrial and ventricular septal defects, tetralogy of Fallot, patent ductus arteriosus - Development delays and neurologic abnormalities - Prenatal and postnatal growth delays - Sleep disturbances Lab Tests: - CBC - Blood glucose - Thyroid-stimulating hormone, thyroxine, triiodothyronine - Drug screen of urine or meconium to reveal substance used by parent - Hair analysis Diagnostic Procedures: - Chest x-ray for fetal alcohol syndrome to rule out congenital heart defects

PostPartum Disorders: Coagulopathies:

Idiopathic Thrombocytopenic Purpura (ITP): Is a coagulopathy that is an autoimmune disorder in which life span of platelets is decreased by antiplatelet antibodies. This can result in severe hemorrhage following a c-section birth or lacerations. Disseminated Intravascular Coagulation (DIC): Is a coagulopathy in which clotting and anti-clotting mechanisms occur at same time. The client is at risk for both internal/external bleeding as well as damage to organs resulting from ischemia caused by microclots - Coagulopathies are suspected when usual measures to stimulate uterine contractions fail to stop vaginal bleeding Risk Factors: ITP: Genetic in origin DIC: Can occur secondary to other complications: - Abruptio placentae (most common) - Amniotic fluid embolism - Missed abortion - Fetal death in utero (fetus has died but is retained in uterus for at least 6 weeks) - Severe preeclampsia or eclampsia (gestational hypertension), HELLP syndrome - Septicemia - Cardiopulmonary arrest - Hemorrhage - Hydatidiform mole Expected Findings: - Unusual spontaneous bleeding from gums/nose - Oozing, trickling, or flow of blood from incision, lacerations, episiotomy - Petechiae and ecchymoses - Excessive bleeding from venipunctures, injection sites, or slight traumas - Hematuria - GI bleeding - Tachycardia, hypotension, diaphoresis Lab Tests: - CBC with differential - Blood typing/crossmatch Clotting Factors: - Platelet levels (thrombocytopenia): Decreased - Fibrinogen levels: Decreased - PT: Prolonged - Fibrin split product levels: Increased - D-dimer test (specific fibrin degradation fragment): Increased Nursing Care: - Assess skin, venipuncture, injection sits, lacerations, episiotomy for bleeding - Monitor vitals and hemodynamic status - Monitor urinary output, usually by insertion of indwelling catheter - Transfuse platelets, clotting factors, other blood products, or volume expanders - Assist in preparing client for splenectomy if ITP does not respond to medical management and provide post-surgical care - Ensure optimal oxygenation DIC: Focus is on assessing for and correcting underlying cause (remove of dead fetus or placental abruption, treatment of infection, preeclampsia, or eclampsia) - Administer fluid volume replacement, which can include blood and blood products - Administer pharmacological interventions including antibiotics, vasoactive meds, and uterotonic agents - Administer supplemental oxygen - Provide protection from injury Therapeutic Procedures: - Correction of underlying cause - Splenectomy: Can be performed by provider if ITP does not respond to medical management - Surgical intervention (hysterectomy) for DIC: Performed by provider as indicated

Dietary Complications During Pregnancy: Maternal Phenylketonuria:

Maternal genetic disease in which high levels of phenylalanine pose a danger to fetus (intellectual disability, behavioral problems) - It's important for the client to resume the PKU diet for at least 3 months prior to pregnancy and continue diet throughout pregnancy - Diet includes foods that are low in phenylalanine. Foods high in protein (fish, poultry, eggs, meat, nuts, dairy products) must be avoided due to high phenylalanine levels. Aspartame, which contains phenylalanine, should be avoided by pregnant clients who have PKU. - Client's blood phenylalanine levels are monitored during pregnancy

Baby-Friendly Care: Complications:

Nursing Actions: - Emphasize verbal and non-verbal communication skills between the client, caregivers, and infant - Provide continued assessment of client's parenting abilities as well as any other caregivers for the infant - Encourage continued support of grandparents and other family members - Provide home visits and group sessions for discussion regarding infant care and parenting problems - Give client and caregivers information about social networks that provide a support system where they can seek assistance - Notify programs that provide prompt and effective community interventions to prevent more serious problems from happening

Labor & Delivery Pre-Procedure:

Nursing Actions: - Lepoid Maneuvers: Abdominal palpation of fetal presenting part, lie, attitude, descent, and probable location where fetal heart tones can be best auscultated on client's abdomen - External electronic monitoring (tocotransducer): Separate transducer applied to maternal abdomen over fundus that measures uterine activity: Displays uterine contraction patterns, Easily applied by nurse but must be repositioned with maternal movement to ensure proper placement - External fetal monitoring (EFM): Transducer applied to abdomen of client to assess FHR patterns during labor and birth. Lab Analysis: - Group B streptococcus: Culture is obtained if results are not available from screening at 35-37 weeks. If positive, an intravenous prophylactic antibiotic is prescribed Urinalysis: Clean-catch urine sample obtained to assess patient for: - Dehydration via specific gravity - Ketonuria (impaired nutrition or uncontrolled glucose) - Proteinuria which can be indicative of gestational hypertension or preeclampsia - Glucosuria which can be indicative of gestational diabetes - Urinary tract infection via bacterial count (more common in clients who have diabetes mellitus) - Blood tests: CBC level, ABO typing and Rh-factor if not previously done Client Education: - The health care team will update you regarding labor and delivery process. - Ask questions for any procedures or information you do not understand.

Co-Parent Adaptation:

Occurs through bonding with infant through these behaviors: - Using skin-to-skin contact, holding infant, engaging in eye-to-eye contact - Observing infant for similarities to parent's own features - Talking, singing, reading to infant

Postpartum Musculoskeletal System:

Physical changes involve a reversal of musculoskeletal adaptations that occurred during pregnancy. By 6-8 weeks after birth: - Joints return to their pre-pregnant state and are completely restabilized. The feet can remain permanently increased in size - Muscle tone begins to be restored throughout body with removal of progesterone's effect following delivery of placenta. The rectus abdominis muscles of abdomen and pubococcygeus muscle tone are restored following placental expulsion and return to the pre-pregnant state about 6 weeks postpartum Assessment: - Assess for changes - Assess abdominal wall for diastasis recti (separation of rectus muscle). It usually resolves within 6 weeks Patient-Centered Care: - Prevent falls by encouraging client to wear non-skid slippers/socks, assisting client with getting out of bed, instructing client to call for assistance initially when getting out of bed Client Education: - Perform postpartum strengthening exercises, starting with simple exercises, then progressing to harder ones - Following c-section, postpone abdominal exercises until about 4-6 weeks after delivery - Use good body mechanics to and proper posture - Ambulate soon after delivery - Perform kegel exercises to strengthen pelvis muscles

Non-Stress Test Indications:

Potential Diagnosis: - Assessing for intact fetal CNS during third trimester. - Ruling out risk for fetal death in clients who have diabetes mellitus. Used twice a week starting at 28-32 weeks of gestation Client Presentation: - Decreased fetal movement - Intrauterine growth restriction - Postmaturity - History of gestational hypertension or diabetes mellitus - Systematic lupus erythematosus - Kidney disease - Intrahepatic cholestatsis - Oligohydramnios - Multiple gestation

Amniocentesis Nursing Actions:

Pre-Procedure: Nursing Action: - Explain the procedure to the client and obtain informed consent Client Education: - Empty the bladder prior to the procedure to reduce its size and reduce risk of inadvertent puncture Intra-Procedure: Nursing Action: - Obtain and document baseline vital signs and FHR prior to procedure - Assist client in supine position and place a wedge under their right hip to displace the uterus off the vena cava and place a drape over the client exposing only the abdomen - Prepare the client for an ultrasound to locate the placenta - Cleanse abdomen with an antiseptic solution prior to the administration of a local anesthetic by the provider. Client Education: - Understand there will be a feeling of slight pressure as the needle is inserted. - Continue breathing, because holding breath will lower the diaphragm against the uterus and shift off the intrauterine contents. Post-Procedure: Nursing Actions: - Administer Rho(D) immune globulin to client if they are Rh-negative Client Education: - Report to the provider if experiencing fever, chills, leakage of fluid or bleeding from the insertion site, decreased fetal movement, vaginal bleeding, or uterine contractions after the procedure.

Cesarean Birth: Procedure:

Pre-Procedure: - Assess/record FHR and vitals - Assist with obtaining an ultrasound to determine whether cesarean birth indicated - Position client in supine position with wedge under one hip to prevent compression of vena cava - Insert indwelling catheter - Ensure client has signed informed consent - Apply a sequential compression device - Administer preoperative medications - Prepare surgical site - Insert IV catheter and initiate IV fluids - Determine whether client had nothing by mouth since midnight before procedure. If client has, notify anesthesiologist - Ensure pre-op diagnostic tests are complete including Rh-factor test - Explain procedure - Provide emotional support Intraprocedure: - Assist in positioning client on operating table - Continue to monitor FHR - Continue to monitor vitals, IV fluids, urinary output - Conduct instrument and sponge counts Post-Procedure: - Monitor for evidence of infection and excessive bleeding at incision site - Assess uterine fundus for firmness or tenderness - Assess lochia for amount and characteristics (tender uterus and foul-smelling lochia can indicate endometritis) - Assess for productive cough or chills, which could be pneumonia - Assess for indications of thrombophlebitis which includes tenderness, pain, heat on palpation - Monitor I/O - Monitor vitals - Provide pain relief and antiemetics as prescribed - Encourage client to turn, cough, deep breathe to prevent pulmonary complications - Encourage splinting of incision with pillows - Encourage ambulation to prevent thrombus formation - Assess client for burning and pain on urination which could be UTI Maternal Complications: - Aspiration - Amniotic fluid pulmonary embolism - Wound infection - Wound dehiscence - Severe abdominal pain - Thrombophlebitis - Hemorrhage - UTI - Injuries to bladder/bowel - Anesthesia associated complications Fetal Complications: - Premature birth of fetus if gestational age is inaccurate - Fetal injuries during surgery

Leopold Maneuvers: Considerations:

Preparation Of Client: - Ask client to empty bladder before - Place in supine position with a pillow under head and have both knees slightly flexed - Place a small rolled towel under clients right or left hip to displace uterus off major blood vessels to prevent supine hypotensive syndrome Ongoing Care: - Identify fetal part occupying the fundus. The head should feel round, firm, and move freely. The breech should feel irregular and soft. This maneuver identifies the fetal lie (longitudinal or transverse) and presenting part (cephalic or breech) - Locate/palpate smooth contour of fetal back using palm of one hand and irregular small parts of hands, feet, elbows using palm of other hand. This maneuver validates the presenting part - Determine the part that is presenting over the true pelvis inlet by gently grasping lower segment of uterus between thumb and fingers. If head is presenting and not engaged, determine whether the head is flexed/extended. This maneuver assists in identifying the descent of presenting part into the pelvis - Face client's feet and outline the fetal head using palmar surface of fingertips on both hands to palpate the cephalic prominence. If the cephalic prominence is on same side as small parts, the head is flexed with vertex presentation. If cephalic prominence is on same side as back, the head is extended with a face presentation. This maneuver identifies fetal attitude Interventions: - Auscultate the FHR post-maneuvers to assess the fetal tolerance to procedure - Document the findings from the maneuvers

Continuous Electronic Fetal Monitoring: Considerations:

Preparation Of Client: - Based on findings obtained form Leopold maneuver auscultate FHR using listening device - Palpate fundus to identify uterine activity for proper placement of tocotransducer to monitor uterine contractions Ongoing Care: - Provide education regarding procedures to client during placement and adjustments of fetal monitor equipment. - Encourage frequent maternal position changes which can require adjustments of transducers with position changes - If client needs to void and can ambulate and it is not contraindicated the nurse can disconnect the external monitor for them to use the bathroom - If disconnecting FHR monitor is contraindicated or an internal FHR monitor is being used, the nurse can bring the client a bedpan

Continuous Internal Fetal Monitoring: Considerations:

Preparation Of Client: - Ensure electronic fetal monitoring equipment is functioning properly - Use aseptic techniques when assisting with procedures Ongoing Care: - Monitor maternal vitals and obtain maternal temperature every 1-2 hr - Encourage frequent repositioning of client. If client is lying supine, place wedge under one hip to tilt uterus Complications: - Misinterpretation of FHR patterns - Maternal or fetal infection - Fetal trauma if fetal monitoring electrode of IUPC are inserted into vagina properly - Supine hypotension secondary to internal monitor placement

Postpartum Immune System:

Rubella: A client who is non-immune to rubella or has negative or low titer is administered a subcutaneous injection of rubella vaccine or a measles, mumps, rubella (MMR) vaccine during postpartum period to protect a subsequent fetus from malformations. The client should not get pregnant for 4 weeks following immunization Rh: All Rh-negative clients who have newborns who are Rh-positive must be given Rho(D) immune globulin IM within first 72 hr of newborn being born to suppress antibody formation in mother - Test client who receives both a live virus vaccine, such as rubella, and Rho(D) immune globulin after 3 months to determine whether immunity to rubella has developed Varicella: If client has no immunity, varicella vaccine is administered before discharge. The client should not get pregnant for 1 month following immunization.. A second dose of vaccine is given at 4-8 weeks Tetanus-diptheria-acellular pertussis vaccine: The vaccine is recommended for clients who have not previously received it. It's also recommended for people who are going to be around the baby frequently if they have not received it previously. Administer prior to discharge or ASAP in postpartum period. Breastfeeding is not contraindicated

Newborn Assessment: Physical Head-To-Toe Exam: Pain Assessment:

Scales: - CRIES scale - Scale for use in newborns (SUN) - Neonatal infant pain scale (NIPS) Behavioral Responses To Pain: - Alterations in sleep-wake cycles, feeding, activity - Fussiness or irritability - Limb withdrawal; thrashing or fist-clenching; muscle rigidity or flaccidity - Facial grimacing: Chin quivering, furrowed brow; tightly closed eyes; open, square-shaped mouth - Crying, groaning, whimpering Physiologic Response To Pain: - Vitals: Rapid or shallow respirations; decreased oxygen saturation; increased heart rate/bp - Skin: Pallor or flushing; palmar or general diaphoresis - Lab Findings: Hyperglycemia, decreased pH, increased blood corticosteroid levels - Other: Increased muscle tone, decreased vagal nerve tone, increased intracranial pressure, dilated pupils

Causes Of Bleeding During Pregnancy: First Trimester:

Spontaneous Abortion: Vaginal bleeding, uterine cramping, and partial or complete expulsion of products of conception Ectopic Pregnancy: Abrupt unilateral lower-quadrant abdominal pain with or without vaginal bleeding

Baby-Friendly Care: Assessment:

This assessment includes noting client's condition after birth, observing maternal adaptation process, assessing maternal emotional readiness to care for infant, and assessing how comfortable client appears in providing infant care. Assess for behaviors that facilitate and indicate parent-infant bonding: - Considers the infant a family member - Holds infant face-to-face (en face position) maintaining eye contact - Assigns meaning to the infant's behavior and views this positively - Identifies the infant's unique characteristics and relates them to those of other family members - Names infant, indicating bonding is occurring - Touches infant and maintains close physical proximity and contact - Provides physical care for the infant (feeding, diapering) - Response to infant's cries - Smiles at, talks to, sings to infant Assess for behaviors that impair/indicate lack of parent-infant bonding: - Apathy when infant cries - Disgust when infant voids, stools, spits up - Expresses disappointment in infant - Turns away from infant - Does not seek close physical proximity to infant - Doesn't talk about infant's unique features - Handles infant roughly - Ignores infant entirely - Doesn't include infant in family context - Perceives infant behavior as uncooperative Assess for manifestations of mood swings, conflict about maternal role, or personal insecurity: - Feelings of being "down" - Feelings of inadequacy - Feelings of anxiety - Emotional liability with frequent crying - Flat affect and being withdrawn - Feeling unable to care for infant

Therapeutic Procedures To Assist W/ Labor/Delivery: 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 (firm, medium, soft) - Cervical position (posterior, mid-position, anterior) - Station of presenting part - The 5 factors are assigned in numerical value of 0-3 and the total score calculated Indications: Potential diagnoses: Any condition in which augmentation or induction of labor is indicated Client readiness: Bishop score for client at 39 weeks of gestation should be a score of 8 or more which is an indication of successful induction

Client Education About Nutrition: Limit Caffeine:

- Daily intake of no more than 200 mg of caffeine - Excessive intake can contribute to infertility, spontaneous abortion, or intrauterine growth restriction (IUGR) - Abstain from alcohol during pregnancy

Expected Findings In Pregnant Client: Skin Change: Linea Nigra:

- Dark line of pigmentation from the umbilicus extending to the pubic area

High Risk Pregnancy: Percutaneous Umbilical Blood Sampling:

(Cordocentesis) - Most common method used for fetal blood sampling and transfusion. - Obtains fetal blood from the umbilical cord by passing a fine-gauge, fiber-optic scope (fetoscope) into the amniotic sac using the amniocentesis technique - The needle is advanced into the umbilical cord under ultrasound guidance and blood is aspirated from the umbilical vein. - Blood studies from this can be: Kleihauer-Betke test ensures that fetal blood was obtained, CBC count with differential, indirect Coombs' test for Rh antibodies, Karyotyping (visualization of chromosomes), blood gases Indications: - Determine fetal blood type - Anemia screening Potential Diagnosis: - Fetal chromosomal disorders - Karyotyping of malformed fetuses - Fetal injection - Altered acid-base balance of fetuses with IUGR Nursing Actions: - Administer medication as prescribed - Offer support - Monitor the FHR as prescribed following procedure Client Education: - Count fetal movements Interpretations Of Findings: - Evaluated for isoimmune fetal hemolytic anemia - Assesses the need for fetal blood transfusion - Determines specifics regarding genetic mutations Complications: - Cord laceration - Preterm labor - Hematoma - Fetomaternal hemorrhage

Pharmacological Pain Management: Analgesia: Opioid Analgesics:

- (Meperidine, hydrochloride, fentanyl, butorphanol, nalbuphine) act in the CNS to decrease the perception of pain without loss of consciousness. - Can be IM or IV but the IV route is recommended during labor bc the action is quicker - Usually given during early part of active labor Butorphanol & nalbuphine: Provide pain relief without causing significant respiratory depression in mother/fetus. Both IM/IV routes used. Adverse Effects: - Respiratory depression in neonate if mother medicated too close to time of delivery - Reduction of gastric emptying: increased risk for nausea/emesis - Increased risk for aspiration of food or fluids in stomach - Bladder/bowel elimination can be inhibited - Sedation - Altered mental status - Tachycardia - Hypotension - Decreased FHR variability - Allergic reaction Nursing Action: - Prior to administering analgesic, verify that labor is well established by performing vaginal exam - Administer antiemetics as prescribed - Monitor maternal vitals, uterine contraction pattern, and continuous FHR monitoring. Assess maternal vitals and fetal heart rate pattern and documented before/after administration of opioids for pain relief - Assess for adverse reactions (difficulty breathing) and be prepared to administer antidotes whenever medication is administered (Naloxone) Client Education: - The medication will cause drowsiness - Request assistance with ambulation

Pharmacological Pain Management: Analgesia: Sedatives (Barbiturates):

- (Secobarbital, pentobarbital, phenobarbital, are not typically used during birth, but they can be used during early/latent phase of labor to relieve anxiety and induce sleep Adverse Effects: - Neonate respiratory depression secondary to medication crossing the placenta and affecting fetus. These medications should not be administered if birth is anticipated within 12-24 hrs. - Unsteady ambulation of client - Inhibition of mother's ability to cope with pain of labor. Sedatives shouldn't be given if client is experiencing pain bc apprehension can increase and client can become hyperactive/disoriented Client Education: - Medication will cause drowsiness - Request assistance to ambulate Nursing Actions: - Dim lights, provide quiet atmosphere - Provide safety for client by lowering position of bed and elevating side rails - Assist mother to cope with labor - Assess neonate for respiratory depression

First Stage Of Labor:

- 12.5 hr duration Latent Phase: - Cervical dilation of 0-3 cm - Onset of labor - Contractions: irregular, mild to moderate at 5-30 min. and lasting 30-45 seconds. - Some dilation and effacement - Talkative and eager Active Phase: - Cervical dilation of 4-7 cm - Contractions more regular, moderate to strong at 3-5 min lasting 40-70 seconds. - Rapid dilation and effacement - Some fetal descent - Feeling of helplessness - Anxiety and restlessness increase as contractions become stronger Transition: - Cervical dilation of 8-10 cm - Contractions are strong to very strong at 2-3 min lasting 45-90 seconds - Complete dilation - Tired, restless, irritable - Feeling out of control, client often states "cannot continue" - Can have nausea and vomiting - Urge to push - Increased rectal pressure and feelings of needing to have a bowel movement - Increased bloody show - Most difficult part of labor

Second Stage Of Labor:

- 30min- 2 hr - Full dilation - Progresses to intense contractions ever 1-2 min. - Birth - Pushing results in birth of fetus

Third Stage Of Labor:

- 5-30 min - Delivery of the neonate - Delivery of placenta - Placental separation and expulsion - Schultze presentation: shiny fetal surface of placenta emerges first - Duncan presentation: dull maternal surface of placenta emerges first

Client Education About Nutrition: Fluid:

- 8-10 glasses (2.3 L) of fluid are recommended daily - Preferred fluids are: water, fruit juice, milk

Preterm Labor Medications: Terbutaline:

- A beta-adrenergic agonist is used as a tocolytic that relaxes smooth muscles and inhibits uterine activity. Nursing Actions: - Assess for history of cardiac disease, pre-gestational or gestational diabetes, preeclampsia with severe features of eclampsia, severe gestational hypertension, hyperthyroidism, or significant hemorrhage. If the client has any of these, the medication should not be given. - Monitor for chest discomfort, palpitations, dysrhythmia, hypokalemia, hyperglycemia, and hypotension. - Notify provider of heart rate greater than 130/min, chest pain, cardiac arrhythmias, myocardial infarction, blood pressure less than 90/60 mmHg, or pulmonary edema. - Administer 0.25 mg subcutaneously every 4 hr for up to 24 hr - Discontinue if client can't tolerate adverse effects

Postpartum Psychosocial:

- A client can experience many different emotions due to hormonal changes. - Monitor for conditions such as postpartum blues and depression Assessment/Interventions: - Allow verbalization of feelings - Assess emotional status - Observe for bonding with infant Monitor for manifestations of postpartum blues/depression - Decreased appetite - Difficulty sleeping - Decreased interaction with others - Lack of communication Patient-Centered Care: - Encourage skin-to-skin contact with baby after delivery - Document interactions/bonding concerns - Encourage rooming with baby in client's room at all times - Provide support and initiate referrals as needed for counseling

Preterm Labor Medications: Betamethasone:

- A glucocorticoid that is given IM in 2 injections 24 hrs apart and requires 24 hr to be effective. The therapeutic action is to enhance fetal lung maturity and surfactant production in fetuses between 24-34 weeks. Nursing Actions: - Administer 12 mg IM for 2 doses 24 hr apart - Ideally give this at least 24 hr (but not more than 7 days) before delivery - Give deep IM using ventral gluteal or vastus lateralis muscle - Monitor for maternal hyperglycemia - Assess the preterm infant's lung sounds Client Education: - Report findings of pulmonary edema (chest pain, shortness of breath, crackles)

Ectopic Pregnancy (2):

- Abnormal implantation of a fertilized ovum outside of the uterine cavity usually in the fallopian tube, which can result in tubal rupture causing a fatal hemorrhage - Second most frequent cause of bleeding in early pregnancy and leading cause of infertility Risk Factors: - Any factor that compromises tubal patency (STIs, assisted reproductive technologies, tubal surgery, contraceptive intrauterine device) Lab Tests: - Serum levels of progesterone and hCG to help determine whether pregnancy has occurred and whether it is likely to be ectopic.

FHR Patterns: Accelerations:

- Variable transitory increase in FHR above baseline Cause/Complications: - Healthy fetal/placental exchange - Intact fetal central nervous system response to fetal movement - Vaginal exam - Uterine contractions - Fetal scalp stimulation - Vibroacoustic stimulation - Fundal pressure Nursing Interventions: - Be reassuring - No intervention required - Indicate reactive nonstress test

Nursing Consideration For Pregnant Client:

- Acknowledge the client's concerns about pregnancy and encourage sharing of these feelings while providing no judgement - Discuss with the client the expected physiological changes and a possible timeline for a return to the pre-pregnant state - Assist the client in setting goals for postpartum period in regarding to self-care and newborn care - Refer the client to counseling if body image concerns appear to have a negative impact on the pregnancy - Provide education about expected physiological and psychosocial changes. Common discomforts of pregnancy and ways to resolve those discomforts are reviewed during prenatal visits - The client is encouraged to keep all follow-up appts and to contact provider immediately if there is any bleeding, leakage of fluid, or contractions at any time during pregnancy

Newborn Assessment: Psychological Response Of Newborn To Birth:

- Adjustments to extrauterine life occur as newborn's respiratory and circulatory systems are required to rapidly adjust to life outside uterus - Establishment of respiratory function with cutting of umbilical cord is most critical extrauterine adjustment as air inflates lungs with first breath - Circulatory changes occur due to changes in pressure of cardiovascular system related to cutting of umbilical cord as newborn begins breathing independently. The 3 shunts (ductus arteriosus, ducgtus venosus, foramen ovale) functionally close during newborn's transition to extrauterine life with flow of oxygenated blood in lungs and readjustment of atrial blood pressure in heart

Nursing Care Of Newborns: Medications: Vitamin K (Phytonadione):

- Administered to prevent hemorrhagic disorders. Vitamin K is not produced in GI tract of newborn until around day 7. Vitamin K is produced in the colon by bacteria once formula or breast milk is introduced Nursing Actions: - Administer 0.5 - 1 mg IM into vastus lateralis (where muscle development is adequate) soon after birth

Nutritional Risk Factors:

- Adolescents might have poor nutritional habits (a diet low in vitamins and protein, not taking prescribed iron supplements) - Clients who follow a vegetarian diet might have decreased intake of protein, calcium, iron, zinc, vitamin B12 - Nausea/vomiting during pregnancy - Anemia - Eating disorders - Pica (craving to eat non-food substances such as dirt or red clay) this disorder may diminish the amount of nutritional foods ingested - Inability to purchase/access food

Infertility Female Assessment:

- Age greater than 35 years can affect fertility - Duration Of Infertility: More than 1 year of coitus without contraceptives. For females older than 35 or who have known risk factor, the recommendation is 6 months - Medical History: Atypical secondary sexual characteristics, such as abnormal body fat distribution/hair growth = endocrine disorder. Check hormonal/adrenal gland disorders (they can cause infertility) - Surgical History: Pelvic/abdominal procedures - Obstetric History: Past episodes of spontaneous abortions. An evaluation of hormone levels throughout client's cycle. This can provide information about anovulation, amenorrhea, and premature ovarian failure. - Gynecologic History: Abnormal uterine conditions or any history of disorders that can contribute to the formation of scar tissue that can cause blockage of ovum or sperm - Sexual History: Intercourse frequently, number of partners across lifespan, any history of STIs - Occupational/Environmental Exposure Risk: Exposure to hazardous teratogenic materials in the home or place of work - Nutrition Status: Overweight/underweight, nutritional deficiencies (like anorexia) - Substance Use: Alcohol, tobacco, heroin, methadone

Trichomoniasis:

- An STI by the protozoan parasite Trichomonas vaginalis - Can be spread penis-to-vagina or vagina-to-vagina - If left untreated in females, it can lead to PID which can cause infertility. - Pregnant clients who have this are more likely to have preterm delivery and premature rupture of membranes Male: - Urethral draining, itching, irritation - Dysuria or pain with ejaculation Female: - Yellow-green frothy vaginal discharge with foul odor - Dyspareunia and vaginal itching - Dysuria - Discharge in vaginal vault during speculum exam, which can be sampled for microscopy - Strawberry spots on cervix (tiny petechiae) - A cervix that bleeds easily Lab Tests: - Sample of discharge is used for application to pH paper and a wet mount and whiff test is performed Diagnostic Procedure: - Wet mount saline prep indicates presence of trichomonads - Pap smear can detect the presence of trichomonads Nursing Care: - Identify and treat all sexual partners - Educate client regarding safe sex Medications: Metronidazole or tinidazole: Orally - It's not given during first trimester due to teratogenic effects on fetus Client Education: - Avoid alcohol while taking this med for 3 days after treatment due to the disulfiram-like reaction that occurs (severe nausea, vomiting) - Take all medication as prescribed - Understand possibility of decreasing effectiveness of oral contraceptive

Amnionfusion:

- An amnioninfusion of normal saline or lactated Ringer's is instilled into the amniotic cavity through a transcervical catheter put into the uterus to supplement amount of amniotic fluid. - The instillation reduces the severity of variable decelerations caused by cord compression Indications: Potential diagnoses: Oligohydramnios (scant amount or absence of amniotic fluid) caused by: - Uteroplental insufficiency - Premature rupture of membranes - Post-maturity of fetus Fetal cord compression secondary to post-maturity of fetus (macrosomic, large body), which places fetus at risk for variable deceleration from cord compression Interventions: - Assist with amniotomy if membranes have not ruptured. Membranes must be ruptured to perform an amnioninfusion - Warm fluid using a blood warmer prior to infusion. Fluid should be room temp. - Perform nursing measures to maintain comfort and dryness bc infused fluid will leak continuously - Monitor client to prevent uterine overdistention and increased uterine tone which can initiate, accelerate, or intensify. uterine contractions and cause nonreassuring FHR changes - Continually assess intensity and frequency of contractions - Continually monitor FHR - Monitor fluid output from vagina to prevent uterine distention

Gestational Diabetes Mellitus:

- An impaired tolerance to glucose with the first onset during pregnancy. Ideal blood glucose level during pregnancy should range between 60-99 mg/dL before meals or fasting and less than/equal to 120 mg/dL 2 hr after meals. - Finding of diabetes mellitus can disappear a few weeks following delivery. However, approx. 50% of clients will develop type II diabetes mellitus later in life. Increased Risks To Fetus: - Marcosomia, birth trauma, electrolyte imbalances, neonatal hypoglycemia. - Infections (urinary/vaginal) related to increased glucose in urine and decreased resistance bc of altered carbohydrate metabolism. - Hydrammnios which can cause overdistention of uterus, placental abruption, preterm labor, postpartum hemorrhage. - Ketoacidosis from diabetogenic effect of pregnancy (increased insulin resistance), untreated hyperglycemia, or inappropriate insulin dosage - Hypoglycemia caused by overdosing in insulin, skipped or late meals, increased exercise - Hyperglycemia which can cause excessive fetal growth (marcosomia) Risk Factors: - Obesity - Hypertension - Glycosuria - Maternal age older than 25 - Family history of diabetes mellitus - Previous delivery of an infant that was large or stillborn Expected Findings: - Hypoglycemia: nervousness, headache, weakness, irritability, hunger, blurred vision - Hyperglycemia: polydipsia, polyphagia, polyuria, nausea, abdominal pain, flushed dry skin, fruity breath - Hypoglycemia - Shaking - Clammy pale skin - Shallow respirations - Rapid pulse - Hyperglycemia - Vomiting - Excess weight gain during pregnancy Lab Tests: - 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 weeks; fasting not necessary; a positive blood glucose screening is 130-140 mg/dL or greater; additional testing with a 3-hr oral glucose tolerance test is indicated. - Oral glucose tolerance test following overnight fasting, avoidance of caffeine, abstinence from smoking for 12 hr prior; a fasting glucose test is obtained, a 100 g glucose load is given, serum glucose levels are determined 1,2,3 hr following glucose ingestion. - Presence of ketones in urine to assess severity of ketoacidosis Diagnostic Procedures: - Biophysical profile to ascertain fetal well-being if non-stress test is non-reactive - Amniocentesis with amniotic fluid phosphatidylglycerol measured to determine fetal lung maturity - Non-stress test to assess fetal well-being Nursing Care: - Monitor client's blood glucose - Monitor fetus Medications: - In contrast to clients who have type I diabetes mellitus, clients who have gestational diabetes mellitus are managed initially with diet and exercise alone. If glucose levels persistently high, insulin is begun - Oral hypoglycemia therapy is alternative to insulin in clients with gestational diabetes mellitus who require meds in addition to diet for blood glucose control. Most oral hypoglycemia agents are contraindicated for gestational diabetes mellitus, but there is limited us of glyburide. Provider will need to make determination if these meds can be used. Client Education: - Perform daily kick counts - Adhere to appropriate diet, including standard diabetic diet and restricted carbohydrate intake. Dietary counseling by a registered dietitian should occur. - Exercise - Perform self-administration of insulin - Understand the need for postpartum lab testing to include OGTT and blood glucose levels. Risk Factors: No single profile identifies risks for gestational hypertensive disorders, but some high risks include these: - Maternal age younger than 19 and older than 40 - First pregnancy - Extreme obesity - Multifetal gestation - Chronic renal disease - Chronic hypertension - Familiar history of preeclampsia - Diabetes mellitus - Rheumatoid arthritis - Systemic lupus erythematosus Expected Findings: - Severe continuous headache - Nausea - Blurring of vision - Flashes of lights or dots before eyes - Hypertension - Proteinuria - Periorbital, facial, hand, abdominal edema - Pitting edema of lower extremities - Vomiting - Oliguria - Hyperreflexia - Scotoma - Epigastric pain - Right upper quadrant pain - Dyspnea - Diminished breath sounds - Seizures - Jaundice - Manifestations of progression of hypertensive disease with indications of worsening liver involvement, kidney failure, worsening hypertension, cerebral involvement, developing coagulopathies Lab Findings: - Elevated liver enzymes (LDH, AS) - Increased creatinine - Increased plasma uric acid - Thrombocytopenia - Hgb (decreased in HELLP, increased in preeclampsia) - Hyperbilirubinemia Lab Tests: - Liver enzymes - Blood creatinine, BUN, uric acid - CBC - Clotting studies - Chemistry profile Diagnostic Procedures: - Dipstick testing of urine for proteinuria - 24-hr urine collection for protein and creatinine clearance - Non-stress test, contraction stress test, biophysical profile, and serial ultrasounds to assess fetal status - Doppler blood flow analysis to assess fetal well-being - Daily kick counts Nursing Care: - Assess level of consciousness - Obtain pulse oximetery - Monitor urine output - Obtain daily weights - Monitor vitals with careful attention to blood pressure measurement (proper size cuff, not talking to client during measurements) - Encourage lateral positioning - Perform non-stress test and daily kick counts - Instruct client to monitor I/O Medications: - Recommended that daily low dose aspirin therapy be initiated late in first trimester for clients who have history of onset of preeclampsia Antihypertensive medications: - Methyldopa - Nifedipine - Hydralazine - Labetalol - Avoid ACE inhibitors and angiotensin II receptor blockers. Anticonvulsant medications: Magnesium Sulfate: - Medication of choice for prophylaxis or treatment to depress CNS and prevent seizures in client who has eclampsia and severe preeclampsia. - Use an infusion control device to maintain a regular flow rate - Monitor blood pressure, pulse, respiratory rate, deep-tendon reflexes, level of consciousness, urinary output (indwelling urinary catheter for accuracy), presence of headache, visual disturbances, epigastric pain, uterine contractions, fetal heart rate/activity. Monitor for manifestations of magnesium sulfate toxicity: - Absence of patellar deep tendon reflexes - Urine output less than 30 ml/hr - Respirations less than 12/min - Decreased level of consciousness - Cardiac dysrhythmias If magnesium toxicity is suspected: - Immediately discontinue infusion - Administer antidote calcium gluconate or calcium chloride - Prepare for actions to prevent respiratory or cardiac arrest - There can be initial feelings of flushing, heat, sedation, diaphoresis, and burning at IV site with magnesium sulfate bolus. Discharge Instructions: - Remain on bed rest in side-lying position - Perform diversional activities (TV, visits from family/friends, gentle exercise) - Avoid foods high in sodium - Avoid alcohol and tobacco and limit caffeine intake - Drink 6-8 ounce glasses of water per day - Maintain a dark quiet environment to avoid stimuli that can precipitate a seizure - Maintain a patent airway in event of a seizure - Take antihypertensives medications as prescribed

Expected Findings In Pregnant Client: Skin Change: Chloasma:

- An increase of pigmentation on the face

HELLP Syndrome:

- Variant of gestational hypertension in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. - Diagnosed by lab tests not clinically: - H: Hemolysis resulting in anemia and jaundice - EL: Elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, and nausea and vomiting. - LP: Low platelets (less than 100,000) resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, possibly disseminated intravascular coagulopathy.

Therapeutic Procedures To Assist W/ Labor/Delivery: External Cephalic Version:

- An ultrasound-guided hands-on procedure to externally manipulate the fetus into a cephalic lie. - Procedure is performed at 37-38 weeks of gestation in an inpatient setting. - There's a high risk of placental abruption, umbilical cord compression, and emergent cesarean birth with this procedure. - Contraindications to performing a version include uterine anomalies, previous cesarean birth, cephalopelvic disproportion, placenta previa, multifetal gestation, oligohydramnios, third-trimester bleeding, uteroplacental insufficiency, or nuchal cord Indications: Potential diagnoses: A malpositioned fetus in a breech or transverse position late in gestation Preparation Of Client: - Have client sign informed consent - Provider will perform ultrasound screening prior to procedure to evaluate fetal position, locate umbilical cord, assess placental placement to rule out placenta previa, determine amount of amniotic fluid, determine fetal age, assess for presence of anomalies, evaluate pelvic adequacy for delivery, and/or guide direction of fetus during procedure - Perform a non-stress test to evaluate fetal well-being - Ensure that Rho(D) immune globulin as administered at 28 weeks of gestation if mother is Rh-negative - Administer IV fluid and tocolytics to relax uterus to permit easier manipulation Ongoing Care: - Continuously monitor FHR patterns to assess for bradycardia and variable decelerations during the version and for 1 hr following the procedure - Monitor vitals - Assess for hypotension to determine whether vena cava compression is occurring - Rh-negative clients should receive Rho(D) immune globulin to suppress maternal immune response to fetal Rh-positive blood after procedure in case minimal bleeding occurs Interventions: - Monitor fetal activity, fetal heart rate, fetal heart rate pattern - Monitor uterine activity, contraction frequency, duration, and intensity - Monitor for rupture of membranes - Monitor for bleeding until maternal condition is stable - Monitor for a decrease in fetal activity

Spontaneous Abortion Medications:

- Analgesics and sedatives - Prostaglandin, as a vaginal suppository - Oxytocin - Broad-spectrum antibiotics, in septic abortion - Rho(D) immune globulin, suppresses immune response of clients who are Rh-negative

PostPartum Disorders: Deep-Vein Thrombosis: Medications: Warfarin:

- Anticoagulant - Used for treatment of clots. It's given orally and is continued by client for approx. 3 months - Phyonadione the warfarin antidote should be readily available - Monitor PT (1.5-2.5) times the control level of 11-12.5 seconds and INR of 2-3 Client Education: - Watch for bleeding of gums/nose, increased vaginal bleeding, blood in urine, frequent bruising - Use birth control to avoid pregnancy due to teratogenic effects of warfarin. Oral contraceptives are contraindicated bc of increased risk for thrombosis

PostPartum Disorders: Deep-Vein Thrombosis: Medications: Heparin:

- Anticoagulant - Given IV to prevent formation of other clots to prevent enlargement of existing clot - Initially IV therapy is given by continuous infusion for 3-5 days with doses adjusted according to coagulation studies. Protamine sulfate the heparin antidote, should be readily available - Monitor aPTT (1.5-2.5) times the control level of 30-40 seconds - Tell client to report bleeding from the gums or nose, increased vaginal bleeding, blood in urine, frequent bruising

Newborn Assessment: Gestational Age Assessment: New Ballard Score: Classifications:

- Appropriate for gestational age (AGA): Weight is between the 10th and 90th percentile - Small for gestational age (SGA): Weight is less than the 10th percentile - Large for gestational age (LGA): Weight is greater than the 90th percentile - Low birth weight (LBW): Weight of 2,500 g or less at birth - Intrauterine growth restriction (IUGR): Growth rate does not meet expected norms - Term: Birth between the beginning of week 37 and prior to end of 42 weeks of gestation - Preterm or premature: Born prior to 37 weeks - Postterm (postdate): Born after completion of 42 weeks of gestation - Postmature: Born after the completion of 42 weeks of gestation with evidence of placental insufficiency

Amniotomy:

- Artificial rupture of amniotic membranes (AROM) by provider using a hook, clamp, or other sharp instrument - Labor typically begins within 12 hr after membranes rupture and can decrease the duration of labor by up to 2 hr - Client is at increased risk for cord prolapse or infection Indications: - Labor progression is too slow and augmentation or induction of labor indicated - An amnionfusion is indicated for cord compression Ongoing Care: - Ensure presenting part of fetus is engaged prior to amniotomy 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, and consistency Interventions: - Document time of rupture - Obtain temperature every 2 hr - Provide comfort measures (frequently changing pads, perineal cleansing)

Amniocentesis:

- 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. - It may be performed after 14 weeks of gestation - Alpha-fetoprotein can be measured from the amniotic fluid between 15-20 weeks (16-18 weeks of gestation is ideal) and can be used to assess for neural tube defects in the fetus or chromosomal disorders. - Can be evaluated to follow up high level of alpha-fetoprotein in maternal blood

Newborn Assessment: Physical Head-To-Toe Exam: Eyes:

- Assess eyes for symmetry in size/shape - Each eye from the inner to outer canthus and the space between the eyes should equal one-third the distance across both eyes to rule out chromosomal abnormalities like Down syndrome - Eyes are usually blue/grey following birth - Lacrimal glands are immature with minimal or no tears - Subconjunctival hemorrhages can result from pressure during birth - Pupillary and red reflex are present - Eyeball movement will demonstrate random, jerky movements

Placenta Previa Nursing Care:

- Assess for bleeding, leakage, or contractions - Assess fundal height - Refrain from performing vaginal exams - Administer IV fluids, blood products, medications as prescribed. Corticosteroids (such as betamethasone) promote fetal lung maturation if early delivery is anticipated (cesarean birth) - Have oxygen equipment available in case of fetal distress Client Education: - Adhere to bed rest - Do not insert anything into vagina because it can worsen bleeding

Newborn Assessment: Physical Head-To-Toe Exam: Extremities:

- Assess for full range of motions and spontaneous movements - Extremities should be flexed - Assess for bowed legs and flat feet which should be present bc lateral muscles are more developed than medial muscles - No clicks should be heart when abducting hips - Gluteal folds should be symmetrical - Soles should be well-lined over two-thirds of feet - Nail beds should be pink and no extra digits present

A nurse in a clinic is caring for a client who is post-operative following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? A) "It is good to know that I won't have a tubal pregnancy in the future." B) "The doctor said that this surgery can affect my ability to get pregnant again." C) "I understand that one of my fallopian tubes had to be removed." D) "Ovulation can still occur because my ovaries were not affected."

A) "It is good to know that I won't have a tubal pregnancy in the future."

Newborn Assessment: Physical Head-To-Toe Exam: Mouth:

- Assess for palate closure and strength of sucking - Lip movements should by symmetrical - Saliva should be scant. Excessive saliva can indicate a tracheoesophageal fistula - Epstein's pearls (small whitish-yellow cysts found on gums and at junction of soft and hard palates) are expected findings. They result from the accumulation of epithelial cells and disappear a few weeks after birth - Tongue should move freely, be symmetrical in shape, not protrude (protruding tongue can be indication of Down syndrome) - Soft and hard palate should be intact - Gray-white patches on tongue/gums can indicate thrush, a fungal infection caused by Candida ablicans, sometimes acquired from mother's vaginal secretions

Postpartum Comfort Levels:

- Assess pain related to episiotomy, lacerations, incisions, afterpaths, sore nipples - Assess location, type, quality of pain to guide nursing interventions and client education - Administer pain meds as prescribed - Teach non-pharm measures (distraction, imagery, heating pads, position changes, cold packs)

BPH Interpretation Of Findings:

- Assesses fetal well-being by measuring 5 variables with a score of 2 for each normal finding, and 0 for each abnormal finding for each variable. Variables: FHR: - Reactive (non-stress test) = 2 - Non-reactive = 0 Fetal breathing movements: - At least 1 episode of greater than 30 seconds duration in 30 min = 2 - Absent or less than 30 seconds duration = 0 Gross body movements: - At least 3 body or limb extensions with return to flexion in 30 min = 2 - Less than 3 episodes = 0 Fetal tone: - At least 1 episode of extension with return to flexion = 2 - Slow 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 Total Score Findings: 8 - 10 = Normal, low risk of chronic fetal asphyxia 4 - 6 = Abnormal, suspect chronic fetal asphyxia Less than 4 = Abnormal, strongly suspect chronic fetal asphyxia

Newborn Assessment: Apgar Score:

- Assigned based on quick review of systems that is completed at 1 and 5 min of life. This allows nurse to rapidly assess extrauterine adaptation and intervene with appropriate actions: - Score of 0-3 indicates severe distress - Score of 4-6 indicates moderate difficulty - Score of 7-10 indicates minimal or no difficulty with adjusting to extrauterine life

Prenatal Visit Client Education: Health Promotion:

- Avoid all over-the-counter medications, supplements, and prescriptions medications unless the provider who's supervising their care has knowledge of this practice - Alcohol (birth defects) and tobacco (low birth weight) are contraindicated during pregnancy - Substance use of any kind is to be avoided during pregnancy and lactation. Strategies to reduce or eliminate substance use are reviewed - Exercise during pregnancy yields positive benefits and should consist of 30 min of moderate exercise (walking/swimming) daily if not medically contraindicated. - Avoid use of hot tubs/saunas - Consume at least 8-10 glasses (2.3 L) of water each day Nurse Educates Client About: - Need for flu immunization - Smoking cessation - Treatment of current infections - Genetic testing/counseling - Exposure to hazardous materials

Physiologic Changes Preceding Labor (Premonitory Signs):

- Backache: Constant low, dull backache caused by pelvis muscle relaxation - Weight loss: 0.5-1.5 kg (1-3.5 lb.) weight loss - Lightening: Fetal head descents into true pelvis about 14 days before labor; feeling that the fetus has "dropped", easier breathing, but more pressure on bladder, resulting in urinary frequency, more pronounced in clients who are primigravida - Contractions: Begin with irregular uterine contractions (Braxton Hicks) that eventually progress in strength and regularity - Increased vaginal discharge or blood show: Expulsion of cervical mucus plug may occur. Brownish or blood-ringed mucus plug resulting from onset of cervical dilation and effacement - Energy burst: Sometimes called "nesting" response - Gastrointestinal changes: Less common, include nausea, vomiting, and indigestion - Cervical ripening: Cervix becomes soft (opens) and partially effaced and can begin to dilate Rupture of membranes: Spontaneous rupture of membranes: - Can initiate labor or can occur anytime during labor, most commonly during transition phase. - Labor usually occurs within 24 hr of rupture of membanres - Prolonged rupture of membranes greater than 24 hr before delivery of fetus can lead to infection - Immediately following rupture of membranes, a nurse should assess the FHR for abrupt decelerations which are indicative of fetal distress to rule out umbilical cord prolapse. Assessment of amniotic fluid: - Completed once membranes rupture - Amniotic fluid should be watery, clear, and have slightly-yellow tinge - Odor should not be foul - Volume between 700-1,000 mL - Use nitrazine paper to confirm amniotic fluid is present - Amniotic fluid is alkaline: Nitrazine paper is deep blue, indicating pH of 6.5-7.5 - Urine is slightly acidic: Nitrazine paper remains yellow

Bacterial Vaginosis:

- Bacterial infection most commonly caused by Haemophilus vaginalis or Gardnerella vaginalis. - Most common vaginal infection in females - Cannot be related to sexual activity it is related to reduction in lactobacilli in vaginal flora - If left untreated it can increase a woman's chance of developing PID which can lead to infertility. - Treatment is especially important for pregnant clients bc it can cause preterm labor and preterm birth Risk Factors: - New or multiple sex partners - Unprotected sex Expected Findings: - Thin, white, or gray discharge with a fish-like odor, especially after sex - Discharge in vaginal vault which can be sampled for microscopy Lab Tests: - Sample of vaginal discharge applied to pH (nitrazine) paper - Saline and potassium hydroxide (KOH) wet smear test Diagnostic Procedures: - pH greater than 4.5 - Wet mount saline prep, which indicates presence of clue cells - Positive whiff test with release of fishy odor Medications: - Metronidazole - Clindamycin - Probiotic lactobacilli used for prevention Client Education: - Avoid alcohol while taking metrondiazole due to a disulfiram-like reaction (severe nausea and vomiting) - Take all medications as prescribed - Understand possibility of decreasing effectiveness of oral contraceptives - Treatment is not usually indicated for sexual partners but this is recommended to prevent recurrence - Adhere to safe sex practices

Cesarean Birth:

- Delivery of fetus through a transabdominal incision of uterus to preserve life/health of client and fetus when there is complications - Incisions are made vertically and horizontally into lower segments of uterus. Horizontal is the optimal incision Possible Diagnoses: - Malpresentation, particularly breech presentation - Cephalopelvic disproprotion - Nonreassuring fetal heart tones - Placental abnormalities - Placenta previa - Abruptio placentae - High-risk pregnancy: Positive HIV, Hypertensive disorders (preeclampsia, eclampsia), diabetes mellitus, active general herpes lesions - Previous cesarean birth - Dystocia - Multiple gestations - Umbilical cord prolapse - Congenital malformations - Maternal cardiac or respiratory disease

Group B Streptococcus:

- Bacterial infection that can be passed to fetus during labor and delivery. - Often an expected part of vaginal flora for non-pregnant clients, and present in some who are pregnant - It can cause pneumonia, respiratory distress syndrome, sepsis, meningitis, if transmitted to neonate Risk Factors: - History of positive culture with previous pregnancy - Prolonged (18 hr or more) rupture of membranes - Preterm delivery - Low birth weight - Use of intrauterine fetal monitoring - Intrapartum maternal fever (100.4 or greater) Expected Findings: - Preterm labor and delivery - Chorioamnionitis - Infection of urinary tract - Maternal sepsis - Endometritis after delivery Lab Tests: - Vaginal and rectal cultures are performed at 35-38 weeks Nursing Care: Administer intrapartum antibiotic prophylaxis to following clients to decrease transmission to neonate: - Client who has a GBS-positive screening during current pregnancy - Client who has unknown GBS status who is delivering at less than 37 weeks - Client who has maternal fever of 100.4 or greater - Client who has rupture of membranes for 18 hr or longer Medications: Penicillin G or ampicillin are most common: - Administer penicillin 5 million units initially IV bolus, followed by 2.5 million units intermittent IV bolus every 4 hr during the intrapartum period. The client can receive ampicillin 2g IV initially, followed by 1g every 4 hr. Client Education: - Notify labor and delivery nurse of GBS status - Decrease the neonatal risks by being screened for GBS at 35-38 weeks

Interventions For Home Care Of Newborn: Cord Care:

- Before discharge, cord clamp is removed - Prevent cord infection by keeping cord dry, and keep top of diaper fold underneath it Client Education: - Sponge baths are given until cord falls off, which occurs 10-14 days after birth. Tub bathing/submersion can follow - Cord infection (a complication of improper cord care) can result if cord is not kept clean/dry: - Monitor for manifestations of a cord that's moist and red, has a foul odor, or has purulent drainage - Notify provider immediately

Second Trimester Client Education:

- Benefits of breastfeeding - Lifestyle: Sex and pregnancy, rest and relaxation, posture, body mechanics, clothing , seat belt safety and travel - Fetal movement - Complications (preterm labor, gestational hypertension, gestational diabetes mellitus, premature rupture of membranes) - Preparation for childbirth and childbirth education classes - Review of birthing methods - Development of birth plan (verbal or written agreement about what client wishes during labor/delivery)

Verifying Pregnancy:

- Blood/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 before expected menses - Production of hCG begins with implantation, peaks at about 60-70 days of gestation, declines until around 100-130 days of pregnancy, then plasma levels remain at this lower level for the remainder of the pregnancy - Higher levels of hCG can indicate multifetal pregnancy, ectopic pregnancy, hydatidiform mole (gestational trophoblastic disease), or a genetic abnormality such as Down syndrome - Lower blood levels of hCG might suggest a miscarriage or ectopic pregnancy - Some medications (anticonvulsants, diuretics, tranquilizers) can cause false-positive or false-negative results - Home pregnancy test: urine samples should be first-voided morning specimens and follow the directions

Physiological Status Of Pregnant Client: Musculoskeletal:

- Body alterations and weight increase necessitate an adjustment in posture - Pelvic joints relax

Danger Signs During First Trimester Of Pregnancy:

- Burning on urination (infection) - Severe vomiting (hyperemesis gravidarum) - Diarrhea (infection) - Fever or chills (infection) - Abdominal cramping and/or vaginal bleeding (miscarriage, ectopic pregnancy)

Therapeutic Procedures To Assist W/ Labor/Delivery: Cervical Ripening:

- By various methods increases cervical readiness for labor through promotion of cervical softening, dilation, and effacement - Cervical ripening can eliminate 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 Mechanical & Physical Methods: - Balloon catheter is inserted into intracervical canal to dilate the cervix - Membrane stripping and an amniotomy can be performed -Hygroscopic dilators can be inserted to absorb fluid from surrounding tissues then enlarge. Fresh dilators can 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 oral medication or vaginal suppositories/gels - Misoprostol: Prostaglandin E1 - Dinoprostone: Prostaglandin E2 Indications: Potential diagnoses: Any condition in which augmentation or induction of labor is indicated Client presentation: Failure of cervix to dilate and efface. Failure of labor to progress Nursing Actions: Ongoing care includes the nurse assessing for: - Urinary retention - Rupture of membranes - Uterine tenderness or pain - Contractions - Vaginal bleeding - Fetal distress Interventions: - Obtain client's informed consent - Obtain baseline data on fetal/maternal well-being - Assist client to void prior - Document number of dilators and/or sponges inserted during procedure - Client should remain in side-lying position - Assist with augmentation/induction of labor as prescribed - Monitor FHR and uterine activity after administration of cervical-ripening agents - Notify the provider if uterine tachysystole or fetal distress noted - Monitor for potential adverse effects (nausea, vomiting, diarrhea, fever, uterine tachysystole) - Proceed with caution in clients who have glaucoma, asthma, cardiovascular or renal disorders Complications: Tachysystole: Nursing Action: Administer subcutaneous injection of terbutaline Fetal distress: Nursing Actions: Apply O2 via faec mask at 10 L/min, position client on left side, increase rate of IV fluid, notify provider

Newborn Assessment: Vital Signs:

- Checked in this sequence: Respirations, heart rate, blood pressure, temperature - Respiratory Rate: Varies from 30-60 breaths/min with short periods of apnea (less than 15 seconds) occurring most frequently during rapid eye movement sleep cycle. Periods of apnea lasting longer than 15 seconds should be evaluated. Crackles and wheezing are manifestations of fluid in lungs. Grunting and nasal flaring are clinical findings of respiratory distress - Normal Heart Rate: Ranges from 110-160/min with brief fluctuations above and below the range depending on activity (crying, sleeping). Apical pulse rate is assessed for 1 full minute preferable when newborn is sleeping. The pediatric stethoscope head is placed on 4th or 5th intercostal space at left midclavicular line over apex of newborn's heart. Heart murmurs are documented/reported. - Blood Pressure: Should be 60-80 mm Hg systolic and 40-50 mm Hg diastolic - Normal Temperature: Is 36.5C to 37.5C (97.7 F - 99.5 F) with 37C (98.6F) being average. Newborn is at risk for hypothermia and hyperthermia until thermoregulation (ability to produce heat and maintain normal body temp.) stabilizes. If newborn becomes chilled (cold stress), oxygen demands can increase and acidosis can occur.

Hormonal Methods: Intrauterine Device (IUD):

- Chemically active T-shape device inserted into the cervix and placed into the uterus. - Releases a chemical substance that damages fertilization - Most effective - Sign consent form/must be monitored monthly - Effective for 3-10 years

Nutrition For Diseases:

- Cleft lip/palate: Determine most effective nipple for feeding. Can use specialized bottles, cups, syringes, to feed infant. Infants who have this can achieve breastfeeding with changes in positioning. Feed newborn in upright position to decrease aspiration risk. Feed newborn slowly, burp them frequently so they do not swallow air. Cleanse mouth with water after feedings - Tracheoesophageal atresia: Withold feedings until esophageal patency is determined. Elevate head of newborn's crib to prevent gastric juice reflux. Supervise first feeding to observe for this anomaly - Duodenal atresia: Withhold feedings until surgical repair is done and newborn has begun to pass stools. Administer IV fluids as prescribed. Monitor for jaundice - PKU: Specialized synthetic formula which phenylalanine is removed/reduced. Parent should restrict meat, dairy products, diet drinks (artificial sweeteners) and protein during pregnancy. Apartame must be avoided - Galactosemia: Give newborn soy-based formula bc galactose is present in milk. Eliminate lactose/galactose in newborn's diet. Breastfeeding is also contraindicated

Position:

- Client should engage in frequent position changes during labor to increase comfort, relieve fatigue, promote circulation - Position during the second 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

Nursing Interventions For Postpartum Care: Sexual Activity:

- Clients can safely resume sexual intercourse by 2nd-4th week after birth, when bleeding has stopped and perineum has healed. OTC lubricant might be needed during first 6 weeks-6 months - Physiological reactions to sexual activity can be slower and less intense for first 3 months following birth

Postpartum Infections: UTI:

- Common secondary to bladder trauma - Potential complication of UTI is progression to pyelonephritis with permanent kidney damage leading to kidney failure Risk Factors: - Postpartal hypotonic bladder or urethra (urinary stasis and retention) - Epidural anesthesia - Urinary bladder catheterization - Frequent pelvic exams - Genital tract injuries - History of UTIs - C-section birth Expected Findings: - Report of urgency, frequency, dysuria, discomfort in pelvic area - Fever - Chills - Malaise - Change in vitals, elevated temp - Urine (cloud, blood-tinged, malodorous, sediment visible) - Urinary retention - Pain in suprapubic area - Pain at costovertebral angle (pyelonephritis) Diagnostic Procedures: - Urinalysis for WBCs, RBCs, protein, bacteria Nursing Care: - Obtain random or clean-catch urine sample - Administer antibiotics and teach client importance of completing entire course as prescribed - Acetaminophen is taken to reduce discomfort/pain associated with UTI - Teach client proper perineal hygiene such as wiping from front to back - Encourage client to increase fluid intake to 3,000 mL/day to dilute bacteria and flush bladder

Vasa Previa:

- Condition when the fetal umbilical vessels implant into the fetal membranes rather than the placenta. Velamentous insertion of the cord: Cord vessels begin in branch at the membranes and then course to the placenta Succenturiate insertion of the cord: The placenta has divided into two or more lobes and not one mass Battledore insertion of the cord: A marginal insertion. Increased risk of fetal hemorrhage Diagnostic Procedures: - Ultrasound for fetal well-being and vessel attachment Nursing Care: - Closely monitor client during labor and delivery for excessive bleeding.

Tetralogy Of Fallot:

- Conserve newborn's energy to reduce workload of heart - Administer gavage feedings, or give oral feedings with a specialized nipple - Elevate newborn's head/shoulders to improve respirations and reduce cardiac workload - Prevent infection - Place newborn in knee-chest position during respiratory distress

Postpartum Disorders: Postpartum Hemorrhage:

- Considered if client loses 500 mL blood after vaginal birth or more than 1,000 mL blood after c-section. 2 complications that can occur following postpartum hemorrhage are hypovolemic shock and anemia. Risk Factors: - Uterine atony or history of uterine atony - Overdistended uterus - Prolonged labor, oxytocin-induced labor - High parity - Ruptured uterus - Complication during pregnancy (placenta previa, abruptio placentae) - Precipitous delivery - Administration of magnesium sulfate therapy during labor - Lacerations and hematomas - Inversion of uterus - Subinvolution of utuers - Retained placental fragments - Coagulopathies (DIC) Medications: Methylergonovine: - Uterine stimulant - Used to promote uterine contractions and expel retained fragments of placenta - Assess uterine tone and vaginal bleeding - Assess for signs of infection such as increased uterine tenderness Antibiotic therapy: Can be prescribed to prevent or treat infection

Pharmacological Anesthesia: Regional Blocks: Pudendal Block:

- Consists of a local anesthetic (lidocaine, bupivacaine) administered transvaginally into space in front of pudendal nerve - This type of block has no maternal/fetal systemic effects but it does provide local anesthesia to perineum, vulva, rectal areas during delivery, episiotomy and episiotomy repair - It's administered during the late second stage of labor 10-20 min. before delivery, providing analgesia prior to spontaneous expulsion for the fetus or forceps-assisted or vacuum-assisted birth - It's suitable during second/third stages of labor and for repair of episiotomy and lacerations Adverse Effects: - Compromise of maternal bearing down reflex Nursing Actions: - Instruct client about the method - Coach client about when to bear down

Induction Of Labor:

- Deliberate initiation of uterine contractions to stimulate labor before spontaneous onset to bring about birth by chemical or mechanical means Methods: - Mechanical or chemical approaches - Administration of IV oxytocin - Nipple stimulation to trigger release of endogenous oxytocin Indications: - Any condition in which augmentation/induction of labor indicated. - Elective induction for non-medical indications must meet criteria of at least 39 weeks of gestation - Elective inductions that don't meet criteria can result in increased risk of infection, premature delivery, longer labor, need for cesarean birth Client Presentation: - Post-term pregnancy (greater than 42 weeks) - Dystocia (prolonged, difficult labor) due to inadequate uterine contractions - Prolonged rupture of membranes which predisposes the client/fetus to risk of infection - Intrauterine growth restriction - Maternal medical complications: Rh-isoimmunization, diabetes mellitus, pulmonary disease, gestational hypertension - Fetal demise - Chorioamnionitis

A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approx. 12 cm with lochia that is bright red and contains small clots. Which finding should the nurse document? A) Moderate lochia rubra B) Excessive lochia serosa C) Light lochia rubra D) Scant lochia serosa

A) Moderate lochia rubra

Pharmacological Anesthesia: Spinal Anesthesia (Block):

- Consists of a local anesthetic that is injected into subarachnoid space into the spinal fluid at the third, fourth, or fifth lumbar interspace. - This can be done alone or in combo with analgesics like fentanyl - Spinal block eliminates all sensations from level of nipples to feet - It's commonly used for cesarean births - Low spinal block can be used for vaginal birth but is not used for labor - It's given in the late second stage or before cesarean birth Adverse Effects: - Maternal hypotension - Fetal bradycardia - Loss of bearing down reflex in client with higher incidence of operative births - Potential headache from leakage of cerebrospinal fluid at puncture site - Higher incidence of maternal bladder and uterine atony following birth Nursing Actions: - Assess maternal vitals every 10 m in - Manage maternal hypotension by administering a fluid bolus as prescribed, positioning the client laterally, increasing IV rate and initiate oxygen - Assess uterine contractions - Assess level of anesthesia - Assess FHR patterns - Provide client safety by raising side rails of bed and assisting with repositioning - Recognize manifestations of impending birth including sitting on one buttock, making grunting sounds, bulging of perineum - Encourage interventions to relieve a postpartum headache resulting from a cerebrospinal fluid leak. Interventions include placing the client in a supine position, promoting bed rest in a dark room, administering oral analgesics, caffeine, fluids. An autologous blood patch is most beneficial and reliable relief measure for cerebrospinal fluid leaks Client Education: - Bear down for expulsion of fetus bc during a vaginal birth contractions will not be felt

Passenger:

- Consists of fetus and placenta - Size of fetal head, fetal presentation, fetal lie, fetal attitude, fetal position affect ability of fetus to navigate the birth canal. The placenta can be considered a passenger bc it also must pass through canal Presentation: - The part of the fetus that is entering the pelvis inlet first and leads through birth canal during labor. - It can be the back of the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum or feet) Lie: - The relationship of maternal longitudinal axis (spine) to the fetal longitudinal axis (spine) - Transverse: Fetal longer axis is horizontal, forms a right angle to maternal axis, and will not accommodate vaginal birth. The shoulder is the presenting part and can require delivery by cesarean birth if fetus does not rotate spontaneously. - Parallel or longitudinal: Fetal long axis is parallel to maternal long axis, either a cephalic or breech presentation. Breech presentation can require a cesarean birth. Attitude: - Relationship of fetal body parts to one another - Fetal flexion: Chin flexed to chest, extremities flexed into torso - Fetal extension: Chin extended away from chest, extremities extended Fetopelvic or fetal position: - The relationship of presenting part of fetus (sacrum, mentum, or occiput) preferably the occiput, in referents to its directional position as it relates to one of the 4 maternal pelvic quadrants. - Right (R) or left (L): The first letter references the side of maternal pelvis - Occiput (O), sacrum (S), mentum (M), or scapula (Sc): The second letter references the presenting part of the fetus - Anterior (A), posterior (P), transverse (T): The third letter references the part of the maternal pelvis Station: - Measurement of fetal descent in cm with station 0 being at the level of an imaginary line at level of ischial spines, minus stations superior to the ischial spine, and plus stations inferior to the ischial spines.

Pharmacological Anesthesia: Regional Blocks: Epidural Block:

- Consists of local anesthetic, bupivacaine, along with an analgesic (morphine or fentanyl) injected into epidural space at level of fourth/fifth vertebrae. - This eliminates pain from level of umbilicus to thighs, relieving discomfort of uterine contractions, fetal descent, stretching of peritoneum. (This might not remove pressure sensations) - It's administered when a client is in active labor and dilated to at least 4cm. - Continuous infusions or intermittent injections can be administered through indwelling epidural catheter - Patient-controlled epidural analgesia is a technique for labor analgesia and is favored method of pain management for labor/birth. It's suitable for all stages of labor and types of birth and for repair of episiotomy and lacerations Adverse Effects: - Maternal hypotension - Fetal bradycardia - Fever - Itching - Inability to feel urge to void - Urinary retention - Loss of the bearing down reflex Nursing Actions: - Administer a bolus of IV fluids to help offset maternal hypotension - Help position and steady client into sitting or side-lying modified Sim's position w/ the back curved to widen the intervertebral space for insertion of epidural catheter - Encourage client to remain in side-lying position after insertion of epidural catheter to avoid supine hypotension syndrome with compression of vena cava - Coach client in pushing efforts and request an evaluation of epidural pain management by anesthesia personnel if pushing efforts are ineffective - Monitor maternal blood pressure/pulse and observe for hypotension, respiratory depression, decreased oxygen saturation - Assess FHR patterns continuously - Maintain IV line, and have oxygen/suction ready - Assess for orthostatic hypotension. Be prepared to administer an IV vasopressor (such as ephedrine), position client laterally, increase rate of IV fluid administration and initiate oxygen - Provide safety like raising the side rails. Do not allow client to ambulate unassisted - Assess bladder for distention at frequent intervals, catheterize if necessary to prevent discomfort and interference with uterine contractions - Monitor for return of sensation and motor control in client's legs after delivery but prior to standing. Assist client with standing/walking for the first time after delivery that included epidural anesthesia

Forceps-Assisted Birth:

- Consists of using an instrument with 2 curved spoon-like blades to assist in the delivery of fetal head. - Traction is applied during contractions Client Presentation: - Prolonged second stage of labor and need to shorten duration (maternal exhaustion) - Fetal distress during labor - Abnormal presentation or a breech position requiring delivery of head - Arrest of rotation Preparation Of Client: - Explain procedure - Assist client into lithotomy position - Assess to ensure client's bladder is empty and catheterize if needed - Assess to ensure fetus is engaged and membranes have ruptured Ongoing Care: - Assist with procedure as necessary Interventions: - Assess/record FHR before, during, after forceps - Compression of cord between fetal head and forceps will cause a decrease in FHR (If this happens the forceps are removed and reapplied) - Observe neonate for bruising and abrasions at site of forceps application after birth. Assess for facial palsy Check client for any possible injuries after birth: - Vaginal or cervical lacerations indicated by bleeding in spite of contracted uterus - Urine retention resulting from bladder or urethral injuries - Hematoma formation in pelvic soft tissues resulting from blood vessel change - Report to the postpartum nursing caregivers that forceps were used Complications: - Lacerations in cervix or vagina and perineum - Injury to bladder - Facial nerve palsy of neonate - Facial bruising of neonate - Subdural hematoma in neonate

Newborn Assessment: Physical Head-To-Toe Exam: Diagnostic & Therapeutic Procedures Following Birth:

- Cord blood is collected at birth. - Lab tests are conducted to determine ABO blood type and Rh status if parent's blood type is O or they are Rh-neg. - A CBC can be done by capillary stick to evaluate for anemia, polycythemia, infection, clotting problems. - Blood glucose is checked to evaluate for hypoglycemia Expected Lab Values: - Hgb: 14-24 g/dL - Platelets: 150,000- 300,000 - Hct: 44%-64% - Glucose: 40-60 - RBC Count: 4.8 x 10 to the 6th power- 7.1 x 10 to the 6th power - Bilirubin: 24 hr: 2-6, 48 hr: 6-7, 3 to 5 days: 4-6 - WBC Count: 9,000 - 30,000

Client Education About Nutrition: Folic Acid:

- Crucial for neurologic development and prevention of fetal neural tube defects - Folate found naturally in foods is converted to folic acid - Foods high in folate include: leafy veggies, dried peas/beans, seeds, orange juice. Breads, cereals, and other grains are fortified with folic acid. - Clients who wish to become pregnant should take 400 mcg of folic acid and clients who are pregnant should take 600 mcg of folic acid.

Small For Gestational Age:

- Describes a newborn whose birth weight is at or below 10th percentile who has intrauterine growth restriction - Common complication of newborns with this are perinatal asphyxia, meconium aspiration, hypoglycemia, polycythemia, instability of body temp. Risk Factors: - Congenital or chromosomal anomalies - Maternal infections, disease, or malnutrition - Gestational hypertension and/or diabetes - Maternal smoking, drug, or alcohol use - Multiple gestations - Placental factors (small placenta, placenta previa, decreased placental perfusion) - Fetal congenital infections (rubella, toxoplasmosis) Expected Findings: - Weight below 10th percentile - Normal skull, but reduced body dimensions - Hair is sparse on scalp - Wide skull sutures from inadequate bone growth - Dry, loose skin - Decreased subcutaneous fat - Decreased muscle mass, particularly over cheeks/butt - Thin, dry, yellow dull umbilical cord rather than gray, glistening, moist - Drawn abdomen rather than well-rounded - Respiratory distress, hypoxia - Wide-eyed and alert, which is attributed to prolonged fetal hypoxia - Hypotonia - Evidence of meconium aspiration - Hypoglycemia - Acrocyanosis Lab Tests: - Blood glucose for hypoglycemia - CBC will show polycythemia resulting from fetal hypoxia and intrauterine stress - ABGs can be prescribed due to chronic hypoxia in utero due to placental insufficiency Nursing Care: - Support respiratory efforts, suction newborn as necessary to maintain open airway - Provide neutral thermal environment for newborn (isolette or radiant heat warmer) to prevent cold stress. - Initiate early feedings (newborn who is SGA will require feedings that are more frequent) - Administer parenteral nutrition if necessary - Maintain adequate hydration - Conserve the newborn's energy level - Prevent skin breakdown - Protect newborn from infection - Provide support to newborns' parents and extended family

Contraceptive Methods: Calendar Rhythm Method:

- Determining fertile dates by tracking menstrual cycle to estimate time of ovulation - The start of the fertile period is figured by subtracting 18 days from the number of days in the shortest menstrual cycle - The end of the fertile period is established by subtracting 11 days from the number of days of the longest cycle - Most useful when combined with basal body temperature or cervical mucous method - Not very reliable - Does NOT protect against STI's - Possible pregnancy

Postpartum Psychosis:

- Develops within first 2-3 weeks of postpartum - Clients who have history of bipolar disorder are at higher risk - Client findings are severe and can include confusion, disorientation, hallucinations, delusions, obsessive behaviors, paranoia - Client might attempt to harm themselves or their infant Expected Findings: - Pronounced sadness - Disorientation - Confusion - Paranoia - Behaviors indication hallucinations or delusional thoughts of self-harm or harming infant

Nursing Interventions For Postpartum Care: Activity:

- Discuss client's usual activity level to determine what tasks might be strenuous for client - Encourage client to be willing to accept help from others - Teach client how to perform pelvic tilt exercises to strengthen back muscles and relieve strain on lower back. These exercises involve alternately arching and straightening the back Client Education: - Regain pelvic floor muscle control by performing kegel exercises. The same muscles are used when starting and stopping flow of urine - Begin simple exercises soon after birth and progress to more strenous activities - Following cesarean birth, postpone abdominal exercises for 4-6 weeks - Following vaginal birth, limit stair climbing for first few weeks postpartum - Following c-section wait until 4-6 week follow-up visit before performing strenuous exercise, heavy lifting, excessive stair climbing. General rule is to climb no more than one flight of stairs once a day and not to lift more than 10 lb for the first 2 weeks - Plan at least one daily rest period; rest when the infant naps

Physiological Status Of Pregnant Client: Body Image Changes:

- Due to physical and psychological changes that occur, the pregnant client requires support from their provider/family members - In the first trimester, physiological changes are not obvious. Many clients look forward to the changes so the pregnancy will be more noticeable - During the second trimester, there are rapid physiological changes due to enlargement of the abdomen and breasts. These changes can affect a client's mobility. Skin changes also occur (stretch marks/hyperpigmentation). They might find themselves losing their balance and feeling back or leg discomfort and fatigue. These factors might lead to negative body image. The client might make statements of resentment toward the pregnancy and express anxiousness for the pregnancy to be over soon.

Baby-Friendly Care: Psychosocial & Maternal Adaptation:

- During first 2-6 weeks after birth, client goes through period of acquaintance with newborn, as well as physical restoration. During this time the client also focuses on competently caring for the newborn. - Finally, the act of achieving maternal identity is accomplished around 4 months following birth. - These stages can overlap, and are variable based on maternal, infant, environment factors

Dystocia Nursing Care:

- Dysfunctional labor - Assist with application of fetal scalp electrode and/or intrauterine pressure catheter - Assist with amniotomy (artificial rupture of membranes) - Encourage client to engage in regular voiding to empty bladder - Encourage position change to aid in fetal descent or to open the pelvic outlet. Assist the client to a position on both hands and knees to help fetus rotate from a posterior to anterior position - Encourage ambulation to enhance progression of labor - Encourage hydrotherapy and other relaxation techniques to aid - Apply counterpressure using fist or heel of hand to sacral area to alleviate discomfort - Assist the client into a beneficial position for pushing and coach them about how to bear down with contractions - Prepare for possible forceps-assisted, vacuum-assisted or cesarean birth - Continue monitoring FHR in response to labor Hypertonic Contractions: - Maintain hydration - Promote rest and relaxation, provide comfort measures between contractions - Place client in a lateral position and provide oxygen by mask Medications: Oxytocin: Therapeutic Intent: Used to augment labor and strengthen uterine contractions Nursing Action: Administer if prescribed to augment labor. Oxytocin is not administered for hypertonic contractions

Non-Stress Test:

- Most widely used technique for antepartum evaluation of fetal well-bring performed during the third trimester. - Non-invasive procedure that monitors response of the FHR to fetal movement. - Doppler transducer (used to monitor FHR) and a tocotransducer (used to monitor uterine contractions) are attached externally to a client's abdomen to obtain tracing strips. - Client pushes button attached to monitor whenever they feel a fetal movement, which is noted on the tracing. - This allows nurse to assess the FHR in relationship to the fetal movement - Disadvantage: High rate of false non-reactive results with fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications, and nicotine use disorder.

Dystocia:

- Dysfunctional labor - Difficult abnormal labor related to the five P's of labor (Passenger, passageway, powers, position, psychologic response) - Atypical uterine contraction patterns prevent normal process of labor and its progression. Contractions can be hypotonic (weak, inefficient, completely absent) or hypertonic (excessively frequent, uncoordinated, strong intensity with inadequate uterine relaxation) with failure to efface and dilate the cervix Risk Factors: - Short stature, overweight status - Age greater than 40 - Uterine abnormalities - Pelvic soft tissue obstructions or pelvic contracture - Cephalopelvic disproportion (fetal head is larger than maternal pelvis) - Congenital abnormalities - Fetal macrosmia - Fetal malpresentation, malposition - Multifetal pregnancy - Hypertonic or hypotonic uterus - Maternal fatigue, fear, or dehydration - Inappropriate timing of anesthesia or analgesics Expected Findings: - Lack of progress in dilation, effacement, or fetal descent during labor - Hypotonic uterus is easily indent-able, even at peak of contractions - Hypertonic uterus cannot be indented, even between contractions - Client is ineffective in pushing with no voluntary urge to bear down - Persistent occiput posterior presentation is when the fetal occiput is directed toward the posterior maternal pelvis rather than the anterior pelvis - Persistent occiput posterior position prolongs labor and client reports greater back pain as the fetus presses against the maternal sacrum Diagnostic & Therapeutic Procedures: - Ultrasound - Amniotomy or stripping of membranes if not ruptured - Oxytocin infusion - Vacuum-assisted birth - Cesarean birth

PostPartum Disorders: Pulmonary Embolus:

- Embolus occurs when fragments or entire clot dislodges and moves into circulation - Pulmonary embolism is a complication of DVT that occurs if embolus moves into pulmonary artery or one of its branches and lodges in a lung, occluding the vessel and obstructing blood flow to the lungs - Acute pulmonary embolus is an emergent situation - Same risk factors as DVT Expected Findings: - Apprehension - Pleuritic chest pain - Dyspnea - Tachypnea - Hemoptysis - Tachycardia - Cough - Syncope - Crackles with breath sounds - Elevated temperature - Hypoxia Diagnostic & Therapeutic Procedures: - Ventilation/perfusion lung scan - Magnetic resonance angiography - Spiral computed tomography - Pulmonary angiogram - Embolectomy to surgically remove the embolus Nursing Care: - Place client in semi-fowler's position with head of bed elevated to facilitate breathing - Administer oxygen by mask Medications: - SAME AS DVT: Heparin/Warfarin - Thrombolytic therapy to break up blood clots can be prescribed: Alteplase, streptokinase: similar adverse effects and contraindications as anticoagulants

Cleft Lip/Palate:

- Encourage expression of parental concerns, grief, fears - Monitor newborn's weight daily - Monitor for manifestations of dehydration - Encourage parental attachment - Suction nose/mouth gently with bulb syringe as needed to clear airway - Position infant facilitate drainage of sections - Educate parents of feeding requirements of infants

Nursing Interventions For Postpartum Care: Nutrition:

- Encourage non-lactating clients to consume 1,800-2,200 kcal/day - Instruct the lactating patient to increase their caloric intake and to include calcium-enriched foods in diet. - 450-500 calories/day added to their pre-pregnancy diet for lactating clients - Iron supplements can be prescribed for clients who have low hemoglobin and hematocrit levels Client Education: - Consume a nutritious diet including all food groups and high in protein, which will aid in tissue repair - Continue taking prenatal vitamins until 6 weeks following birth

Pain Relief Measures During Labor: Vaginal Birth:

- Epidural (block) analgesia - Epidural (block) anesthesia - Combined spinal-epidural (CSE) analgesia - Nitrous oxide - Local infiltration anesthesia - Pudendal block - Spinal (block) anesthesia

Nursing Care Of Newborns: Patient-Centered Care: Infection Control:

- Essential in preventing cross-contamination from newborn to newborn and between newborns and staff. Newborns are at risk for infection during first few months of life bc of immature immune systems - Provide individual bassinets equipped with diapers, T-shirts, bathing supplies - All personnel who care for newborn should scrub with antimicrobial soap from elbows to finger tips before entering nursery. In between care of newborn, nurse should follow facility hygiene protocols. Cover gowns or special uniforms are used to avoid direct contact with clothes.

Interventions For Home Care Of Newborn: Newborn Wellness Check Ups:

- Every newborn should be examined at provider's office within 72 hr (2-3 days) after discharge. Wellness checks at 2-5 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 2.5 years, 3 years, 4 years, every year thereafter - Review schedule for immunizations with parents. Stress importance of receiving these on a schedule for newborn to be protected against diptheria, tetanus, pertussis, hepatitis B, Haemophilus influenzae, polio, measles, mumps, rubella, influenza, rotavirus, pneumococcal, varicella

Hyperemesis Gravidarum:

- Excessive nausea/vomiting (possibly related to elevated hCG levels) that is prolonged past 16 weeks or that is excessive and causes weight loss, dehydration, nutritional deficiencies, electrolyte imbalances, ketonuria. - There is a risk to fetus for intrauterine growth restriction, small for gestational age, preterm birth if condition persists Risk Factors: - Maternal age younger than 30 - Multifetal gestation - Gestational trophoblastic disease - Psychosocial issues and high levels of emotional stress - Clinical hyperthyroid disorders - Diabetes - Gastrointestinal disorders - Family history of hyperemesis Expected Findings: - Excessive vomiting for prolonged periods - Dehydration with possible electrolyte imbalance - Weight loss - Increased pulse rate - Decreased blood pressure - Poor skin turgor and dry mucous membranes Lab Tests: - Urinalysis for ketones and acetones (breakdown of protein and fat) is most important initial lab test: Elevated specific gravity - Chemistry profile revealing electrolyte imbalances: Sodium, potassium, chloride reduced from low intake, metabolic acidosis (secondary to starvation), metabolic alkalosis due to excessive vomiting, elevated liver enzymes, bilirubin level - Thyroid test indicating hyperthyroidism - Complete blood count: Elevated Hct concentration because inability to retain fluid results in hemoconcentration Nursing Care: - Monitor I/O - Assess skin turgor and mucous membranes - Monitor vitals - Monitor weight - Have client remain NPO until vomiting stops Medications: - Give IV lactated Ringer's for hydration - Give pyridoxine (vitamin B6) and other vitamin supplements as tolerated. Recommended use of pyridoxine alone or in combo with doxylamine as safe/effective. - Use antiemetic medications (metoclopramide) cautiously for uncontrollable nausea/vomiting - Use corticosteroids to treat refractory hyperemesis gravidarum Discharge Instructions: - Advance to diet of clear liquids and bland foods once vomiting has stopped. - Advance client's diet as tolerated with frequent small meals. Start with dry toast, crackers, or cereal, then move to a soft diet and finally to a normal diet as tolerated. - In severe cases, enteral nutrition per feeding tube or total parental nutrition can be considered.

Fetal Tachycardia:

- FHR greater than 160/min for 10 min. or more 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 non-breather face mask - Administer IV fluid bolus

FHR Patterns: Fetal Bradycardia:

- FHR less than 110/min for 10 min. or more 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 being administered - Assist client to side-lying position - Administer oxygen by mask at 10 L/min via non-breather face mask - Insert IV catheter if one is not placed and administer IV fluids - Administer a tocolytic medication - Notify provider

Contraceptive Methods: Cervical Mucous Ovulation Detection Method:

- Fertility awareness method ("Billings method) is a symptom-based method in which the client analyzes cervical mucous to determine ovulation - Following ovulation, the cervical mucous becomes thin and flexible under the influence of estrogen and progesterone to allow for sperm viability and motility - The ability for the mucous to stretch between the fingers is greatest during ovulation. This is the spinnbarkeit sign - The fertile period begins when the cervical mucus is thin, slippery, and lasts until 4 days after the last day of cervical mucus having this appearance.

Expected Findings In Pregnant Client:

- Fetal hear tones are heart at a normal baseline rate of 110-160/min with reassuring FHR accelerations noted, which indicates an intact fetal CNS - The client's heart changes in size/shape with resulting cardiac hypertrophy to accommodate increased blood volume with a more distinguishable splitting of S1 and S2 with S3 more easily heart following 20 weeks of gestation. Murmurs also might be auscultated. Heart size/shape should return to normal shortly after delivery - Uterine size changes from a uterine weight of 50-1,000g (0.1-2.2 lb). By 36 weeks of gestation, the top of the uterus and fundus will reach the xiphoid process. This might cause the pregnant client to experience shortness of breath as the uterus pushes against the diaphragm - Cervical changes are obvious as 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

Physiological Status Of Pregnant Client: Renal:

- 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 during pregnancy

Dietary Complications During Pregnancy: Nausea and Constipation:

- For nausea, eat small amounts frequently (every 2-3 hr) to avoid large meals that distend stomach, avoid alcohol, caffeine, fried fatty spicy foods. Also avoid excessive amounts of fluid and DO NOT take a medication to control nausea without first checking with provider. Ginger and herbal tea might be helpful. - For constipation, increase fluid consumption, perform physical activity, include extra fiber in diet. Fruits, veggies, whole grains contain fiber.

Tracheoesophageal Fistula:

- GI anomaly that can occur independently or together with an EA. It alone can include a variety of abnormal connections between esophagus and trachea. TEP & EP combined include a blind esophagus pouch and/or abnormal connection between esophagus and trachea. Presence of a TEF places infant at risk for aspiration and respiratory complications - Can be detected/diagnosed during a prenatal ultrasound Risk Factors: - History of polyhydramnios - Cardiac anomaly - Cleft lip/palate - Neural tube defects Expected Findings: - Depends on specific defect - Excessive oral secretions - Drooling - Feeding intolerance (gagging, coughing during feeding, spitting up, gastric distention) - Respiratory distress and cyanosis Nursing Care: - Position supine with head of bed elevated - Orogastric tube to low-continuous suction - Monitor for signs of respiratory distress Medications: - Antireflux medications - Antacids Therapeutic Procedures: - Surgical intervention to correct specific defect Complications: - Respiratory distress - Depends upon other anomalies present

Advantages Of Breastfeeding:

- Give education on breastfeeding/bottle-feeding to parents during pregnancy so they can make a decision. - Reduces risk of infection by providing IgA antibodies, lysozymes, leukocytes, macrophages, lactoferrin that prevents infection - Promotes rapid brain growth due to large amounts of lactose - Provides protein and nitrogen for neurologic cell building and improving newborn's ability to regulate calcium and phosphorus levels - Contains electrolytes and minerals - Easy for newborn to digest - Reduces incidence of sudden infant death syndrome (SIDS), allergies, childhood obesity - Promotes maternal-infant bonding and attachment Benefits specific to the infant: Decreased risk for GI infections, celiac disease, asthma, lower-respiratory tract infections, otitis media, sudden infant death syndrome (SIDS), obesity in adolescence and adulthood, diabetes mellitus types 1 & 2, acute lymphocytic and myeloid leukemia Benefits specific to the nursing parent: Decreased postpartum bleeding and more rapid uterine involution' decreased risk for ovarian and breast cancer, diabetes mellitus type 2, hypertension, hypercholesterolemia, cardiovascular disease, rheumatoid arthritis Benefits specific to families and society: Less expensive than formula, reduces annual health care costs, reduces environmental effects related to disposal of formula packaging and equipment

Nursing Care Of Newborns: Patient-Centered Care: Umbilical Cord Care:

- Goal of cord care is to prevent or decrease risk of infection/hemorrhage - Cord clamp stays in place for 24-48 hr - Recommendation for cord care include cleaning cord with water (use cleanser sparingly if needed to remove debris) during initial bath of newborn - Assess stump and base of cord for erythema, edema, drainage with each diaper change - Newborn's diaper should be folded down and away from umbilical stump - Bathing infant by submerging in water should not occur until cord has fallen out - Most cords fall off within the first 10-14 days

Danger Signs During Second/Third Trimester Of Pregnancy:

- Gush of fluid from vagina (rupture of amniotic fluid prior to 37 weeks of gestation) - Vaginal bleeding (placenta problems such as abruption or previa) - Abdominal pain (premature labor, abruptio placentae, or ectopic pregnancy) - Changes in fetal activity (decreased fetal movement might indicate fetal distress) - Persistent vomiting (hyperemesis gravidarum) - Severe headaches (gestational hypertension) - Elevated temperature (infection) - Dysuria (UTI) - Blurred vision (gestational hypertension) - Edema of face/hands (gestational hypertension) - Epigastric pain (gestational hypertension) - Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, increased thirst and urination, and headache (hyperglycemia) - Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, and lightheadedness (hypoglycemia)

PostPartum Assessment:

- Happens immediately after delivery including monitoring vitals, uterine firmness and its location in relation to umbilicus, uterine position in relation to midline of abdomen, amount of vaginal bleeding - Blood pressure and pulse should be assessed every 15 min for first 2 hr after birth. Temperature should be assessed every 4 hr the first 8 hr after birth and then every 8 hr A focused postpartum physical assessment includes: B: Breasts U: Uterus (fundal height, uterine placement, consistency) B: Bowel & GI function B: Bladder function L: Lochia (color, odor, consistency and amount of COCA) E: Episiotomy (edema, ecchymosis, approximation) Vital signs Teaching needs Lab Tests: - Urinalysis and CBC with. monitoring of Hgb, Hct, WBC, and platelet count - If rubella and Rh status are unknown, tests should be performed to determine their status

Physiological Status Of Pregnant Client: Gastrointestinal:

- Nausea and vomiting might occur due to hormonal changes and/or increase of pressure within the abdominal cavity as the pregnant client's stomach and intestines are displaced within the abdomen - Constipation might occur due to increased transit time of food through the GI tract and thus, increased water absorption

Newborn Assessment: Physical Head-To-Toe Exam: Head:

- Head should be 2-3 cm larger than chest circumference. If head circumference is greater than or equal to 4 cm larger than chest circumference this can be an indication of hydrocephalus (excessive cerebral fluid within brain cavity surrounding the brain). If head circumference is less than or equal to 32 cm, this can be indication of microcephaly (abnormally small head) - Anterior fontanel should be palpable and approx. 5 cm on average and diamond shaped. Posterior fontanel is smaller and triangle-shaped. Fontanels should be soft and flat. They can bulge when newborn cries, coughs, vomits, but should be flat when newborn is quiet. Bulging fontanels at rest can indicate increased intracranial pressure, infection, or hemorrhage. Depressed fontanels can indicate dehydration! - Sutures should be palpable, separated, can be overlapping (molding), a normal occurrence resulting from head compression during labor - Caput Succedaneum: Localized swelling of soft tissues on scalp caused by pressure on head during labor which is an expected finding that can be palpated as a soft edematous mass and can cross over the suture line. Usually resolves in 3-4 days and does not require treatment. - Cephalohematoma: A collection of blood between the periosteum and skull bone that it covers. It doesn't cross the suture line. It results from trauma during birth such as pressure of fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery. It appears in first 1-2 days after birth and resolves in 2-8 weeks

Nursing Care Of Newborns: Lab Tests:

- Hgb & Hct: If prescribed - Blood Glucose For Hypoglycemia: If prescribed Metabolic Screening: - Newborn genetic screening is mandated in all states. A capillary heel stick should be done 24 hr following birth. For results to be accurate, newborn must have received formula or breast milk for at least 24 hr. If newborn is discharged before 24 hr of age, test should be repeated in 1-2 weeks - All states require for phenulketonuria (PKU). It's a defect in protein metabolism in which the accumulation of amino acid phenylalanine can result in mental retardation (Treatment in first 2 months of life can prevent mental retardation) - Other Genetic Testing: That can be done includes: galactosemia, cystic fibrosis, maple syrup urine disease, hypothyroidism, sickle cell disease - Serum Bilirubin: On all newborns prior to discharge Collecting Blood Samples: - Heel stick blood samples are obtained by nurse, who dons clean gloves - Warm newborn's heel first to increase circulation - Cleanse the area with appropriate antiseptic and allow for drying - A spring-activated lancet is used so skin incision is made quickly/painlessly - Outer aspect of heel should be used and the lancet should go no deeper than 2.4 mm to prevent necrotizing osteochondritis resulting from penetration of bone with lancet - Follow facility protocol for specimen collection - Apply pressure with dry gauze (do not use alcohol bc it was cause bleeding to continue) until bleeding stops and cover w/ adhesive bandage - Cuddle and comfort newborn when procedure is done to reassure newborn and promote feelings of safety Diagnostic Procedures: Newborn Hearing Screening: Is required in most states. Newborns are screened so that hearing impairment can be detected/treated early

Gestational Hypertension:

- Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on end-organ effects and progresses along a continuum from mild gestational hypertension; mild and severe preeclampsia; eclampsia; and hemolysis. elevated liver enzymes, low platelets (HELLP) syndrome. - Vasospasm contributing to poor tissue perfusion is underlying mechanism for manifestations of pregnancy hypertensive disorders. - Gestational hypertensive disease and chronic hypertension can occur simultaneously. - Gestational hypertensive diseases are associated with placental abruption, kidney failure, hepatic rupture, preterm birth, fetal/maternal death.

Client Education About Nutrition: Calcium:

- Important in a developing fetus - Involved in bone/teeth formation - Sources of calcium: milk, calcium-fortified soy milk, fortified orange juice, nuts, legumes, dark green leafy veggies. - Daily recommendation is 1,000 mg/day for pregnant and non-pregnant clients age 19-50 years and 1,300 mg/day for those under 19 years.

Calculating Delivery Date & Determining Number Of Pregnancies For Pregnant Client: Measurement Of Fundal Height:

- In centimeters from the symphysis pubis to the top of the uterine fundus (between 18 and 30 weeks of gestation) - Approximates the gestational age, plus or minus 2 gestational weeks

Infertility:

- Inability to conceive despite engaging in unprotected sexual intercourse for a prolonged period of time or at least 12 months - Decreased sperm count, endometriosis, ovulation disorders, tubal occlusions

Continuous Electronic Fetal Monitoring: Interpretation Of Findings: Category II:

- Includes all tracings in category I or category III. Examples of category II fetal heart rate tracings contain any of these: 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 fetal heart rate deceleration equal or greater than 2 min but less than 10 min - Recurrent late decelerations with moderate baseline variability - Recurrent variable decelerations with minimal or moderate baseline variability - Variable decelerations with additional characteristics like "overshoots", "shoulders", or slow return to baseline fetal heart rate Accelerations: - Absence of induced accelerations after fetal stimulation

Complications Related To Newborn Home Care:

- Infected cord or circumcision from improper care or tub bathing too soon - Falls, suffocation, strangulation, burns resulting in injuries, fractures, aspiration, death due to improper safety precautions - Respiratory infections due to passive smoke/inhaled powders - Improper or no use of a care seat resulting in injury/death - Serious infections due to lack of nonadherence with immunization schedule

PostPartum: Uterus:

- Physical changes of uterus include involution of uterus - Involution occurs with contractions of uterine smooth muscle, whereby uterus returns to its pre-pregnant state - The uterus also rapidly decreases in size from approx. 1,000 g at end of third stage of labor to 60-80 g at 6 weeks postpartum with fundal height steadily descending into pelvis approx. 1 fingerbreadth (1 cm) per day. - At end of third stage of labor the uterus should be palpable at midline and 2 cm below the umbilicus - 1 hr. after delivery the fundus (top portion of uterus) should rise to the level of umbilicus - Every 24 hr the fundus should descent approx. 1-2 cm. It should be halfway between the symphysis pubis and umbilicus by the sixth postpartum day - After about 2 weeks the uterus should lie within the true pelvis and should not be palpable

Intermittent Auscultation & Uterine Contraction Palpation:

- Intermittent auscultation of the FHR is a low-technology method that can be performed during labor using a hand-held Doppler ultrasound device, ultrasound stethoscope, or fetoscope to assess FHR. - In conjunction, palpation of contractions at fundus for frequency, intensity, duration, resting tone is used to evaluate fetal well-being - During labor uterine contractions compress the uteroplacental arteries temporarily stopping maternal blood flow into uterus and placenta resumes during uterine relaxation between contractions - For low-risk labor/delivery this procedure allows client freedom of movement and can be done at home or a birthing center Guidelines For Internal Auscultation Or Continuous Electronic Fetal Monitoring: - During latent phase: every 30-60 min - During active phase: every 15-30 min - During second stage: every 5-15 min Indications: - Determine active labor - Rupture of membranes, spontaneously or artificially - Preceding and subsequent to ambulation - Prior to and following administration of or a change in medication analgesia - At peak action of anesthesia - Following vaginal examination - Following expulsion of an enema - After urinary catheterization - Abnormal or excessive uterine contractions

Transvaginal Ultrasound:

- Invasive procedure where a probe is inserted vaginally to allow for a more accurate evaluation. - Does not require a full bladder. - Especially useful for obese clients and those in the first trimester to detect ectopic pregnancy. - Also can be used in third trimester in conjunction with abdominal ultrasound to evaluate preterm labor.

Vacuum-Assisted Delivery:

- Involved the use of a cup-like suction device that is attached to fetal head. - Traction is applied during contractions to assist in descent and birth of head, after which the vacuum cup is released and removed preceding delivery of fetal body Conditions For Use: - Vertex presentation - Cervical dilation of 10 cm - Absence of cephalopelvic disproprotion - Ruptured membranes Associated Risks: - Scalp lacerations - Subdural hematoma of neonate - Cephalohematoma - Maternal lacerations of cervix, vagina, or perineum Indications: - Maternal exhaustion and ineffective pushing efforts - Fetal distress during second stage of labor - Generally not used to assist birth before 34 weeks Preparation Of Client: - Provide client and partner support and educate them about procedure - Assist client into lithotomy position to allow sufficient traction of vacuum cup when it's applied to fetal head - Assess/record FHR before and during vacuum assistance - Assess for bladder distention and catheterize if necessary Ongoing Care: - Prepare for a forceps-assisted birth if vacuum-assisted birth is not successful Interventions: - Alert postpartum care providers that vacuum assisstance was used - Observe the neonate for lacerations, cephalohematoma, or subdrual hematomas after delivery - Check neonate for caput succedaneum: swelling of scalp in newborn that usually disappears within 3-5 days

Preterm Labor Medications: Indomethacin:

- Is a non-steroidal anti-inflammatory drug (NSAID) that suppresses preterm labor by blocking production of prostaglandins. This inhibition of prostaglandins suppresses uterine contractions - This medication can cause premature narrowing or closure of ductus arteriosus in the fetus. Nursing Action: - Monitor client closely. Discontinue tocolytic therapy immediately if client experiences pulmonary edema, which includes manifestations of chest pain, shortness of breath, respiratory distress, audible wheezing and crackles, and productive cough containing blood-tinged sputum. - Treatment should not exceed 48 hr - Should only be used if gestational age is less than 32 weeks - Monitor for postpartum hemorrhage related to reduced platelet aggregation - Administer this with food or rectally to decrease GI distress - Notify provider if client reports blurred vision, headache, nausea, vomiting, ringing in ears, difficulty breathing - Monitor the neonate at birth

Newborn Assessment: Gestational Age Assessment:

- Is performed on newborns within first 48 hr following birth - Neonatal morbidity and mortality are related to gestational age and birth weight. - The gestational age assessment involves taking measurements of newborn and use of New Ballard Score. - This score provides an estimation of gestational age and a baseline to assess growth and development

Large For Gestational Age (Macrosoamic) Newborn:

- LGA occurs in neonates who weigh above the 90th percentile or more than 4,000 g (8.8 lb) - Neonates who are LGA can be preterm, postmature, or full-term - Newborns who are macrosomic are at risk for birth injuries (shoulder dystocia, clavicle fracture or c-section, asphyxia, hypoglycemia, polycythemia, and Erb-Duchenne paralysis due to birth trauma) - Uncontrolled hyperglycemia during pregnancy (leading risk factor for LGA) can lead to congenital defects with most common being congenital heart defects, tracheoesophageal fistula (TEF), CNS anomalies Risk Factors: - Newborns who are post-mature - Maternal diabetes mellitus during pregnancy (high glucose levels stimulate continued insulin production by fetus) - Genetic factors - Maternal obesity - Multiparity Expected Findings: - Weight above 90th percentile (4,000 g) - Large head - Plump and full-faced (cushingold appearance) from increased subcutaneous fat - Manifestations of hypoxia including tachypnea, retractions, cyanosis, nasal flaring, grunting - Birth trauma (fractures, shoulder dystocia, intracranial hemorrhage, CNS injury) - Sluggishness, hypotonic muscles, and hypoactivity - Tremors from hypocalcemia - Hypoglycemia - Respiratory distress from immature lungs or meconium aspiration Findings Of Increased Intracranial Pressure: - Dilated pupils, vomiting, bulging fontanels, high-pitched cry Lab Tests: - Blood glucose levels to monitor closely for hypoglycemia - ABGs can be prescribed due to chronic hypoxia in utero secondary to placental insufficiency - CBC shows polycythemia (Hct greater than 65%) from in utero hypoxia - Hyperbilirubinemia resulting from polycythemia as excessive RBCs break down after birth - Hypocalcemia can result in response to a long and difficult birth Diagnostic Procedures: - Chest x-ray to rule out meconium aspiration syndrome Nursing Care: Prior To Delivery: - Prepare client for possible vacuum-assisted or c-section - Prepare to place client in McRoberts position (lithotomy position w/ legs flexed to chest to maximize pelvic outlet) - Prepare to apply suprapubic pressure to aid in delivery of anterior shoulder, which is located inferior to maternal symphysis pubis - Assess newborn for birth trauma (broken clavicle, Erb-Duchenne paralysis) For Newborn Who Is LGA Following Delivery: - Obtain early and frequent heel sticks (blood glucose testing) - Initiate early feedings or IV therapy to maintain glucose levels within range - Provide thermoregulation with an isolette - Identify and treat any birth injuries

Nursing Care Of Newborns: Patient-Centered Care: Family Education:

- Provide family education while performing all nursing care. Encourage family involvement, allowing parent and family to perform newborn care with direct supervision and support by nurse - Encourage parents and family to hold newborn so they can experience eye-to-eye contact/interaction - Foster sibling interaction in newborn care

Intervening For Newborn Nutrition:

- Provide parent with education about feeding-readiness cues exhibited by newborns and encourage parent to begin feeding newborn upon cues rather than waiting until they cry. Cues include: - Hand-to-mouth or hand-to-hand movements - Sucking motions - Rooting - Mouthing

PostPartum Disorders: Lacerations & Hematomas:

- Lacerations that occur during labor and birth consist of tearing of soft tissues in birth canal and adjacent structures including cervical, vaginal, vulvar, perineal, and/or rectal areas - An episiotomy can extend and become a third-or-fourth degree laceration - A hematoma is a collection of clotted blood within tissues that can appear like a bruise. Hematomas can occur in pelvic region or higher in vagina or broad ligament - Pain, rather than noticeable bleeding is the distinguishable clinical finding of hematoma - Client is at risk for hemorrhage or infection due to a laceration or hematoma Risk Factors: - Operative vaginal birth (forceps-assisted, vacuum-assisted) - Precipitous birth - Cephalopelvic disproportion - Size (macrosomic infant) and abnormal presentation or position of fetus - Prolonged pressure of fetal head on vaginal mucous - Previous scarring of birth canal from infection, injury, operation Expected Findings: Laceration: - Sensation of oozing or trickling of blood - Excessive rubra lochia (with/without clots) - Vaginal bleeding even though uterus is firm and contracted - Continuous slow trickle of bright red blood from vagina, laceration, episiotomy Hematoma: - Pain - Pressure sensation in rectum (urge to defecate) or vagina - Difficulty voiding - Bulging, bluish mass or area of red-purple discoloration on vulva, perineum, or rectum Nursing Care: - Assess pain - Visually or manually inspect the vulva, perineum, and rectum for laceration and/or hematomas - Evaluate lochia - Continue to assess vitals and hemodynamic status - Attempt to identify source of bleeding - Assist provider with repair procedures - Use ice packs to treat small hematoma - Administer pain meds - Encourage sitz baths and frequent perineal hygiene Therapeutic Procedures: - Repair and suturing of episiotomy or lacerations is done by provider - Ligation of bleeding vessel or surgical incision for evacuation of clotted blood from hematoma is done by provider

Nursing Care: Third Stage:

- Lasts from birth of fetus until placenta is delivered Assessments: - Blood pressure, pulse, respiration measurements every 15 min Clinical findings of placental separation from uterus 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 to the neonate Nursing Actions: - Instruct client to push once findings of placental separation present. Keep client/parents informed of progress of placental expulsion and perineal repair if appropriate - Administer oxytocin as prescribed to stimulate uterus to contract and this prevent hemorrhage - Administer analgesics - Gently cleanse perineal area with warm water and apply a perineal pad or ice pack to perineum - Promote baby-friendly activities between family and newborn, which facilitates the release of endogenous maternal oxytocin. Ex: introducing the baby to parents and facilitating attachment process by promoting skin-to-skin contact immediately following birth. Allow private time and encourage breastfeeding

Nursing Care: Second Stage:

- Lasts from time cervix is fully dilated to birth Assessment: - Begins with complete dilation and effacement - Blood pressure, pulse, respirations very 5-30 min - Uterine contractions - Pushing efforts by client - Increase in bloody show - Shaking of extremities - FHR every 5-15 min (depending on fetal risk status) and immediately following birth Assessment For Perineal Lacerations Which Usually Occur As Fetal Head Is Expulsed. Perineal Lacerations Are Defined In Terms Of Depth: - First Degree: Laceration extends through skin of perineum and does not involve the muscles - Second Degree: Lacerations extend through the skin and muscles into the perineum but not the anal sphincter - Third Degree: Lacerations extend through the skin, muscles, perineum, and external anal sphincter muscle - Fourth Degree: Laceration extends through skin, muscles, anal sphincter, and anterior rectal wall Nursing Actions: - Continue to monitor client/fetus - Assist in positioning the client 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 such as cold compress - Cleanse client's perineum as needed if fecal material comes out during pushing - Prepare for episiotomy if needed - Provide feedback on labor progress to client Provide for care of neonate. A nurse trained in neonatal resuscitation should be present at delivery: - Check oxygen flow/tank on a warmer - Preheat radiant warmer - Lay out newborn stethoscope and bulb syringe - Have resuscitation equipment in working order (resuscitation bag, laryngoscope) and emergency meds available - Check suction apparatus

True Labor:

- Leads to cervical dilation and effacement - Contractions can begin irregularly, but become regular in frequency - Stronger, last longer and more frequent - Felt in lower back radiating to abdomen - Walking can increase contraction intensity - Continue despite comfort measures - Cervix (assessed by vaginal exam) - Progressive change in dilation and effacement - Moves to anterior position - Bloody show - Fetus: Presenting part engages in pelvis

Postpartum: Lochia:

- Lochia is post-birth uterine discharge that contains blood mucus and uterine tissue. - The amount of lochia is similar to a heavy menstrual period about 2 hr after delivery then it decreases gradually to a consistent rate 3 Stages Of Lochia: - Lochia Rubra: Dark red color, bloody consistency, fleshy odor, can contain small clots, transient flow increases during breastfeeding and upon rising. Lasts 1-3 days after delivery - Lochia Serosa: Pinkish brown color and serosanguineous consistency. Can contain small clots and leukocytes. Lasts approx. day 4 to day 10 after delivery - Lochia Alba: Yellowish white creamy color, fleshy odor. Can consist of mucous and leukocytes. Lasts from approx day 10 up to 8 weeks postpartum

Newborn Assessment: Physical Head-To-Toe Exam: Posture:

- Lying in a curled-up position with arms/legs in moderate flexion - Resistant to extension of extremities

Gestational Trophoblastic Disease Nursing Care:

- Measure fundal height - Assess vaginal bleeding and discharge - Assess gastrointestinal status and appetite - Monitor for manifestations of preeclampsia - Administer medications as prescribed (Rho(D) immune globulin to client who is Rh-negative, chemotherapeutic medication for findings of malignant cells indicating choriocarcinoma - Advise client to save clots or tissue for evaluation - Provide client education and emotional support Client Education: - Consider pregnancy loss support groups referred by nurse - Use reliable contraception as a component of follow-up care. Avoid using an IUD. - Follow-up is important due to increased risk of choriocarcinoma

Neonatal Substance Withdrawal:

- Substance withdrawal in newborn occurs when parents use drugs that have addictive properties during pregnancy. This includes alcohol, tobacco, illegal drugs, prescription meds. - Fetal alcohol syndrome results from chronic or periodic intake of alcohol during pregnancy. Alcohol is considered teratogenic, so daily intake of alcohol increases risk of fetal alcohol syndrome. Long-Term Complications: - Feeding problems - CNS dysfunction (cognitive impairment, cerebral palsy) - Attention deficit disorder - Language abnormalities - Microcephaly - Delayed growth and development - Poor maternal-newborn bonding

Meconium-Stained Amniotic Fluid:

- Meconium passage in the amniotic fluid during the antepartum period prior to the start of labor is typically not associated with an unfavorable fetal outcome - The fetus has had an episode of loss of sphincter control, allowing meconium to pass into amniotic fluid Risk Factors: - Increased incident for meconium in amniotic fluid after 38 weeks gestation due to fetal maturity of normal physiological functions - Umbilical cord compression results in fetal hypoxia that stimulates the vagal nerve in mature fetuses - Hypoxia stimulates the vagal nerve, which induces peristalsis of the fetal gastrointestinal tract and relaxation of the anal sphincter Expected Findings: - Amniotic fluid can vary in color: black to greenish or yellow, but meconium-stained amniotic fluid is often green. Consistency can be thin or thick Criteria for evaluation of meconium-stained amniotic fluid: - Often present in breech presentation and might not indicate fetal hypoxia - Present with no changes in FHR - Stained fluid accompanied by variable or late decelerations in FHR (ominous finding) Diagnostic Procedures: - Electronic fetal monitoring Nursing Care: - Document color/consistency of stained amniotic fluid - Notify neonatal resuscitation team to be present at birth - Gather equipment needed for neonatal resuscitation - Assess neonate's respiratory effects, muscle tone, heart rate - Suction mouth/nose using bulb syringe if respiratory efforts are strong, muscle tone is good, heart rate is greater than 100/min - Suction below the vocal cords using an endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, heart rate is less than 100/min

Male Infertility Assessment:

- Medical History: Mumps, especially after adolescence, endocrine disorders, genetic disorders, anomalies in reproductive system

Postpartum Infections: Mastitis:

- Milk stasis, which can be caused by blocked duct, engorgement, or bra with underwire - Nipple trauma and cracked or fissured nipples - Poor breastfeeding technique with improper latching of infant onto breast, which can lead to sore or cracked nipples - Decrease in breastfeeding frequency due to supplementation with bottle feeding - Contamination of breasts due to poor hygiene Expected Finding: - Painful or tender localized hard mass and reddened area, usually on one breast - Influenza-like manifestations (chills, fever, headache, body ache) - Fatigue - Axillary adenopathy in affected side (enlarged tender axillary lymph nodes) with an area of inflammation that can be red, swollen, warm, tender Nursing Care: - Administer antibiotics Client Education: - Breast hygiene can prevent and manage mastitis - Thoroughly wash hands prior to breastfeeding - Maintain cleanliness of breasts with frequent changing of breast pads - Allow nipples to air-dry - Proper infant positioning and latching-on techniques include both the nipple and areola. Release infant's grasp on nipple prior to removing infant from the breast - Completely empty breasts with each feeding to prevent milk stasis, which provides a medium for bacterial growth - Use ice packs or warm packs on affected breasts for discomfort - Continue breastfeeding frequently (at least every 2-4 hr) especially on affected side - Manually express breast milk or use pump if breastfeeding is too painful - Breastfeed or pump frequently emptying affected side - Rest, take analgesics, maintain fluid intake of at least 3,000 mL per day - Wear a well-fitting bra for support. Bra should NOT have underwire bc that increases risk for infection - Report reddness/fever - Complete entire course of antibiotics as prescribed

Nursing Care Of Newborns: Patient-Centered Care: Elimination:

- Monitor habits: - Newborns should void once within 24 hr of birth - They should void 6-8 times per 24 hr after day 4 - Meconium should be passed within first 24 hr to 48 hr after birth. Newborn will continue to pass stool 3-4 times a day depending on if they're breastfed or bottle-fed. - Stools of newborns breastfed are yellow/seedy. They should have at least 3 stools per day for first month. These stools are lighter in color and looser than stools of newborns who are formula-fed - Monitor/document output Keep perineal area clean/dry. The ammonia in urine is irritating to skin and can cause diaper rash: - After each diaper change, cleans perineal area with clear water or water with. mild soap. Diaper wipes with alcohol should be avoided. Pat dry and apply triple antibiotic ointment, petroleum jelly or zinc oxide

Ongoing Prenatal Visits:

- Monitor weight, blood pressure, urine for glucose, protein, leukocytes - Monitor for presence of edema Monitor fetal development: - FHR can be detected at early appointments by ultrasound. The heartbeat can be heart by Doppler late in the first trimester. Listen at the midline, right above the symphysis pubis, by holding the Doppler firmly on the abdomen - Measure fundal height starting in the second trimester. From weeks 18-30, the fundal height in cm is approx. the same as the number of weeks of gestation - Fetal health assessment: begin assessing for fetal movement between 16-20 weeks of gestation - Provide education for self-care to include management of common discomforts and concerns of pregnancy (nausea/vomiting, fatigue, backache, varicosities, heartburns, activity, sexuality)

Human Papilloma Virus (HPV):

- Most common STI - Some types can cause genital warts known as Condyloma acuminata and cervical cancers - It is spread through oral, vaginal, anal sex (most commonly vaginal/anal) - When large, widespread, or occluding the birth canal, genital warts can complicate a vaginal delivery. A cesarean section can be recommended - Routine screening for females can provide early detection - During pregnancy the lesions can expand and obscure birth canal. This can interfere with descent of fetus as well as client's ability to urinate/defecate Risk Factors: - Multiple partners - Unprotected sex Expected Findings: - Client reports bumps in genital area that might not itch/hurt, vaginal discharge, dyspareunia, bleeding after intercourse - Small warts or a group of warts in genital area that can have a cauliflower-like appearance - Abnormal changes to cervix that can be detected by a pap test Lab Tests: - Females 21-29 should have a pap test every 3 years - Females 30-65 should have a pap test and an HPV test every 5 years - Females older than 65 who have had regular screenings with normal results should not be screened for cervical cancer unless they have cervical pre-cancer in which they continue to be screened for 20 years after pre-cancer diagnosis. Diagnostic Procedures: - Genital warts are diagnosed by provider based on appearance during physical exam - Based on pap test result, colposcopy and biopsy can be performed to diagnose cervical pre-cancer and cancer Medications: For genital warts and Condyloma acuminata: - Client-applied cream such as bichloroacetic acid, which is safe during pregnancy and imiquimod which is recommended for people 13 and older who are not pregnant - Provider-administered therapy such as trichloracetic acid application which is safe during pregnancy - Podphyllin can be used but is not recommended if pregnant Therapeutic Procedures: - For precancerous change son cervix, provider can perform treatments including laser therapy or cone biopsy; for a pregnant woman with an abnormal pap that requires further follow-up, further evaluation and treatment are usually deferred until after birth Client Education: - Vaccines are recommended to protect against low-risk types of HPV that can cause genital warts and high-risk types of HPV that can cause cancer. Vaccine is indicated for ages 9-26 and ideally given at age 11-12 years old. 3 doses of this vaccine will be received during a 6-month period - Consider abstinence or safe sex practices - If therapy is deferred until after delivery, remember that the lesions are infectious

Contraceptive Methods: Abstinence:

- Most effective method of birth control - Eliminates risk of STI

Interventions For Home Care Of Newborn: Home Safety:

- Never leave newborn unattended with pets or other small children - Keep small objects out of reach due to choking hazard - Never leave newborn alone on bed, couch, table. Newborns move enough to reach edge and fall off - Never place newborn on stomach to sleep during first few months. Back-lying position is position of choice. Newborn can be placed on abdomen when awake/supervised - Never provide a newborn with a soft surface to sleep on (pillows). Newborn's mattress should be firm. No pillows, toys, bumper pads, loose blankets in crib. Linens should be tight-fitting - Do not tie anything around the neck - Monitor the safety of newborn's crib. Space between mattress and sides of crib should be less than 2 fingerbreadths. The slats on cribs should be no more than 5.7 cm (2.25 in) apart - Newborns' crib or playpen should be away from window blinds/drapery cords. Newborns can become strangled by them. - Bassinet/crib should be placed on inner wall, not next to window to prevent cold stress by radiation - Smoke detectors should be on every floor of home and should be checked monthly to ensure they're working. Batteries changed twice a year. - Eliminate potential fire hazards. Keep crib/playpen away from heaters, radiators, heat vents. Linens should catch fire if they come into contact with heat sources - Control temperature and humidity of newborn's environment by providing adequate ventilation - Avoid exposure newborn to cigarette smoke in home/elsewhere. Secondhand exposure increases newborn's risk of respiratory illness - All visitors should wash their hands before touching newborn. Any individual with infection should be kept away - Carefully handle newborn. Do not toss up in the air or swing them by extremities. Do not shake newborn

Post-Mature Infants:

- Newborn who is born after completion of 42 weeks of gestation Postmaturity in infant can be associated with: - Dysmaturity from placental degeneration and uteroplacental insufficiency: Placental functions effectively for approd. 40 weeks. resulting in chronic fetal hypoxia and fetal distress in utero, Fetal response is polycythemia, meconium aspiration, and/or neonatal respiratory problems. Perinatal mortality is higher when a postmature placenta fails to meet increased oxygen demands of fetus during labor - Continued growth of the fetus in utero: Bc the placenta continues to function effectively and the newborn becomes LGA at birth. This leads to a difficult delivery, cephalopelvic disproportion as well as high insulin reserves and insufficient glucose reserves at birth. The neonatal response can be birth trauma, perinatal asphyxia, clavicle fracture, seizures, hypoglycemia, and/or temperature instability (cold stress) - Newborn who is postmature can be either SGA or LGA depending on how well placenta functions during last week of pregnancy - Newborns who are postmature have increased risk for aspirating the meconium passed by fetus in utero - Persistent pulmonary hypertension (persistent fetal circulation) is complication that can result from meconium aspiration. There's an interference in transition from fetal to neonatal circulation, and ductus arteriosus (connecting main pulmonary artery and the aorta) and foramen ovale (shunt between right and left atria) remain open, fetal pathways of blood flow continue Risk Factors: - In most cases, cause of pregnancy that extends beyond 40 weeks gestations is unknown but there's higher incidence in first pregnancies and in clients who have had a previous postmature pregnancy Expected Findings: - Wasted appearance, thin with loose skin, having lost some of the subcutaneous fat - Peeling, cracked, dry skin; leathery from decreased protection of vernix and amniotic fluid - Long thin body - Meconium staining of fingernails and umbilical cord - Hair/nails can be long - Alertness similar to 2-week old newborn - Difficulty establishing respirations secondary to meconium aspiration - Hypoglycemia due to insufficient stores of glycogen - Neurological manifestations that become apparent with development of fine motor skills - Macrosomia Lab Tests: - Blood glucose to monitor for hypoglycemia - ABGs secondary to chronic hypoxia in utero due to placental insufficiency - CBC to show polycythemia from decreased oxygenation in utero - Hct elevated from polycythemia and dehydration Diagnostic Procedures: - C-section - Chest x-ray to rule out meconium aspiration syndrome Nursing Care: - Monitor vitals - Administer/monitor IV fluids - Moisturize skin with petrolatum-based ointment - Use mechanical ventilation if necessary - Administer oxygen as prescribed - Prepare and/or assist with exchange transfusion if hematocrit is high - Provide thermoregulation in an isolette to avoid cold stress - Provide early feedings to avoid hypoglycemia - Identify and treat any birth injuries

Hypoglycemia:

- Newborn's source of glucose stops when umbilical cord is clamped. If they have other physiological stress, they can experience hypoglycemia due to inadequate gluconeogenesis or increased use of glycogen stores - A healthy term newborn's blood glucose is between 30-60 - Hypoglycemia differs for newborn who is preterm/term. Hypoglycemia in first 3 days of life in term born is defined as blood glucose level less than 30 - Untreated hypoglycemia can result in seizures, brain damage, death Risk Factors: - Maternal diabetes mellitus - Preterm infant - LGA or SGA - Stress at birth (cold stress, asphyxia) Expected Findings: - Poor feeding - Jitteriness/tremors - Hypothermia - Weak cry - Lethargy - Flaccid muscle tone - Seizures/coma - Irregular respirations - Cyanosis - Apnea Lab Tests: - Obtain lab specimen to verify bedside glucose finding less than 45 mg/dL Nursing Care: - Obtain blood by heel stick for glucose monitoring - An asymptomatic at-risk newborn who has blood glucose level less than 25 mg/dL in first 4 hr, or less than 35 mg/dL from 4 hr - 24 hr or fage, should be offered oral feedings to increase levels to greater than 45 mg/dL - Initiate IV dextrose for a symptomatic newborn - Provide frequent oral and or gavage feedings or continuous parenteral nutrition early after birth to treat hypoglycemia - Monitor neonate's blood glucose level - Monitor IV if neonate is unable to feed orally - Maintain skin-to-skin contact to treat hypothermia

Interventions For Home Care Of Newborn: Sleep-Wake Cycle:

- Newborns sleep approx. 16-19 hr/day with periods of wakefulness gradually increasing - Many parents believe adding solid foods to diet will help with sleep patterns. During first 6 months, recommendation is only breastfeeding. Most newborns will sleep through night without a feeding by 4-5 months. Client Education: - Placing newborn in supine position for sleeping greatly decreases risk of sudden infant death syndrome - Keep newborn's environment quiet/dark at night - Place newborn in a crib or bassinet to sleep. - Most newborns get their days/nights mixed up: - Bring newborn out into center of action in afternoon and keep them their until bedtime - Bathe them right before bedtime so they feel soothed - Give them their last feeding around 2300 then place them in the crib - When awake, newborn can be placed on abdomen to promote muscle development for crawling. Infant should be supervised - For nighttime feedings and diaper changes, keep small night-light on to avoid having to turn on bright lights. Speak softly, handle newborn gently so they go back to sleep easily

Doppler Ultrasound Blood Flow Analysis:

- Non-invasive external ultrasound method to study the maternal-fetal blood flow by measuring the velocity at which RBCs travel in the uterine and fetal vessels using a handheld ultrasound device that reflects sound waves from a moving target. - Especially useful in fetal intrauterine growth restriction (IUGR) and poor placental perfusion and as an adjunct in pregnancies at risk because of hypertension, diabetes mellitus, multiple fetuses, or preterm labor. - 2D: Standard medical scan; black, white, or shades of gray. - 3D: Multiple pictures at once; almost as clear as a photography; images look more lifelike than standard ultrasound images. - 4D: Like 3D but also shows fetal movements in a video.

Continuous Electronic Fetal Monitoring: Interpretation Of Findings:

- Normal fetal heart rate baseline at term is 110-160/min excluding accelerations, decelerations, periods of marked variability within 10 min. window. At least 2 min of baseline segments in a 120 min window should be presented. A single number should be documented instead of a baseline range Fetal heart rate baseline variability is described as fluctuations in FHR baseline that are irregular in frequency and amplitude. Expected variability should be moderate variability. Classification of variability is: - Absent or undetectable variability (considered nonreassuring) - Minimal variability (detectable but equal to or less than 5/min) - Moderate variability (6-25/min) - Marked variability (greater than 25/min) - Changes in fetal heart rate patterns are categorized as episodic or periodic changes. Episodic changes are not associated with uterine contractions and periodic changes occur with uterine contractions. These changes include accelerations/decelerations.

Spontaneous Abortion Client Education:

- Notify provider of heavy, bright red vaginal bleeding, elevated temperature, or foul-smelling vaginal discharge. - A small amount of discharge is normal for 1-2 weeks - Take prescribed antibiotics - Refrain from tub baths, sexual intercourse, or placing anything into the vagina for 2 weeks - Discuss grief and loss with the provider before attempting another pregnancy

Calculating Delivery Date & Determining Number Of Pregnancies For Pregnant Client: Gravidity:

- Number of pregnancies - Nulligravida: A client who has never been pregnant - Primigravida: A client in their first pregnancy - Multigravida: A client who has had 2 or more pregnancies

Calculating Delivery Date & Determining Number Of Pregnancies For Pregnant Client: Parity:

- Number of pregnancies in which the fetus reaches 20 weeks, not the number of fetuses. - Parity is not affected whether the fetus is born/stillborn/alive - Nullipara: No pregnancy beyond the stage of viability - Primipara: Has completed 1 pregnancy to stage of viability - Multipara: Has completed 2 or more pregnancies to stage of viability

Iron Deficiency Anemia:

- Occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron Risk Factors: - Less than 2 years between pregnancies - Heavy menses - Diet low in iron - Unhealthy weight loss programs Expected Findings: - Fatigue/weakness - Craving unusual food (pica) Lab Tests: - Hgb less than 11 mg/dL in first and third trimester and less than 10.5 mg/dL in second trimester - Hct less than 33% - Blood ferritin less than 12 mcg/L in presence of low Hgb Nursing Care: - Recommended iron intake for pregnant clients is 27 mg/day. Prenatal vitamins typically contain 30 mg iron. If maternal iron deficiency anemia is present, increased dosages of 60-120 mg/d.ay can be required. - Increase dietary intake of foods rich in iron (legumes, dried fruit, dark green leafy veggies, meat) - Educate client about ways to minimize gastrointestinal adverse effects. Medications: Ferrous sulfate iron supplements: - Take supplements on empty stomach and take with orange juice to increase absorption. - Adhere to a diet rich in vitamin C-containing foods to increase absorption - Increase roughage and fluid intake in diet to assist with discomforts of constipation z Parenteral Iron Therapy: - For pregnant clients who cannot tolerate oral iron. Severe anemic clients can receive blood transfusions.

Birth Trauma Or Injury:

- Occurs in childbirth resulting in physical injury to newborn - Most injuries are minor and resolve rapidly. Types Of Birth Injuries: - Skull: Linear fracture, depressed fracture - Scalp: Caput succedaneum, hemorrhage - Intracranial: Epidural or subdural hematoma, contusions - Spinal Cord: Spinal cord transaction or injury, vertebral artery injury - Plexus: Brachial plexus injury, Klumpke's palsy - Cranial & Peripheral Nerve: Radial nerve palsy, diaphragmatic paralysis Risk Factor: - Maternal age: younger than 16 or older than 35 - Fetal macrosomia - Abnormal/difficult presentations - Prolonged labor - Precipitous labor - Oligohydramnios - Cephalopelvic disproportion - Multifetal gestation - Congenital abnormalities - Internal FHR monitoring - Forceps or vacuum extraction - External version - C-section Expected Findings: - Irritability, seizures within first 72 hr and decreased level of consciousness are manifestations of subarachnoid hemorrhage - Facial flattening and unresponsiveness to grimace that accompanies crying or stimulation, as well as eyes remaining open, are findings to assess for facial paralysis - Weak or hoarse cry is characteristic of laryngeal nerve palsy from excessive traction on neck - Flaccid muscle tone can signal joint dislocations and separation during birth - Flaccid muscle tone of extremities suggests nerve-plexus injuries or long bone fractures - Limited motion of arm, crepitus over a clavicle, absence of Moro reflex on affected side are manifestations of clavicular fractures - A flaccid arm with elbow extended and the hand rotated inward , absence of Moro reflex on affected side, sensory loss over lateral aspect of arm, intact grasp reflex are manifestations of Erb-Duchenne paralysis (brachial paralysis) - Localized discoloration, ecchymosis, petechiae, and edema over presenting part are seen with soft-tissue injuries. Diagnostic Procedures; - Birth injuries are normally diagnosed by CT scan, x-ray of suspected area of fracture, or neurological exam to determine paralysis of nerves Nursing Care; - Review maternal history for factors that can predispose newborn to injuries - Review Apgar scoring that might indicate a possibility of birth injury - Perform frequent head-to-toe physical assessment - Obtain vitals/temperature - Promote parent-newborn interactions as much as possible - Administer treatment to newborn based on injury and according to provider's prescriptions Client Education: Discharge Instructions: - Understand injury and management of it - Perform parent-newborn bonding

Prolapsed Umbilical Cord:

- Occurs when umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix. This results in cord compression and compromised fetal circulation. Risk Factors: - Rupture of amniotic membranes - Abnormal fetal presentation (any presentation other than vertex [occiput as presenting part]) - Transverse lie: Presenting part not engaged, which leaves room for cord to descend - Small for gestational age fetus - Unusually long umbilical cord - Multifetal pregnancy - Unengaged presenting part - Hydramnios or polyhydramnios Expected Findings: - Client reports they feel something coming through the vagina - Visualization or palpation of umbilical cord protruding from the introitus - FHR monitoring shows variable or prolonged deceleration - Excessive fatal activity followed by cessation of movement; suggestive of severe fetal hypoxia Nursing Care: - Call for assistance immediately - Do not leave client - Notify provider - Use a sterile-gloved hand and insert 2 fingers into vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off the cord. Stay in this position until delivery of baby - Reposition client in knee-chest, Trendelenburg, or side-lying position with a rolled towel under client's right or left hip to relieve pressure on cord - Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying to maintain blood flow - Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia - Administer oxygen at 8-10 L/min via face mask to improve fetal oxygenation - Initiate IV access, and administer IV fluid bolus - Prepare for an immediate vaginal birth if cervix is fully dilated or cesarean section if it is not - Inform and educate the client and their partner about the interventions

Postpartum Depression:

- Occurs within 12 months of delivery - Characterized by persistent feeling of sadness and intense mood swings - Occurs in 10%-15% of new parents and usually does not resolve without intervention - Similar to non-postpartum mood disorders Risk Factors: - Hormonal changes with rapid decline in estrogen and progesterone levels - Individual socioeconomic factors - Decreased social support system - Anxiety about assuming new role as parent - Unintended pregnancy - Low self-esteem - History of partner violence - Medical conditions (thyroid imbalance, diabetes, infertility) - Complications with breastfeeding - Parent of multiples Expected Findings: - Feelings of guilt and inadequacies - Irritability - Anxiety - Fatigue persisting beyond a reasonable amount of time - Feeling of loss - Lack of appetite - Persistent feeling of sadness - Intense mood swings - Sleep pattern disturbances - Crying - Weight loss - Flat affect - Rejection of infant - Severe anxiety and panic attack Nursing Care: - Monitor interaction between client and infant. Encouraging bonding activies - Monitor client's mood/affect - Reinforce that feeling down in postpartum period is normal and self-limiting. Encourage client to notify provider if it persists - Encourage client to communicate feelings, validate and address personal conflicts, reinforce personal power and autonomy - Reinforce importance of compliance with any prescribed medication - Contact community resource to schedule follow-up visit after discharge for clients who are at high-risk for postpartum depression - Ask client if they have thoughts of self-harm, suicide, harming the infant. Provide for the safety of the infant and client as priority of care. Medications: - Antidepressants: Can be prescribed by provider if indicated - Antipsychotics/Mood stabilizers: Can be prescribed for clients who have postpartum psychosis Client Education: Care After Discharge: - Get plenty of rest and nap when infant sleeps - Remember importance of taking time out for self - Schedule follow-up visit prior to traditional postpartum visit for developing postpartum depression - Consider community resources - Seek counseling, consider social agencies

Client Education About Nutrition: Iron Supplements:

- Often added to prenatal plan to facilitate an increase of maternal RBC mass. - Iron is best absorbed between meals and when given with a source of vitamin C - Milk/caffeine interfere with iron supplement absorption - Food sources of iron: beef liver, red meats, fish, poultry, dried peas/beans, fortified cereals/breads - A stool softener may be needed to decrease constipation experienced with iron supplements

Biophysical Profile:

- Uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. - It combines FHR monitoring (non-stress test) and fetal ultrasound. Nursing Actions: - Prepare the client the same way you would an ultrasound

Postpartum GI System & Bowel Function:

- Operative vaginal birth (forceps/vacuum-assisted) and anal sphincter lacerations increase risk of temporary postpartum anal incontinence that usually resolves within 6 months. Physical Changes In GI System: - Increased appetite following delivery - Constipation - Hemorrhoids Assessment: - Assess for reports of hunger. Expect client to have good appetite - Assess for bowel sound and return of normal bowel function. Spontaneous bowel movement might not occur for 2-3 days after delivery secondary to decreased intestinal muscle tone during labor and puerperium, prelabor, diarrhea, dehydration, or medication adverse effects - Assess for discomfort with defecation due to perineal tenderness, episiotomy, lacerations, or hemorrhoids - Assess rectal area for hemorrhoids (varicosites) Patient-Centered Care: - Encourage interventions to promote bowel function (early ambulation, increased fluids, intake of high-fiber foods) - Administer stool softener (docusate sodium) to prevent constipation - Enemas and suppositories are contraindicated for clients who have third or fourth-degree perineal lacerations - Flatus is common after c-section. Encourage client to ambulate or rock in chair to promote passage of flatus and to avoid gas-forming foods. Anti-flatulence meds can be required

Ectopic Pregnancy:

- Ovum implants in the fallopian tubes or abdominal cavity due to presence of endometrial tissue - As ovum increases in size, fallopian tube can rupture and extensive bleeding occurs, resulting in surgical remove of damaged tube - If it's identified before to rupture of the tube, surgical removal of the products of conception may be performed, or methotrexate is prescribed to dissolve pregnancy - Client faces increased risk of recurrence of an ectopic pregnancy and infertility

Pain Assessment:

- Pain level cannot always be assessed by monitoring outward expressions of the client. - Can require persistent questioning and observations - Cultural beliefs/behaviors of clients during labor/delivery can affect their pain management - Anxiety/fear are associated with pain. As they increase, muscle tension increases and the experience of pain increases becoming a cycle of pain. - Fear, tension, and 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/non-verbal cues. - Use appropriate pain scale allowing client to indicate severity of their pain on a scale of 0-10 - Help patient maintain proper position during administration of pharmacological interventions. Also assist with positioning for comfort during labor/birth after pharmacological interventions - Provide client safety after any pharmacological interventions by putting the bed in the lowest position maintaining side rails in up position and placing the call light within their reach and advising them to call for assistance if they need to ambulate. - Evaluate client's response to pain relief methods used

Spontaneous Abortion Nursing Care:

- Perform a pregnancy test - Observe color and amount of bleeding (count pads) - Maintain client on bed rest. Inform client of risk for falls due to sedative medications (if prescribed) - Avoid vaginal exams - Assist with an ultrasound - Administer medications and blood products as prescribed - Determine how much tissue has passed and save passed tissue for examination - Assist with termination of pregnancy (D&C, D&E, prostaglanding administration) as indicated. - Use the lay term "miscarriage" with clients because the medical term "abortion" can be misunderstood - Provide client education and emotional support - Provide referral for client and partner to pregnancy loss support groups

Newborn Assessment: Initial Assessment:

- Perform a quick initial assessment to review newborn's systems and observe for life-threatening abnormalities and respiratory issues - External assessment: Skin, color, peeling, birthmarks, foot creases, breast tissue, nasal patency, meconium staining (can indicate fetal hypoxia) - Chest: Point of maximal impulse location; ease of breathing; auscultation for heart rate and quality of tones; respirations for crackles, wheezes, equality of bilateral breath sounds - Abdomen: Rounded abdomen and umbilical cord with 1 vein and 2 arteries - Neurologic: Muscle tone and reflex reaction (Moro reflex); palpation for presence and size of fontanels and sutures; assessment of fontanels for fullness/bulge - Other observations: Inspection for gross structural malformations Expected Reference Ranges: Weight: 2,500-4,00 g (5.5-8.8 lb) Length: 45-55 cm (18-22 in) Head Circumference: 32-36.8 cm (12.6-14.5 in) Chest Circumference: 30-33 cm (12-13 in)

Prenatal Visit Nursing Care:

- Perform or assist with Leopold maneuvers to palpate presentation and position of fetus - Assist the provider with the gynecological exams. This exam is performed to determine the status of a client's reproductive organs and birth canal. Pelvic measurements determine whether the pelvis will allow for the passage of the fetus at delivery: The nurse has the client empty their bladder and take deep breaths during the exam to decrease discomfort - Administer Rho(D) immune globulin IM around 28 weeks of gestations for clients who are Rh-negative

First Trimester Client 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, STI's (encourage safe sexual practices) - Possible complications and indications to report (preterm labor) - Fetal growth and development - Prenatal exercise - Expected lab testing

PostPartum Breasts:

- Physical changes include secretion of colostrum which occurs during pregnancy and 2-3 days after birth. - Milk is produced 3-5 days after delivery of newborn Assessment: - Determine client's choice of breastfeeding and do physical exam of breasts - Colostrum (early milk) transitions to mature milk by 72-96 hr after birth; this transition is called the milk coming in - Engorgement (fullness) of breast tissue is result of lymphatic circulation, milk production, temporary vein congestion. Breast will appear tight, tender, warm, full - Inform client who do not plan to breastfeed that this will resolve on its own, but breast binders or support bras can be used or an ice pack or cabbage leaves - Inform clients who plan to breastfeed that breast care and frequent feedings will prevent or manage engorgement - Observe for erythema, breast tenderness, cracked nipples, indications of mastitis (infection in a milk duct of breast with concurrent flu-like manifestations) - Determine client's ability to assist newborn with latching on and ensure newborn has latched on correctly to prevent sore nipples - Ineffective newborn feeding patterns are related to maternal dehydration, maternal discomfort, newborn positioning, or difficulty with newborn latching on breast Patient-Centered Care: - Promote early breastfeeding within first 1-2 hr after birth - Encourage early demand feeding for client who chooses to breastfeed. This will stimulate production of natural oxytocin and help prevent uterine hemorrhage - Assist client into comfortable position and have them try different positions during breastfeeding. The four traditional positions are football hold (under the arm), cradle, across the lap (modified cradle), and side-lying. Explain how varying positions can prevent nipple soreness - Teach the importance of proper latch techniques (newborn takes in part of areola and nipple, not just the tip of nipple) to prevent nipple soreness - Inform client that breastfeeding causes the release of oxytocin which stimulates uterine contractions. This is a normal occurrence and beneficial to uterine tone - Advise clients who do not plan to breastfeed to not stimulate the breast or express breast milk

Postpartum Physical Changes:

- Physiological changes include of uterine involution, lochia flow, cervical involution, decrease in vaginal distention, alteration in ovarian function and menstruation, cardiovascular, urinary tract, breast and GI changes - Greatest risk is hemorrhage, shock, infection Oxytocin (hormone from pituitary gland) coordinates and strengthens uterine contractions: - Breastfeeding stimulates release of endogenous oxytocin - Exogenous oxytocin can be administered postpartum to improve quality of uterine contractions. A firm and contracted uterus prevents excessive bleeding/hemorrhage - Uncomfortable uterine cramping is called afterpains After delivery of placenta, hormones (estrogen, progesterone, placental enzyme insulinase) decrease resulting in decreased blood glucose, estrogen, and progesterone levels: - Decreased estrogen associated w/ breast engorgement, diaphoresis and diuresis (increased formation and excretion of urine) of excess extracellular fluid accumulated during pregnancy. - Decreased estrogen diminishes vaginal lubrication. Local dryness and intercourse discomfort can persist until ovarian function returns and menstruation resumes - Decreased progesterone = an increase in muscle tone throughout body - Decreased placental enzyme insulinase = reversal of the diabetogenic effects of pregnancy which lowers blood glucose levels immediately - Human chorionic gonadotropin (hCG) disappears from blood quickly but some can be detected for up to 4 weeks postpartum Lactating and non-lactating clients differ in timing of the first ovulation and resumption of menstruation: - In lactating clients the blood prolactin levels remain elevated and suppress ovulation - The return of ovulation is influenced by breastfeeding frequency, length of each feeding, and use of supplementation - The infant's suck is also believed to affect prolactin levels - Length of time to the first postpartum ovulation is approx. 6 months - In non-lactating clients, prolactin declines and reaches the pre-pregnant level by the third week postpartum: - Ovulation occurs 7-9 weeks after birth - Menses resume by 12 week postpartum

Calculating Delivery Date & Determining Number Of Pregnancies For Pregnant Client: Viability:

- Point in time when an infant has the capacity to survive outside the uterus. - There is not a specific week of gestation, however, infants born between 22-25 weeks are considered on the threshold of viability

Client Education & Discharge Teaching: Indications Of Potential Complications:

- Postpartum complications include hemorrhage, infection of breasts, wounds, incisions, and postpartum depression - Ensure client has appt. set up for postpartum follow-up visit or a number to call and schedule. Following a vaginal delivery the follow-up visit should take place in 4-6 weeks and in 2 weeks for a c-section. Write date/time in discharge instructions. Client Education: Report indicators of potential complications to provider: - Chills or fever: greater than 100.4F after 24 hr - Change in vaginal discharge: with increased amount, large clots, change in previous lochia color such as bright red bleeding and foul odor - Episiotomy, laceration, or incisional pain: that does not resolve with analgesics, foul-smelling drainage, redness, edema - Pain or tenderness in abdominal/pelvic area: that does not resolve with analgesics - Breasts with localized areas of pain/tenderness: with firmness, heat, swelling and/or nipples with cracks, redness, bruising, blisters, fissures - Calves with localized pain, tenderness, redness, swelling: a lower extremity with either areas of redness and warmth or tenderness - Urination with burning, pain, frequency, urgency - Indications of possible depression: including apathy toward infant, cannot provide self-or infant-care, or has feelings that they might hurt themselves or the infant

Abruptio Placentae:

- Premature separation of placenta from uterus, which can be a partial or complete de-attachment. - This separation occurs after 20 weeks of gestation usually in third trimester. - It has significant maternal and fetal morbidity and mortality and is a leading cause of maternal death - Coagulation defect such as disseminate intravascular coagulopathy (DIC) is often associated with moderate to severe abruption Risk Factors: - Maternal hypertension (chronic or gestational) - Blunt external abdominal trauma (motor-vehicle crash, maternal battering) - Cocaine use resulting in vasoconstriction - Previous incidents of abruptio placentae - Cigarette smoking or other nicotine use - Premature rupture of membranes - Multifetal pregnancy Expected Findings: - 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 with hypertonicity - Fetal distress - Clinical findings of hypovolemic shock Lab Tests: - Hgb and Hct decreased - Coagulation factors decreased - Clotting defects (disseminated intravascular coagulation) - Cross and type match for possible blood transfusions - Kleihauer-Betke test (used to detect fetal blood in maternal circulation) Diagnostic Procedures: - Ultrasound for fetal well-being and placental assessment - Biophysical profile to ascertain fetal well-being Nursing Care: - Palpate uterus for tenderness and tone - Perform serial monitoring of fundal height - Assess FHR pattern - Immediate birth is the management: Administer IV fluids, blood products, meds. as prescribed. Administer oxygen 8-10 L/min via face mask. Monitor maternal vitals, observing for declining hemodynamic status. Perform continuous fetal monitoring. Assess urinary output and monitor fluid balance. - Provide emotional support for the client/family

Assessment Of Family Readiness For Home Care Of Newborn:

- Previous newborn experience/knowledge - Parent- newborn attachment - Adjustment to the parental role - Social support - Educational needs - Sibling rivalry issues - Readiness of parents to have their home and lifestyle altered to accommodate their newborn - Parents' ability to verbalize and demonstrate newborn care following teaching

Ultrasound:

- Procedure lasting about 20 min. that consists of high-frequency sound waves used to visualize internal organs and tissues by producing a real-time, 3-D image of the developing fetus and maternal structures (FHR, pelvic anatomy). - Allows for early diagnosis of complications, permits earlier interventions, decreases neonatal and maternal morbidity and mortality. - 3 types: external abdominal, transvaginal, Doppler.

Nursing Care Of Newborns: Medications: Erythromycin:

- Prophylactic eye care is mandatory instillation of antibiotic ointment into eyes to prevent ophthalmia newonatorum - Infections can be transmitted during descent through birth canal. Ophthalmia neonatorum is caused by Neisseria gonorrhoeae or chlamydia trachomatis and can cause blindness Nursing Actions: - Use single-dose unit to avoid cross-contamination - Apply a 1-2 cm ribbon of ointment to lower conjunctival sac of each eye, starting from inner canthus moving outward - A possible side effect is chemical conjunctivitis causing redness, swelling, drainage, temporary blurred vision for 24-48 hr. Reassure parents this will resolve on its own - Application can be delayed for 1 hr after birth to facilitate baby-friendly activities during first period of newborn reactivity

Co-Parent Adaptation: Nursing Actions:

- Provide education about infant care with each parent and encourage hands-on approach - Assist the co-parent to transition to the parental role by providing guidance and encouraging equal participation in infant care - Encourage parents to verbalize concerns and expectations related to infant care

Nursing Care Of Newborns: Patient-Centered Care: Thermoregulation:

- Provides neutral thermal environment that helps a newborn maintain a normal core temp. with minimal oxygen consumption and caloric expenditure. A newborn has a relatively large surface-to-weight ratio, reduced metabolism per unit area, blood vessels close to 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 newborn's oxygen demands and rapidly use brown fat reserves. Monitoring temp. regulation is very important Monitor for hypothermia in newborn: - Axillary temp. of less than 36.5C (97.7F) - Cyanosis - Increased respiratory rate - Core temp. varies within newborns but should be kept approx. at 36.5C - 47C (97.7F - 98.6F) Interventions To Maintain Thermoregulation: Heat loss occurs by 4 mechanisms: - Conduction: Loss of body heat resulting from direct contact with a cooler surface. Pre-heat a radiant warmer, warm a stethoscope and other instruments, and pad a scale before weighing newborn. Newborn should be placed directly on patient's chest and covered with warm blanket - Convection: Flow of heat from body surface to cooler environmental air. Place bassinet out of direct line of a fan or AC vent, swaddle newborn in blanket, keep head covered. Any procedure done with newborn uncovered should be performed under radiant heat source. Keep ambient temp. of nursery/client's room at 22-26C (72-78F) - Evaporation: Loss of heat as surface liquid is converted to vapor. Gently rub newborn dry with a warm sterile blanket immediately after delivery. If thermoregulation is unstable, postpone initial bath until newborn's skin temp is 36.5C (97.7F). When bathing, expose only one body part at a time, washing/drying thoroughly - Radiation: Loss of heat from body surface to a cooler solid surface that is close to, but not in direct contact. Keep newborn and examining tables away from windows & AC units. - Temp. stabilizes at 37C (98.6F) within 12 hr after birth if chilling is prevented - Best method for promoting temp is skin-to-skin early!

Nursing Care Of Newborns: Medications: Hepatitis B Immunization:

- Provides protection against Hepatitis B Nursing Action: - Recommended to be given to all newborns - Informed consent must be obtained - For newborns born to health clients, recommend dosage schedule is at birth, 1 month, and 6 months - For parents infected with hepatitis B, hepatitis B immunoglobulin, the hepatitis B vaccine is given within 12 hr of birth. It's given alone at 1 month, 2 months, 12 months DO NOT GIVE VITAMIN K.& HEPATITIS B INJECTIONS IN SAME THIGH!

Pharmacological Anesthesia: General Anesthesia:

- Rarely used for vaginal/cesarean birth when there are no complications present. - It's only used in the event of a delivery complication or emergency when there is a contraindication to nerve block analgesia or anesthesia. - Produces unconsciousness Nursing Actions: - Monitor maternal vitals - Monitor FHR pattern - Ensure client has had nothing by mouth - Ensure IV infusion is in place - Apply antiembolic stockings or sequential compression devices - Pre-medicate client with oral antacid to neutralize acidic stomach contents - Administer a histamine2-receptor antagonist like ranitidine to decrease gastric acid production - Administer metoclopramide to increase gastric emptying as prescribed - Place wedge under one of client's hips to displace uterus - Maintain an open airway and cardiopulmonary function - Assess client postpartum for decreased uterine tone which can lead to hemorrhage and be produced by pharmacological agents used in general anesthesia Client Education: - Facilitate parent-newborn attachment ASAP

Nutrition During Pregnancy:

- Recommended weight gain is 25-35 lb. - General rule is clients should gain 2.2-4.4 lb. during the first trimester and after that approx. 1 lb. a week for the last two trimesters. - Underweight clients are advised to gain 28-40 lb. - Overweight clients are advised to gain (15-25 lb) - Excessive weight can lead to macrosomia and labor complications - Inability to gain weight could result in low birth weight of newborn

Ectopic Pregnancy Nursing Care:

- Replace fluids and maintain electrolyte imbalance - Provide client education and psychological support - Administer medications as prescribed - Prepare client for surgery and post-op nursing care - Provide emotional care/support - Provide referral for client/partner to pregnancy loss support group - Obtain serum hCG and progesterone levels, liver and renal function studies, CBC, and type and Rh. Client Education: - If taking methotrexate, avoid vitamins containing folic acid to prevent a toxic response to the medication - Use protection against sun exposure (photosensitivity)

HIV/AIDS:

- Retrovirus that attacks and causes destruction of T lymphocytes. - It causes immunosuppression in a client. - Clients who are severely immunosuppressed develop AIDS - HIV is transmitted from mother to neonate perinatally through placenta and postnatally through breast milk. - Routine lab testing in early prenatal period includes testing for HIV. Early identification and treatment significantly decreases incidence of perinatal transmission. - Testing is recommended in third trimester for clients who are at an increased risk. Rapid HIV testing should be done if client is in labor and their HIV status is unknown. - Procedures such as amniocentesis and episiotomy should be avoided due to risk of maternal blood exposure. - Use of internal fetal monitors, vacuum extraction, and forceps during labor should be avoided due to risk of fetal bleeding. - Newborn administration of injections and blood testing should not take place until after first bath is given. - If client is HIV positive and taking antiviral medications, they should be informed that they can transmit the infection to the neonate.

External Abdominal Ultrasound:

- Safe, non-invasive, painless procedure where a ultrasound transducer is moved over client's abdomen to obtain an image. - More useful after first trimester when the gravid uterus is larger. - Client should have a full bladder for this procedure.

High-Risk Pregnancy: Maternal Alpha-Fetoprotein (MSAFP):

- Screening tool used to detect neural tube defects. - Clients who have abnormal feelings should be referred for a quad marker screening, genetic counseling, ultrasound, and amniocentesis Potential Diagnosis: - All pregnant clients, preferably between 16-18 weeks of gestation Pre-Procedure Nursing Actions: - Discuss testing with client - Draw blood sample - Offer support/education as needed Interpretation Of Findings: - High levels can indicate a neural tube defect or open abdominal defect - Low levels can indicate Down Syndrome - This is only used as a screening tool. Abnormal results should be confirmed with further testing.

Nursing Care Of Newborns: Patient-Centered Care: Identification:

- Using 2 identifiers is applied immediately after birth - Newborn, client, client's partner are identified by plastic ID wristbands w/ permanent locks that must be cut to be removed. ID bands include: newborn's name, sex, date, time of birth, client's health record number. Newborn should have 1 band placed on ankle and one on wrist. In addition, newborn's footprints and client's thumb prints are taken. - Each time newborn is given to parents the ID band should be verified against the client's ID band - All facility staff who assist in caring for newborn are required to wear photo ID badges - Newborn is not given to anyone who does not have a photo ID badge - Many facilities have locked maternal-newborn units that require a staff members to permit entrance/exit.

Preterm Labor:

- Uterine contractions and cervical changes that occur between 20-36 weeks and 6 days of gestation. - Can be categorized as very preterm (less than 32 weeks), moderately preterm (32-34 weeks), and late preterm (34-36 weeks). - Shorter gestation is associated with increased neonatal risks Risk Factors: - Infections of urinary tract/vagina, HIV, active herpes infection, or chorioamnionitis (infection of amniotic sac) - Previous preterm birth - Multifetal pregnancy - Oligohydramnios (too little fluid) - Hydramnios (excessive amniotic fluid) - Advanced maternal age - Smoking - Substance use - Violence/abuse - History of multiple miscarriages or abortions - Diabetes mellitus - Chronic hypertension - Preeclampsia - Lack of prenatal care - Recurrent premature dilation of cervix - Placenta previa or abruptio placentae - Preterm premature rupture of membranes - Uterine abnormalities - Second trimester bleeding - Low pre-pregnancy weight - Lack of access to prenatal care - Congenital fetal anomalies Expected Findings: - Uterine contractions - Pressure in pelvis and menstrual-like cramping - Persistent low backache - GI cramping, sometimes with diarrhea - Urinary frequency - Increase, change, odor or blood in vaginal discharge - Change in cervical dilation - Regular uterine contractions with a frequency of every 10 min. or greater, lasting 1 hr or longer - Premature rupture of membranes - Discomfort (dull lower abdominal pain or back pain, pelvic pressure or heaviness) Lab Tests: - Fetal fibronectin - Cervical cultures - CBC - Urinalysis Diagnostic Procedures: - Obtain swab of vaginal secretions for fetal fibronectin. This protein can be expected during early and late pregnancy, but presence between 24-34 weeks, 6 days can indicate inflammation, which increases risk for preterm labor within next 2 weeks. Fetal fibronectin testing combined with cervical measurements is best way to determine risk for preterm labor. - Measure for a shortened endovervical length with an ultrasound. Cervical shortening occurs before uterine activity (contractions) so this can be predictor of risk in conjunction with other findings. Cervical length greater than 30 mm indicates low risk of preterm labor - Obtain cervical cultures to check for presence of infectious organisms. Culture and sensitivity results guide prescription of an appropriate antibiotic, if indicated. - Perform a biophysical profile and/or a non-stress test to provide information about fetal well-being. Nursing Care: - Management of a client who is in preterm labor includes focusing on stopping uterine contractions. Activity Restriction: - Usually modified bed rest with bathroom privileges. Encourage client to engage in activities that can be completed in bed or on couch. Strict bed rest can have adverse effects. - Encourage client to rest in left lateral position to increase blood flow to uterus and decrease uterine activity. - Tell client to avoid intercourse - Ensuring Hydration: Dehydration stimulates the pituitary gland to secrete an antidiuretic hormone and oxytocin. Preventing dehydration prevents release of oxytocin, which stimulates uterine contractions - Identifying and treating an infection: Have client report any vaginal discharge, noting amount, color, consistency, and odor. Monitor vitals/temperature. - Chorioamnionitis; Should be suspected with occurrence of elevated temperature and tachycardia. - Monitor FHR and contraction pattern - Fetal tachycardia: Which is a prolonged increase in the FHR greater than 160/min can indicate infection, is frequently associated with preterm labor.

Continuous Electronic Fetal Monitoring:

- Securing an ultrasound transducer over client's abdomen which records FHR pattern and a tocotransducer on fundus that records uterine contractions Advantages: - Monitoring is non-invasive and 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 nurse - Provides permanent record of FHR and uterine contraction tracing Disadvantages: - Contraction intensity is not measurable - Movement of client requires frequent repositioning of transducers - Quality of recording is affected by client obesity and fetal position Indications: - Multiple gestations - Oxytocin infusion (augmentation or induction of labor) - Placenta previa - Fetal bradycardia - Maternal complications (gestational diabetes mellitus, gestational hypertension, kidney disease) - Intrauterine growth restriction - Post-date gestation - Active labor - Meconium-stained amniotic fluid - Abruptio placentae: suspected or actual - Abnormal non-stress test or contraction stress test - Abnormal uterine contractions - Fetal distress

Newborn Assessment: Physical Head-To-Toe Exam: Chest:

- Should be barrel-shaped - Respirations are primarily diaphragmatic - Clavicles should be intact - Retractions should be absent - Nipples should be prominent, well formed, symmetrical - Breast nodules can be 3-10 mm

Newborn Assessment: Physical Head-To-Toe Exam: Nose:

- Should be midline, flat, broad with lack of bridge - Some mucous could be present but with no drainage - Newborns are obligate nose breathers and do not develop response of opening mouth with a nasal obstruction until 3 weeks after birth. Therefor, a nasal blockage can result in flaring of nares, cyanosis, or asphyxia - Newborns sneeze to clear nasal passages

Newborn Assessment: Physical Head-To-Toe Exam: Neck:

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

Continuous Electronic Fetal Monitoring: Interpretation Of Findings: Category III:

- Sinusoidal pattern Absent baseline fetal heart rate variability and any of these: - Recurrent variable decelerations - Recurrent late decelerations - Bradycardia Each uterine contraction is comprised of: - Increment: Beginning of contraction as intensity is increasing - Acme: Peak of intensity of contraction - Decrement: The decline of contraction intensity as contraction is ending Nonreassuring FHR Patterns Are Associated W/ Fetal Hypoxia & Include: - Fetal bradycardia - Fetal tachycardia - Absence of FHR variability - Late decelerations - Variable decelerations

Newborn Assessment: Physical Head-To-Toe Exam: Skin:

- Skin color should be initially deep red to purple with acrocyanosis (bluish tint to hands/feet). Skin color should fade to color congruent to newborns genetic background. Secondary to increased bilirubin, jaundice can appear on third day of life, but then decreases spontaneously - Skin turgor should be quick indicating newborn is well hydrated. Skin should spring back immediately when pinched - Texture should be dry, soft, smooth showing good hydration. Cracks in hands/feet can be present. In full-term newborns, desquamation (peeling) occurs a few days after birth - Vernix caseosa (protective, thick, cheesy covering) amounts vary with more present in creases and skin folds - Lanugo (fine downy hair) varies regarding amount present. Usually found on pinnae of ears, forehead, shoulders Normal Deviations: - Milia: Small raised pearly white spots on nose, chin, forehead. These spots disappear spontaneously without treatment (parents should not squeeze spots) - Mongolian spots: Spots of pigmentation that are blue, gray, brown, or black. They are commonly noted on back of buttocks. These spots are more commonly present on newborns who have dark skin and can be linked to genetics. Be sure parents are aware of this and document location/presence - Telangiectatic Nevi: Stroke bites are flat pink or red marks that are easily blanch and are found on back of neck, nose, upper eyelids, and middle of forehead. Usually fade by second year of life - Nevus Flammeus: Port wine stain is a capillary angioma below surface of skin that is purple or red and varies in size and shape and is commonly seen on face and does not blanch or disappear - Erythema Toxicum: Erythema neonatorum is a pink rash that appears suddenly anywhere on body of a term newborn during first 3 weeks. This is frequently referred to as newborn rash. No treatment required

Nursing Care Of Newborns: Patient-Centered Care: Sleep:

- Sleep-wake states are variations of consciousness in newborn consisting of 6 states along a continuum comprised of deep sleep, light sleep, drowsy, quiet alert, active alert, crying Newborns sleep approx. 16-19 hr daily with periods of wakefulness gradually increasing. They are positioned supine, "safe sleep", to decrease incidence of sudden infant death syndrome (SIDS): - No bumper pads, loose linens, or toys should be in bassinet - Parents should sleep in close proximity but not in shared space. Higher incidence rates are noted for SIDS and suffocation with bed sharing - Educate parent about need for immunization as a measure to prevent SIDS

Complications For Newborn Nutrition: Failure To Thrive:

- Slow weight gain. Newborn usually fails below 5th percentile. Newborns Who Are Breastfeeding: - Evaluate positioning and latch-on - Massage breast during feeding - Determine feeding patterns and length of feedings - If newborn is spitting up, newborn can have allergy to dairy products. Determine maternal intake of dairy products. Parent might need to eliminate dairy from their diet. Instruct them to consume other food sources high in calcium or calcium supplements Newborns Who Are Formula Feeding: - Evaluate how much and how often - If newborn spitting up or vomiting, they can have allergy or intolerance to cow's milk-based formula and can require soy-based formula

Late Deceleration Of FHR:

- Slowing of FHR after contraction has started with 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 tachystystole with oxytocin - Preeclampsia - Late or post-term pregnancy - Maternal diabetes mellitus Nursing Interventions: - Place client in side-lying position - Insert IV catheter and increase rate of fluids - Discontinue oxytocin if being infused - Administer oxygen by mask at 8 L/min via non-breather face mask - Elevate client's legs - Notify provider - Prepare for assisted vaginal birth or cesarean birth

Early Deceleration Of FHR:

- Slowing of FHR at start of contraction with return of FHR to baseline at end of contraction Causes/Complications: - Compression of fetal head resulting from uterine contraction - Uterine contractions - Vaginal exam - Fundal pressure No nursing interventions required

Expected Findings In Pregnant Client: Skin Change: Striae Gravidarum:

- Stretch marks most notably found on the abdomon and thighs

Newborn Assessment: Physical Head-To-Toe Exam: Reflexes:

- Sucking & Rooting Reflex: By stroking cheeks or edge of mouth. Newborn turns the head toward side that is touched and starts to suck. Expected age is that is usually disappears after 3-4 months but can persist up to 1 year - Palmar Grasp: By placing examiner's finger in palm of newborn's hand. The newborn's fingers curl around examiner's fingers. Expected age is that it lessens by 3-4 months - Plantar Grasp: By placing examiner's fingers at base of newborn's toes. Newborn responds by curling toes downwards. Expected age is birth-8 months - Moro Reflex: By allowing head and trunk of newborn in a semi-sitting position to fall backward to an angle of at least 30 degree. The newborn will symmetrically extend and then abduct the arms at the elbows and fingers to form a "C". Expected age is that complete response can be seen until 8 weeks, body jerk only 8-19 weeks and then absent by 6 months - Tonic Neck Reflex (Fencer Position): With newborn in supine, neutral position, examiner turns newborn's head quickly to one side. Newborn's arm and leg on that side extend and opposing arm/leg flex. Expected age is birth to 3-4 months - Babinski Reflex: By stroking outer edge of sole of foot, moving up toward toes. Toes will fan upward and out. Expected age is birth - 1 year - Stepping: By holding the newborn upright with feet touching a flat surface. Newborn responds with stepping movements. Expected age is birth - 4 weeks

Calculating Delivery Date & Determining Number Of Pregnancies For Pregnant Client: Nagel's Rule:

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

Interventions For Home Care Of Newborn: Bathing:

- Teach parents proper newborn bathing techniques by demonstration. Have them do return demonstration - After initial bath, newborn's face, diaper area, skin folds are cleansed daily. Complete bathing is performed 2-3 times per week using mild soap Client Education: - Bathing by immersion is not done until newborn's umbilical cord has fallen off and circumcision has healed. Wash area around cord, taking care not to get cord wet. Move from cleanest to dirtiest part of newborn's body beginning with eyes, face, head, then proceed to chest, arms, legs (wash groin area last) - Bathing should take place at convenience of parents, but not immediately after feeding to prevent spitting up/vomiting - Organize all equipment so that newborn is not left unattended. Never leave newborn alone in tub/sink - Make sure hot water is set to 49C (120.2F) or less. Room should be warm, bath water should be 38C (100.4F). Test water for comfort with your elbow prior to bathing newborn - Avoid drafts/chilling of newborn. Expose only body part being bathed and dry newborn thoroughly to prevent chilling/heat loss - Clean newborn's eyes using a clean portion of wash cloth. Use clear water to clean each eye, moving from inner to outer canthus - Each area of the bod should be washed, rinsed, dried, with no soap left on skin. - Wrap newborn in towel and swaddle them in a football hold to shampoo head. Rinse shampoo from head and dry to avoid chilling - Cleansed an uncircumcised penis, wash with soap and water and rinse penis. Foreskin should not be forced back or constriction can result - To cleanse circumcised penis, use warm water. Do not use soap until circumcision healed - Wash vulva by wiping front to back to prevent contamination of vagina or urethra from rectal bacteria - Apply fragrance-free, hypoallergenic, moisturizing, emollient immediately after bathing to help prevent dry skin

Contraceptive Methods: Basal Body Temperature (BBT):

- Temperature of the body at rest - Prior to ovulation, the temperature drops slightly and rises during ovulation. - Identifying the time of ovulation is symptom-based method that can be used to facilitate or avoid conception Client Education: . - Take temperature immediately after waking up and before getting out of bed. - The first day the temperature drops or elevates is considered the first fertile day. Fertility extends through 3 consecutive days of temperature evaluation. - Use this method with the calendar method to increase effectiveness - Not too reliable - Does NOT protect against STI's - Possible pregnancy

High-Risk Pregnancy: Chorionic Villus Sampling:

- The assessment of a portion of 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 - First-trimester alternative to amniocentesis with one of its advantages being an earlier diagnosis of any abnormalities - Ideally performed 10-13 weeks of gestation Potential Diagnosis: - Risk for giving birth to a neonate who has a genetic chromosomal abnormality (cannot determine spina bifida or anencephaly) Nursing Actions: - Obtain informed consent - Provide ongoing education/support Client Education: - Drink 1-2 glasses of fluid prior to test and avoid urination for several hours prior to testing. Full bladder is necessary for this. Complications: - Spontaneous abortion - Risk for fetal limb loss (greatest risk prior to 9 weeks of gestation) - Miscarriage - Chorioamnionitis and rupture of membranes

Physiological Status Of Pregnant Client: Endocrine:

- 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 body for delivery

Postpartum Disorders: Retained Placenta:

- The placenta or fragments of placenta remain in uterus and prevent uterus from contracting which can lead to uterine atony or subinvoluation - A placenta that has not been delivered within 30 min of birth is a retained placenta Risk Factors: - Partial separation of a normal placenta - Entrapment of a partially or completely separated placenta by constricting ring of the uterus - Excessive traction on umbilical cord prior to complete separation of placenta - Placental tissue that is abnormally adherent to uterine wall - Preterm births between 20-24 week of gestation Expected Findings: - Uterine atony, subinvolution, or inversion - Excessive bleeding or blood clots larger than a quarter - Return of lochia rubra once lochia has progressed to serosa alba - Malodorous lochia or vaginal discharge - Elevated temperature Lab Tests: - Hgb and Hct Diagnostic Procedures: - Manual separation and removal of placenta is done by provider - D&C if oxytocics are ineffective in expelling the placental fragments Nursing Care: - Monitor uterus for fundal height, consistency, position - Monitor lochia for color, amount, consistency, odor - Monitor vitals - Maintain or initiate IV fluids - Anticipate surgical interventions, D&C, if postpartum bleeding is present and continues Medications: Oxytocin: - To expel retained fragments of placenta - Uterine stimulant - Promotes uterine contractions - Assess uterine tone and vaginal bleeding - Monitor for adverse reactions of water intoxication (lightheadedness, nausea, vomiting, headache, malaise) which can progress to cerebral edema with seizures, coma, death Client Education: - After becoming stable, limit physical activity to conserve strength - Increase iron and protein intake to promote the rebuilding of RBC volume

Gestational Trophoblastic Disease:

- The proliferation and degeneration of trophoblastic villi in the placenta that becomes swollen, fluid-filled, and take on appearance of grape-like clusters - The embryo falls to develop beyond a primitive state and these structures are associated with choriocarcinoma, which is a rapidly metastasizing malignancy - 2 types of molar growths are identified by chromosomal analysis Complete Mole: - All genetic material is paternally derived - The ovum has no genetic material, or the material is inactive - The complete mole contains no fetus, placenta, amniotic membranes, or fluid - There is no placenta to receive maternal blood. Hemorrhage into the uterine cavity occurs, and vaginal bleeding results - Approx. 20% of complete moles progress toward a choriocarcinoma Partial Mole: - Genetic material is derived both maternally and paternally - A normal ovum is fertilized by two sperm and one sperm in which meiosis or chromosome reduction and division did not occur - A partial mole often contains abnormal embryonic or fetal parts, an amniotic sac, and fetal blood, but congenital anomalies are present - Approx. 6% of partial moles progress toward a choriocarcinoma

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 with aggressive use of oxytocin or rupture of membranes Risk Factors: - Administration procedures, nursing assessments and interventions and possible procedure complications are the same for labor induction

Interventions For Home Care Of Newborn: Diapering:

- To avoid rash, newborn's diaper area should be kept clean and dry. Diapers should be changed frequently and perineal area cleaned with warm water or wipes and dried thoroughly to prevent skin breakdown - Provide instructions regarding perineal cleansing of vulva, or for circumcised/uncircumcised penis

TORCH Infections:

- Toxoplasmosis, other infections (hepatitis), rubella virus, cytomegalovirus, and herpes simplex virus are known collectively as TORCH which is a group of infections that can negatively affect a client who is pregnant. - These infections can cross the placenta and have teratogenic effects on fetus - TORCH does not include all major infections that present risks to mother and fetus - Rubella can cause fetal consequences (miscarriage, congenital anomalies, death) - HSV can cause miscarriage, preterm labor, intrauterine growth restriction

Variable Deceleration Of FHR:

- Transitory, abrupt slowing of FHR 15/min or more below baseline for at least 15 seconds, variable in duration, intensity, timing in relation to uterine contractions 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 non-breather face mask - Perform or assist with vaginal exam - Assist with an amnioinfusion if prescribed

Ectopic Pregnancy Diagnostic/Therapeutic Procedures:

- Transvaginal ultrasound shows an empty uterus - Use caution if vaginal and bimanual examination are used Rapid Treatment: - Medical Management: If rupture has not occurred and tube preservation desired - Methotrexate: Inhibits cell division and embryo enlargement, dissolving the pregnancy - Salpingostomy: Is done to salvage the fallopian tube if not ruptured - Laparoscopic Salpingectomy: Removal of the tube, is performed when the tube has ruptured

Postpartum Disorders: Inversion Of The Uterus:

- Turning inside out of uterus and can be partial or complete. - It's an emergency situation that can result in postpartum hemorrhage and requires immediate intervention Risk Factors: - Retained placenta - Tocolysis - Fetal macrosomnia - Nulliparity - Uterine atony - Vigorous fundal pressure - Abnormally adherent placental tissue - Fundal implantation of placenta - Excessive traction applied to umbilical cord - Short umbilical cord - Prolonged labor Expected Findings: - Pain in lower abdomen Vaginal bleeding: Hemorrhage - Complete inversion as evidenced by fundus presenting as a mass in vagina - Prolapsed inversion as evidenced by large, red, rounded mass that protrudes 20-30 cm outside the introitus - Incomplete inversion as evidenced by palpation of a smooth m ass through dilated cervix - Dizziness - Low BP, increased pulse (shock) - Pallor Therapeutic Procedures: - Manual replacement of uterus into uterine cavity and repositioning of uterus by provider Nursing Care: - Assess for inverted uterus: Visualize the introitus, perform a pelvic exam - Maintain IV fluids - Administer oxygen - Stop oxytocin if it's being given at time of uterine inversion - Avoid excessive traction on umbilical cord - Anticipate surgery if non-surgical interventions and management are unsuccessful Medications: Terbutaline: - Tocolytic - Used to relax uterus prior to provider's attempt at replacement of uterus into uterine cavity and uterus repositioning Nursing Actions: Following replacement of uterus into uterine cavity: - Closely observe client's response to treatment and assess for stabilization of hemodynamic status - Avoid aggressive fundal massage - Administer oxytocins as prescribed - Administer broad-spectrum antibiotics for infection prophylaxis

Newborn Assessment: Physical Head-To-Toe Exam: Abdomen:

- Umbilical cord should be odorless and exhibit no intestinal structures - Abdomen should be round, dome-shaped, non-distended - Bowel sounds should be present within a few minutes following birth

Expected Vital Signs Of Pregnant Clients: Respirations:

- Unchanged or slightly increased - Respiratory changes during pregnancy are attributed to the elevation of the diaphragm by as much as 4 cm, as well as changes to the chest wall to facilitate increased maternal oxygen demands. - Some shortness of breath might be noted

Ectopic Pregnancy Expected Findings:

- Unilateral stabbing pain and tenderness in lower abdominal quadrant - Menses that is delayed (1-2 weeks), lighter than usual or irregular - 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 peritoneal cavity irritating diaphragm or phrenic nerve after tubal rupture - Findings of hemorrhage and shock (hypotension, tachycardia, pallor, dizziness) if a large amount of bleeding has occurred.

Interventions For Home Care Of Newborn: Car Seat Safety:

- Use an approved rear-facing car seat in back seat, preferably in middle (away from airbags and side impact) to transport newborn - Keep infants in rear-facing seat until age 2 or until child reaches max. height/weight for seat

Physiological Status Of Pregnant Client: Reproductive:

- Uterus increases in size and changes shape/position - Ovulation and menses cease during pregnancy

Newborn Assessment: Physical Head-To-Toe Exam: Senses:

- Vision: Newborn should be able to focus on objects 8-12 in away from face. This is approx. distance the mother's face is when newborn is breastfeeding. Eyes are sensitive to light so newborns prefer dim lighting. Pupils are reactive to light and the blink reflex is easily stimulated. The newborn can track high-contrast objects and prefers black and white patterns. Term newborns can see objects as far as 2.5 feet. Within 2-3 months, they can discriminate colors - Hearing: Similar to one of adult once the amniotic fluid drains from ears. Newborns exhibit selective listening to familiar voices and rhythms of intrauterine life. The newborn turns toward general direction of a sound. - Touch: Newborn should respond to tactile messages of pain and touch. The mouth, hands, soles of feet are areas most sensitive to touch in newborn - Taste: Newborns can taste and prefer sweet to salty, sour, bitter - Smell: Newborns have highly developed senses of smell, and they prefer sweet smells and can recognize mother's smell - Habitation: This is a protective mechanism whereby the newborn becomes accustomed to environmental stimuli. Response to a consistent or repetitive stimuli is decreased. This allows newborn to select stimuli that promotes continued learning, avoiding overload.

Nursing Care Of Newborns: Physical Assessment:

- Vitals should be checked on admission/birth every 30 min x2, every 1 hr x2, and then every 8 hr - Weight should be checked daily at same time using same scale - Inspect umbilical cord. Observe for any bleeding from cord and ensure it's clamped securely to prevent hemorrhage - In first 6-8 hr of life as body systems stabilize and pass through periods of adjustment, observe for periods of reactivity: - First Period Of Reactivity: Newborn is alert, exhibits exploring activity, makes sucking sounds, has rapid heart/respiratory rate. Heart rate can be as high as 160-180 min, but will stabilize at baseline of 100-120/min during period that lasts 30 min. after birth - Period Of Relative Inactivity: Newborn will become quiet and begin to rest/sleep. Heart rate and respirations will decrease and this period will last from 60-100 min. after birth - Second Part Of Reactivity: Newborn reawakens, becomes responsive again, often gags and chokes on mucus that has accumulated in mouth. This period usually occurs 2-8 hr after birth and can last 10 min - several hours.

Candidiasis:

- Vulvovaginal Candidiasis (yeast infection) - Fungal infection most often caused by Candida albicans, but non-Candida albicans infections are possible - It is second most common type of vaginal infection - During pregnancy it is treated to relieve discomfort and prevent oral thrush in the neonate Risk Factors: - Pregnancy - Diabetes mellitus - Oral contraceptives - Recent antibiotic treatment - Obesity - Diet high in refined sugars Expected Findings: - Vulvar and vaginal pruritus, painful urination due to excoriation from itching - Speculum exam: Thick, creamy, white, cottage cheese-like vaginal discharge - Vulvar and vaginal erythema and inflammation - White patches on vaginal walls Lab Tests: - Sample of discharge used for application to pH paper - Saline and potassium chloride (KOH) wet mount smear Diagnostic Test: - pH less than 4.5 (normal pH) - Wet mount potassium hydroxide prep, which indicates presence of yeast buds, hyphae, pseudohyphae Medications: - Topical therapies recommended for pregnant clients - Fluconazole: Can be prescribed as a single low dose to clients who are not pregnant/lactating - OTC Treatments: (such as clotrimazole) are available for treatment and are used for 3-7 days. It is important for a provider to diagnose candidiasis first. Client Education: - Avoid tight-fitting clothing and wear cotton-lined panties - Remove damp clothing as soon as possible - Avoid douching - Increase dietary intake of yogurt with active cultures - If infections are recurrent or frequent, diabetes should be ruled out

Vaginal Birth After Cesarean (VBAC):

- When client delivers vaginally after having a previous cesarean birth Client Presentation: - No other uterine scars or history of previous rupture - 1 or 2 previous low transverse cesarean births - Clinically adequate pelvis - Clients who had prior cesarean for dysfunctional labor, breech presentation, or abnormal FHR pattern which are considered nonrecurring events - Providers immediately available throughout active labor capable of monitoring labor and performing a emergency cesarean birth if needed No current contraindications: - Large for gestational age newborn - Malpresentation - Cephalopelvic disproportion - Previous classical vertical uterine incision Pre-Procedure: - Review medical record for evidence of previous low-segment transverse cesarean incision - Explain procedure Intraprocedure: - Assess/record FHR during labor - Assess/record contraction patterns for strength, duration, frequency of contraction - Assess for evidence of uterine rupture - Promote relaxation and breathing techniques during labor - Provide analgesia as prescribed/requested Post-Procedure: - Nursing interventions for a vaginal delivery after a cesarean birth are same as for vaginal delivery

Newborn Assessment: Physical Head-To-Toe Exam: Ears:

- When examining the placement of ears, draw imaginary line through the inner to outer canthus of newborn's eye. The line should be even with top notch of newborn's ear where the ears meets scalp. Ears that are low-set can indicate chromosomal abnormalities such as Down syndrome or a kidney disorder - Cartilage should be firm and well formed. Lack of cartilage indicates prematurity - Newborn should respond to voices and other sounds - Inspect ears for skin tags

Spontaneous Abortion:

- When pregnancy ends as result of natural causes before 20 weeks of gestation (point of fetal viability) if a fetus weighs less than 500g. - Types of abortions: threatened, inevitable, incomplete, complete, missed

Continuous Internal Fetal Monitoring:

- With a scalp electrode performed by attaching small spiral electrode to presenting part of fetus to monitor the FHR. The electrode wires are attached to a leg plate that is placed on client's thigh and then attached to fetal monitor Indications: - Continuous fetal monitoring can be used in conjunction with a intrauterine pressure catheter (IUPC) which is a solid or fluid-filled transducer placed inside client's uterine cavity to monitor frequency, duration, intensity of contractions 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 to use internal monitoring - Cervix must be adequately dilated to a minimum of 2-3 cm - Presenting part must have descended to place electrode - Potential risk of injury to fetus if electrode is not properly applied - A provider, NP/midwife, must perform this - Potential risk of infection to client/fetus

A nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a genetic counselor? A) A client whose sister has alopecia B) A client whose partner has von Willebrand disease C) A client who has an allergy to sulfa D) A client who has rubella 3 months ago

B) A client whose partner has von Willebrand disease

Creating A Postpartum Nutritional Plan:

A lactating client's nutritional plan includes the following instructions: - Increase protein and calorie 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 newborn - Take calcium supplements if unable to consume adequate amount of dietary calcium - A nutritional plan for a client who is not breast feeding should include resumption of a previous well-balanced diet

A nurse in a health clinic is reviewing contraceptive use within a group of clients. Which of the following statements demonstrates understanding? A) "A water-soluble lubricant should be used with condoms." B) "A diaphragm should be removed 2 hours after intercourse." C) "Oral contraceptives can worsen a case of acne." D) "A contraceptive patch is replaced once a month."

A) "A water-soluble lubricant should be used with condoms."

A nurse in a clinic is teaching a client about a new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (SATA) A) "Weight fluctuations can occur." B) "You are protected against STIs." C) "You should increase your intake of calcium." D) "You should avoid taking antibiotics." E) "Irregular vaginal spotting can occur."

A) "Weight fluctuations can occur." C) "You should increase your intake of calcium." E) "Irregular vaginal spotting can occur."

A client who is at 8 weeks of gestation tells the nurse "I am not sure I a happy about being pregnant." Which of the following responses should the nurse make? A) "I will inform the provider that you are having these feelings." c C) "You should be happy that you are going to bring new life into the world." D) "I am going to make an appointment with the counselor for you to discuss these thoughts."

A) Breast tenderness B) Urinary frequency C) Epistaxis

A nurse is teaching a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? (SATA) A) Breast tenderness B) Urinary frequency C) Epistaxis D) Dysuria E) Epigastric pain

A) Breast tenderness B) Urinary frequency C) Epistaxis

A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse expect the provider will prescribe? A) Ceftriaxone B) Fluconazole C) Metronidazole D) Zidovudine

A) Ceftriaxone

A nurse in a prenatal clinic is caring for a client who is in the first trimester. The client's health record includes this data: G3, T1, P0, A1, L1. How should the nurse interpret this information? (SATA) A) Client has delivered one newborn to term B) Client has experienced no preterm labor C) Client has been through active labor D) Client has had two prior pregnancies E) Client has one living child

A) Client has delivered one newborn to term D) Client has had two prior pregnancies E) Client has one living child

A nurse in a prenatal clinic is providing education to a client who is at 8 weeks of gestation. The client states, "I don't like milk." Which of the following foods should the nurse recommended as a good source of calcium? A) Dark green leafy veggies B) Deep red or orange veggies C) White breads and rice D) Meat, poultry, and fish

A) Dark green leafy veggies

A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? (SATA) A) Decreased fetal movement B) Intrauterine growth restriction (IUGR) C) Post-maturity D) Placenta previa E) Amniotic fluid emboli

A) Decreased fetal movement B) Intrauterine growth restriction (IUGR) C) Post-maturity

A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? SATA A) Demonstrates apathy when newborn cries B) Touches the newborn and maintains close physical proximity C) View the newborn's behaviors as uncooperative during diaper changing D) Identifies and relates newborn's characteristics to those of family members E) Interprets the newborn's behaviors as meaningful and a way of expressing needs

A) Demonstrates apathy when newborn cries C) View the newborn's behaviors as uncooperative during diaper changing

A nurse is caring for a client who is 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? (SATA) A) Diabetes B) Multifetal pregnancy C) Maternal age greater than 40 D) Gestational trophoblastic disease E) Oligohydramnios

A) Diabetes B) Multifetal pregnancy D) Gestational trophoblastic disease

A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include? A) Eat crackers or plain toast before getting out of bed B) Awaken during the night to eat a snack C) Skip breakfast and eat lunch after nausea has subsided D) Eat a large evening meal

A) Eat crackers or plain toast before getting out of bed

A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3-5 min and becoming stronger. A vaginal exam reveals that client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? SATA A) Encourage use of patterned breathing techniques B) Insert an indwelling urinary catheter C) Administer opioid analgesic meds D) Suggest application of cold E) Provide ice chips

A) Encourage use of patterned breathing techniques C) Administer opioid analgesic meds D) Suggest application of cold

A nurse is discussing risk factors for UTI with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? SATA A) Epidural anesthesia B) Urinary bladder catheterization C) Frequent pelvic exams D) History of UTIs E) Vaginal birth

A) Epidural anesthesia B) Urinary bladder catheterization C) Frequent pelvic exams D) History of UTIs

A nurse is caring for a client who has no prenatal care, is Rh-negative, and will undergo an external version at 38 weeks of gestation. Which of the following medications should the nurse plan to administer prior to the version? A) Postaglandin gel B) Magnesium sulfate C) Rho(D) immune globulin D) Oxytocin

C) Rho(D) immune globulin

A nurse is caring for a client who has been in labor for 12 hr with intact membranes. The nurse performs a vaginal exam to ensure which of the following prior to the performance of the amniotomy? A) Fetal engagement B) Fetal lie C) Fetal attitude D) Fetal position

A) Fetal engagement

A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A) Hands and knees B) Lithotomy C) Trendelenburg D) Supine with a rolled towel under one hip

A) Hands and knees

A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of following conditions are contraindications? SATA A) Hypospadias B) Hydrocele C) Family history of hemophilia D) Hyperbilirbuinemia E) Epispadias

A) Hypospadias C) Family history of hemophilia E) Epispadias

A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? A) Increasing pulse and decreasing blood pressure B) Dizziness and increasing respiratory rate C) Cool, clammy skin, and pale mucous membranes D) Altered mental status and level of consciousness

A) Increasing pulse and decreasing blood pressure

A nurse is caring for a client who is pregnant and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? A) January 8 B) January 15 C) February 8 D) February 15

A) January 8

A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of the following findings should the nurse expect? (SATA) A) Joint pain B) Malaise C) Rash D) Urinary frequency E) Tender lymph nodes

A) Joint pain B) Malaise C) Rash E) Tender lymph nodes

A nurse is caring for a client win the third stage of labor. Which of the following findings indicate placental separation? SATA A) Lengthening of the umbilical cord B) Swift gush of clear amniotic fluid C) Softening of the lower uterine segment D) Appearance of dark blood from vagina E) Fundus firm upon palpation

A) Lengthening of the umbilical cord D) Appearance of dark blood from vagina E) Fundus firm upon palpation

A nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based on the use of external electronic fetal monitoring the nurse notes a FHR of 115-125/min with occasional increases up to 150-155/min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. The client is exhibiting manifestations of which of the following? SATA A) Moderate variability B) FHR accelerations C) FHR decelerations D) Normal baseline FHR E) Fetal tachycardia

A) Moderate variability B) FHR accelerations D) Normal baseline FHR

A nurse in an infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which of the following data should the nurse assess? (SATA) A) Occupation B) Menstrual history C) Childhood infectious diseases D) History of falls E) Recent blood transfusions

A) Occupation B) Menstrual history C) Childhood infectious diseases

A nurse is caring for a client who is 42 weeks of gestation and is having an ultrasound. For which of the following conditions should the nurse plan for an amnioinfusion? SATA A) Oligohydramnios B) Hydramnios C) Fetal cord compression D) Hydration E) Fetal immaturity

A) Oligohydramnios C) Fetal cord compression

A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate newborn's condition following administration of synthetic surfactant? A) Oxygen saturation B) Body temperature C) Serum bilirubin D) Heart rate

A) Oxygen saturation

A nurse is administering magnesium sulfate IV for seizures prophylaxis to a client who has severe preeclampsia. Which of the following indicates magnesium sulfate toxicity? (SATA) A) Respirations less than 12/min B) Urinary output less than 25 ml/hr C) Hyperreflexic deep-tendon reflexes D) Decreased level of consciousness E) Flushing and sweating

A) Respirations less than 12/min B) Urinary output less than 25 ml/hr D) Decreased level of consciousness

A nurse is caring for a client who reports manifestations of preterm labor. Which of the following findings are risk factors of this condition? (SATA) A) Urinary tract infections B) Multifetal pregnancy C) Oligohydramnios D) Diabetes mellitus E) Uterine abnormalities

A) Urinary tract infections B) Multifetal pregnancy D) Diabetes mellitus E) Uterine abnormalities

A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? (SATA) A) Vacuum extractor B) Oxytocin infusion C) Forceps D) Cesarean birth E) Internal fetal monitoring

A) Vacuum extractor C) Forceps E) Internal fetal monitoring

HIV/AIDS Medications:

Antiretroviral Therapy (ART): - All HIV positive infected clients should be treated with combination therapy. - This is given orally and should be taken as soon as possible throughout pregnancy and before onset of labor or cesarean birth - ART can cause bone marrow suppression Highly Active Antiretroviral Therapy (HAART): - Decrease transmission to child - Intra-partum: IV zidovudine 3 hr prior to scheduled cesarean section until birth - Nursing actions: Administer zidovudine to infant at delivery and for 6 weeks following birth Client Education: - Discuss HIV and safe sexual relations with client - Continue to use barrier protection during sexual activity to prevent further exposure to HIV virus, which would increase viral load Discharge Instructions: - Do not breastfeed - Consider meeting with provider specializing in care of HIV - All states have a reportable disease list. HIV/AIDS is a commonly reported condition. Provider's responsibility to report this.

Nursing Care During Stages Of Labor: Nursing Responsibilities: Assessment:

Assess client's labor status prior to admission to birthing facility. During this time, conduct an admission history, review of antepartum care, review of birth plan: - Obtain lab reports - Monitor baseline fetal heart tones and uterine contraction patterns for 20-30 min - Obtain maternal vitals - Check status of amniotic membranes - Orient the client and their partner to the unit during admission - Perform maternal and fetal assessment continuously throughout labor process and immediately after birth - Avoid vaginal exam in presence of vaginal bleeding or until placenta previa or abruptio placentae is ruled out. If necessary, vaginal exams should be done by provider - Cervical dilation is the single most important indicator of progress of labor - Progress of labor is affected by size of fetal head, fetal presentation, fetal lie, fetal attitude, and fetal position - Frequency, duration, strength (intensity) of uterine contractions cause fetal descent and cervical dilation

Postpartum: Cervix, Vagina, Perineum Assessment & Patient-Centered Care:

Assessment: Assess for cervical, vaginal , perineal healing: - Observe perineum for erythema, edema, hematoma - Assess episiotomy and lacerations for approx. drainage, quantity, quality. A bright red trickle of blood from episiotomy site in early postpartum is normal - Initial healing occurs in 2-3 weeks and complete healing is in 4-6 months Patient-Centered Care: Perineal tenderness, laceration, and episiotomy: - Promote measures to help soften client's stool - Promote comfort measures: - Apply ice/cold pack to perineum for first 24 hr to reduce edema and provide anesthetic effect. Do not apply directly to perineum - Heat therapies (hot packs), moist heat, sitz baths can be used to increase circulation and promote healing and comfort. - Encourage sitz baths at a hot or cool temp. for at least 20 min for at least twice a day - Administer analgesics such as non-opioids (acetaminophen), non-steroidal anti-inflammatories (ibuprofen), and opioids (codeine, hydrocodone) for pain/discomfort - Opioid analgesics can be give via a PCA pump after c-section. Continuous epidural infusion can also be used for pain control after c-section - Apply topical anesthetics (benzocaine spray) to client's perineal area as needed or witch hazel compresses or hemorrhoidal creams to rectal area for hemorrhoids - Educate patient about proper cleansing to prevent infections Client Education: - Wash both hands before and after voiding - Use squeeze bottle filled with warm water or antiseptic solution after each voiding to cleanse perineal area - Blot perineal area to clean it after toileting, starting from front to back (urethra to anus) - Use topical antiseptic cream or spray sparingly - Change perineal pad removing front part first, peeling it toward the back after voiding or defecating

Sibling Adaptation:

Assessment: Assess for positive responses from the sibling: - Interest and concern for infant - Increased independence Assess for adverse responses from the sibling: - Indications of sibling rivalry and jealousy - Regression in toileting and sleep habits - Aggression toward the infant - Increased attention-seeking behaviors and whining Nursing Actions: - Take the sibling on tour of unit Encourage parents to: - Let sibling be one of the first to see infant - Provide a gift from infant to give to sibling - Arrange for one parent to spend time with the sibling while the other parent cares for infant - Allow older siblings to help in providing care for infant - Provide preschool-aged siblings with a doll to care for

PostPartum: Uterus: Assessment & Patient-Centered Care:

Assessment: Assess fundal height, uterine placement, uterine consistency at least every 8 hr after recovery period has ended: - Explain procedure - Position client in supine with knees slightly flexed so the fundal height is not influenced by positioning - Apply clean gloves and a lower perineal pad and observe lochia flow as fundus is palpated - Cup one had just above symphysis pubis to support lower segment of uterus and with other hand palpate abdomen to locate fundus. Never palpate the fundus without cupping uterus. Document fundal height, location, uterine consistency: - Determine fundal height by placing fingers on one abdomen and measuring how many fingerbreadths (cm) fit between fundus and umbilicus above, below, or at umbilical level. - Determine whether fundus is midline in pelvis or displaced laterally (caused by full bladder) - Determine whether fundus is firm or boggy. If the fundus is boggy (not firm) lightly massage, keep massaging and notify provider Document position and location of uterus by number of fingerbreadths: - If above umbilicus document as +1, U+1, 1/U - If below umbilicus document as -1, U-1, U/1 Patient-Centered Care: Administer oxytocics intramuscularly or IV after placenta is delivered to promote uterine contraction and prevent hemorrhage: - Oxytocics include oxytocin, methylergonovine, carboprost. Misoprostol a prostaglandin can also be given Monitor for adverse effects of meds: - Oxytocin and misoprostol can cause hypotension - Methylergonovine, erogonovine, carboprost can cause hypertension - Encourage early breastfeeding for client who is lactating. This will stimulate production of natural oxytocin and prevent hemorrhage - Encourage emptying of bladder to prevent possible uterine displacement and atony

Lochia: Assessment:

Assessment: Lochia amount is assessed by quantity of saturation on perineal pad as being: - Scant: less than 2.5 cm - Light: 2.5 - 10 cm - Moderate: more than 10 cm - Heavy: one pad saturated within 2 hr - Excessive blood loss: one pad saturated in 15 min or less, or pooling of blood under buttocks Assess lochia for normal color, amount, odor, consistency: - Assess frequently to determine amount of bleeding. Check at least every 15 min. for first hour after delivery then every 1 hr for next 4 hr and then every 4-8 hr - Lochia trickles from vaginal opening but flows more steadily during uterine contractions - Assess for pooled lochia on pad under client which they might not feel. This can identify heavy bleeding which can go unnoticed - Massaging uterus or ambulation can result in a gush of lochia with expression of clots and dark blood that has pooled in vagina, but should soon decrease to a trickle of bright red lochia when in early postpartum - Soiled pads can be weighed to give better estimate of bleeding - If cesarean section was done, amount of bleeding will be decreased bc provider cleans out uterus after surgery Manifestations Of Abnormal Lochia: - Excessive squirting of bright red blood from vagina, possibly indicating a cervical or vaginal tear - Numerous large clots and excessive blood loss (saturation of one pad in 15 min or less) which can indicate hemorrhage - Foul odor, which suggests infection - Persistent heavy lochia rubra in early postpartum period beyond day 3 which can indicate placental fragments - Continued flow of lochia serosa or alba beyond normal length of time can indicate endometritis especially if it's accompanied by fever, pain, abdominal tenderness Client Education: - Change pads frequently - Perform hand hygiene after perineal care and changing of soiled pads - Do not use tampons due to increased risk for infection

A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which statement by the client indicates understanding of teaching? A) "I will need to use contraception for 3 months before considering pregnancy." B) "I need a second vaccination at my postpartum visit." C) "I was given the vaccine bc my baby is O-positive." D) "I will be tested in 3 months to see if I have developed immunity."

B) "I need a second vaccination at my postpartum visit."

A nurse is teaching a client about benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? SATA A) "It is considered a non-invasive procedure." B) "It can detect abnormal fetal heart tones early." C) "It can determine the amount of amniotic fluid you have." D) "It allows for accurate readings with maternal movement." E) "It can measure uterine contraction intensity."

B) "It can detect abnormal fetal heart tones early." D) "It allows for accurate readings with maternal movement." E) "It can measure uterine contraction intensity."

A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate an understanding of the teaching? A) "The newborn will have decreased muscle tone." B) "The newborn will have a continuous high-pitched cry." C) "The newborn will sleep for 2-3 hours after feeding." D) "The newborn will have mild tremors when disturbed."

B) "The newborn will have a continuous high-pitched cry."

A nurse is caring for a client who is 2 days postpartum. The client states, "M 4-year old son was toilet trained and now he is frequently wetting himself." Which statement should the nurse provide to the client? A) "Your son was probably not ready for toilet training and should wear training pants." B) "Your son is showing an adverse sibling response." C) "Your son may need counseling." D) "You should try sending your son to preschool to resolve the behavior."

B) "Your son is showing an adverse sibling response."

A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? A) 1.8 kg (4 lb) weight gain and is in the first trimester B) 3.6 kg (8 lb) weight gain and is in the first trimester C) 6.8 kg (15 lb) weight gain and is in the second trimester D) 11.3 kg (25 lb) weight gain and is in the third trimester?

B) 3.6 kg (8 lb) weight gain and is in the first trimester

A nurse is caring for a client who is in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and fetus was at a -2 station. The client suddenly states, "My water broke." The monitor reveals a FHR of 80-85/min, and the nurse performs a vaginal exam, noticing clear fluid and pulsing loop of umbilical cord in client's vagina. Which of the following actions should the nurse perform first? A) Place client in Trendelenburg position B) Apply pressure to presenting part with the fingers C) Administer oxygen at 10 L/min via a face mask D) Initiate IV fluids

B) Apply pressure to presenting part with the fingers

A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A) Reinforce the need to take antipsychotics as prescribed B) Ask the client if they have thought of harming themselves or their infant C) Monitor the infant for indications of failure to thrive D) Review the client's medical record for history of bipolar disorder

B) Ask the client if they have thought of harming themselves or their infant

A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed? A) Spits up clear mucus B) Attempts to place their hand in their mouth C) Turns the head towards sounds D) Lies quietly with their eyes open

B) Attempts to place their hand in their mouth

A nurse is providing care for a client who has a marginal abruptio placentae. Which of the following findings are risk factors for developing the condition? (SATA) A) Fetal position B) Blunt abdominal trauma C) Cocaine use D) Maternal age E) Cigarette smoking

B) Blunt abdominal trauma C) Cocaine use E) Cigarette smoking

A nurse is caring for a client who is at 40 weeks of gestation and reports having large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? A) Examine amniotic fluid for meconium B) Check the FHR C) Dry the client and make them comfortable D) Apply a tocotransducer

B) Check the FHR

A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? SATA A) Paranoia that their infant will be harmed B) Concerns about lack of income to pay bills C) Anxiety about assuming a new role as a parent D) Rapid decline in estrogen and progesterone E) Feeling of inadequacy with new role as a parent

B) Concerns about lack of income to pay bills C) Anxiety about assuming a new role as a parent D) Rapid decline in estrogen and progesterone E) Feeling of inadequacy with new role as a parent

A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? A) Blood-tinged sputum B) Dizziness C) Pallor D) Somnolence

B) Dizziness

A nurse is caring for a client who is receiving oxytocin for induction of labor and an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? A) Frequency of every 2 min B) Duration of 90-120 seconds C) Intensity of 60-90 mm Hg D) Resting tone of 15 mm Hg

B) Duration of 90-120 seconds

A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, "I missed one menstrual cycle and cannot be pregnant because I have an IUD." The nurse should suspect which of the following? A) Missed abortion B) Ectopic pregnancy C) Severe preeclampsia D) Hydatidiform mole

B) Ectopic pregnancy

A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? A) Come back later when the client is more cooperative B) Give the client time to express feelings C) Tell the client they need to be quiet so the assessment can be completed D) Redirect the client's focus so that they will become quiet

B) Give the client time to express feelings

A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnant. Which of the following findings should the nurse expect? (SATA) A) Montgomery glands B) Goodell's sign C) Ballottement D) Chadwick's sign E) Quickening

B) Goodell's sign C) Ballottement D) Chadwick's sign

A nurse is reviewing the following medical record for a client who is to undergo hysterosalpingography. Which of the following data alert the nurse that the client is at risk for a complication related to this procedure? Vitals: 97F, HR 60/min History/Physical: Employed as a radiology technician, allergy to shrimp, tonsillectomy at 18 Lab Findings: Glucose 103, HgB 13.1, Cholesterol 265 Medications: Rosuvastatin, Magnesium oxide, Mafenide acetate A) Vital signs B) History and physical C) Lab findings D) Medications

B) History and physical

A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (SATA) A) Tinnitus B) Irregular vaginal bleeding C) Weight gain D) Nausea E) Gingival hyperplasia

B) Irregular vaginal bleeding C) Weight gain D) Nausea

A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? A) Alpha-fetoprotein (AFP) B) Lecithin/Sphingomyelin (L/S) Ratio C) Kleihauver-Betke test D) Indirect Coombs' test

B) Lecithin/Sphingomyelin (L/S) Ratio

A nurse is performing Leopold maneuvers on a client who is in labor. Which techniques should the nurse use to identify fetal lie? A) Apply palms of both hands to sides of uterus B) Palpate the fundus of uterus C) Grasp lower uterine segment between thumb and fingers D) Stand facing client's feet with fingertips outlining cephalic prominence

B) Palpate the fundus of uterus

A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? A) Assist the client to the bathroom B) Prepare for an impending delivery C) Prepare to remove a fecal impaction D) Encourage the client to take deep, cleansing breaths

B) Prepare for an impending delivery

A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? A) Prolonged labor B) Reduced fetal oxygen supply C) Delayed cervical dilation D) Increased maternal stress

B) Reduced fetal oxygen supply

A nurse is caring for a client who is in active labor. Client reports lower-back pain. Nurse suspects that this pain is related to persistent occiput posterior fetal position. Which of the following non-pharmacological nursing interventions should the nurse recommend? A) Abdominal effleurage B) Sacral counterpressure C) Showering if not contraindicated D) Back rub and massage

B) Sacral counterpressure

A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's lab reports. Which of the following findings is a manifestation of this condition? A) Hgb 12.2 g/dL B) Urine ketones present C) Alanine aminotransferase 20 IU/L D) Blood glucose 114 mg/dL

B) Urine ketones present

Non-Pharmacological Pain Management: Cutaneous Stimulation Strategies:

Based on gate control theory to promote relaxation/pain relief - Therapeutic touch/massage, back rubs - Walking - Rocking - Effleurage: light gentle circular stroking of client's abdomen with fingertips in rhythm with breathing during contractions - Sacral counter-pressure: consistent pressure is applied by the support person using heel of the hand or first against client's sacral area to counteract pain in lower back - Application of heat or cold - Transcutaneous electrical nerve stimulation (TENS) therapy - Hydrotherapy (whirlpool or shower) increases maternal endorphin levels - Acupressure Frequent maternal position changes to promote relaxation/pain relief: - Semi-sitting - Squatting - Kneeling - Kneeling and rocking back and forth - Supine position only w/ placement of wedge under one hip to tilt the uterus and avoid supine hypotension syndrome

A nurse is providing discharge teaching to parents of newborn regarding circumcision care. Which statements made by a parent indicates an understanding of the teaching? A) "The circumcision will heal within a couple of days." B) "I should remove the yellow mucus that will form." C) "I will clean the penis with each diaper change." D) "I will give him a tub bath within a couple of days."

C) "I will clean the penis with each diaper change."

A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process? A) "You will need to see a genetic counselor as part of the assessment." B) "It is usually the female who is having trouble so the male doesn't have to be involved." C) "The male is the easiest to assess and the provider will usually begin there." D) "Think about adopting first because there are many babies that need a good home."

C) "The male is the easiest to assess and the provider will usually begin there."

A nurse is caring for a client and partner during second stage of labor. The client's partner asks the nurse to explain how to know when crowning occurs. Which of the following responses should the nurse make? A) "The placenta will protrude from the vagina." B) "Your partner will report a decrease in the intensity of contractions." C) "The vaginal area will bulge as the baby's head appears." D) "Your partner will report less rectal pressure."

C) "The vaginal area will bulge as the baby's head appears."

A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? A) "This is due to an increase in blood volume." B) "This is due to pressure from the uterus on the diaphragm." C) "This is due to the weight of the uterus on the vena cava." D) "This is due to increased cardiac output."

C) "This is due to the weight of the uterus on the vena cava."

A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? A) "You will lay on your right side during the procedure." B) "You should not eat anything for 24 hours prior to the procedure." C) "You should empty your bladder prior to the procedure." D) "The test is done to determine gestational age."

C) "You should empty your bladder prior to the procedure."

During ambulation to bathroom, a postpartum client experiences gush of dark red blood that soon stops. On assessment, a nurse finds uterus to be firm, midline, and at level of umbilicus. Which finding should the nurse interpret this data as being? A) Evidence of possible vaginal hematoma B) An indication of a cervical or perineal laceration C) A normal postural discharge of lochia D) Abnormally excessive lochia rubra flow

C) A normal postural discharge of lochia

A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which actions should the nurse implement? A) Apply Gelfoam powder to the site B) Place newborn in prone position C) Apply petroleum gauze to the site D) Avoid changing the diaper until the first voiding

C) Apply petroleum gauze to the site

A nurse is reviewing car seat safety with parents of a newborn. Which instructions should the nurse include in teaching regarding car seat position? A) Front seat, rear-facing B) Front seat, forward-facing C) Back seat, rear-facing D) Back seat, forward-facing

C) Back seat, rear-facing

A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which medication should be given? A) Ofloxacin B) Nystatin C) Erythromycin D) Ceftriaxone

C) Erythromycin

A newborn was not dried completely after birth. This places the infant at risk for which of the following types of heat loss? A) Conduction B) Convection C) Evaporation D) Radiation

C) Evaporation

A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea, vomiting, and scant prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect? A) Hyperemesis gravidarum B) Threatened abortion C) Hydatidiform mole D) Preterm labor

C) Hydatidiform mole

A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A) Burp the newborns at end of feeding B) Hold the newborn close in a supine position C) Keep the nipple full of formula throughout feeding D) Refrigerate any unused formula

C) Keep the nipple full of formula throughout feeding

A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? A) Sit-ups B) Pelvic tilt exercises C) Kegel exercises D) Abdominal crunches

C) Kegel exercises

A nurse is taking a newborn to a parent following a circumcision. Which of the following actions should the nurse take for security purposes? A) Ask parent to state their full name. B) Look at name on newborn's bassinet C) Match parent's identification band with newborn's band D) Compare name on bassinet and room number

C) Match parent's identification band with newborn's band

A nurse caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? A) Intrauterine growth restriction B) Hyperglycemia C) Meconium aspiration D) Polyhydramnios

C) Meconium aspiration

A nurse is reviewing formula preparations with parents who plan to bottle-feed their newborn. Which information should the nurse include in the teaching? SATA A) Use a disinfectant wipe to clean lid of the formula can B) Store prepared formula in refrigerator for 72 hr C) Place used bottles in dishwasher D) Check nipple for appropriate flow of formula E) Use tap water to dilute concentrated formula

C) Place used bottles in dishwasher D) Check nipple for appropriate flow of formula E) Use tap water to dilute concentrated formula

A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? A) Scant, non-odorous white vaginal discharge B) Uterine cramping during breastfeeding C) Sore nipple with cracks and fissures D) Decreased response with sexual activity

C) Sore nipple with cracks and fissures

A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is priority finding in the newborn? A) Conjunctivitis B) Bronze skin discoloration C) Sunken fontanels D) Maculopapular skin rash

C) Sunken fontanels

A nurse is caring for a client who is in active labor, irritable, and reports urge to have a bowel movement. The client vomits and states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing? A) Second stage B) Fourth stage C) Transition phase D) Latent phase

C) Transition phase

Postpartum: Cervix, Vagina, Perineum Physical Changes:

Cervix is soft directly after birth and can be edematous, bruised, have small lacerations: - Within 2-3 days postpartum it shortens, regains its form and becomes firm, with the os gradually closing - Lacerations to cervix can decrease amount of cervical mucus - External os will no longer have round-dimple shape and will have a slit-like appearance The vagina which is distended, gradually returns to its pre-pregnancy size with the reappearance of rugae and a thickening of vaginal mucosa: - Muscle tone is never restored completely - Breastfeeding increases incidence of vaginal dryness and atrophy The soft tissues of perineum can be erythematous and edematous, especially in areas of an episiotomy or lacerations: - Hematoma or hemorrhoids can be present - Pelvic floor muscles can be overstretched and weak

Signs Of Pregnancy: Presumptive Signs:

Changes that client experiences that make them think they are pregnant: - Amenorrhea - Fatigue - Nausea/vomiting - Urinary frequency - Breast changes: darkened areolae, enlarged Montgomery's glands - Quickening: Slight fluttering movements of the fetus felt by the client, usually between 16-20 weeks of gestation - Uterine enlargement

Interventions For Home Care Of Newborn: Crying:

Client Education: - Newborns cry when they're hungry, overstimulated, wet, cold, hot, tired, bored, need to be burped. In time parents learn what newborn's cry means - Do not feed newborn every time they cry. Overfeeding can lead to stomach aches/diarrhea - Newborns often have fussy time of the day when they cry for no reason. They can cry themselves to sleep Quieting Techniques: - Swaddling - Close skin contact - Non-nutritive sucking with pacifier - Rhythmic noises to stimulate utero sounds - Movement (car ride, vibrating chair, infant swing, rocking) - Placing newborn on stomach across holder's lap while gently bouncing legs - En face position for eye contact (when parents' and newborns' faces are about 30 cm (12 in) apart and on the same plane) - Stimulation

Nursing Actions For Transvaginal Ultrasound:

Client Preparation: - Assist the client into a lithotomy position. - Vaginal probe is covered with a protective device (like a condom), lubricated with a water-soluble gel, and inserted by the client or examiner. Ongoing Care: - During procedure, the position of the probe or tilt of the table can be changed to facilitate the complete view of the pelvis. - Inform the client that they might feel pressure as the probe is moved.

Non-Stress Test Nursing Actions:

Client Preparation: - Seat client in reclining chair, or place in semi-fowler's or left-lateral position - Apply conduction gel to abdomen - Apply two belts to client's abdomen and attach the FHR and uterine contraction monitors Ongoing Care: - Instruct client to press the button on the handheld event marker each time they feel the fetus move - If there are no fetal movements (fetus sleeping), vibroacoustic stimulation (sound source, usually laryngeal stimulation) can be activated for 3 seconds on maternal abdomen over fetal head to awaken sleeping fetus - Takes 20-30 min.

Induction Of Labor: Considerations:

Client Preparation: Prepare client for cervical ripening: - Obtain informed consent - If cervical ripening agents are used, baseline data on fetal/maternal well-being obtained - Monitor FHR and uterine activity after administration of cervical ripening agents - Notify provider of uterine tachysystole or fetal distress Prepare the client for misoprostol administration: - It's a tablet inserted vaginally to ripen cervix - Encourage client to void prior Prepare client for oxytocin administration: - Prior to administration, nurse must confirm that fetus is engaged in birth canal at a minimum station of 0 - Initiate oxytocin no sooner than 4 hr after administration of misoprostol and 6-12 hr after dinoprostone gel instillation or removal of a dinoprostone insert - Use infusion port closet to client for administration. Oxytocin should be connected to main IV line and administered as intermittent IV bolus via infusion pump - An intrauterine pressure catheter (IUPC) can be used to monitor frequency, duration, intensity of contractions - When oxytocin is given, assessments include maternal blood pressure, pulse, respirations every 30-60 min and with every change in dose - Monitor FHR and contraction pattern every 15 min in first stage of labor, every 5 min in second stage, and withe very change in dose - Assess fluid intake and urinary output- - A bishop score rating should be obtained prior to starting any labor induction protocol Ongoing Care: Assist with or perform administration of labor induction agents: Increase oxytocin until desired contraction pattern is obtained and then maintain the dose if there is: - Contraction frequency 2-3 min - Contraction duration of 80-90 seconds - Contraction intensity of 40-90 mm Hg on IUPC or strong to palpation - Uterine resting tone of 10-15 mm Hg on IUPC - Cervical dilation of 1 cm/hr - Reassuring FHR between 110-160/min Discontinue oxytocin if uterine tachysystole occurs. Clinical findings of uterine tachysystole are: - Contraction frequency more often than every 2 min - Contraction duration longer than 90 seconds - Contraction intensity that results in pressures greater than 90 mm Hg as shown by IUPC - Uterine resting tone greater than 20 mm Hg between contractions - No relaxation of uterine between contractions Complications: Nonreassuring FHR: - Abnormal baseline less than 110 or greater than 160/min - Loss of variability - Late or prolonged decelerations Nursing Actions: - Notify provider - Position client in side-lying position to increase uteroplacental perfusion - Keep IV line open and increase fluid rate to 200 mL/hr unless contraindicated - Administer O2 by face mask at 8-10 L/min - Administer the tocolytic terbutaline 0.25 mg subcutaneously to diminish uterine activity - Monitor FHR and patterns in conjunction with uterine activity - Document response to interventions - If unable to restore reassuring FHR, prepare for an emergency cesarean birth

Pharmacological Pain Management: Analgesia: Epidural & Spinal REgional Analgesia:

Consists of using analgesics such as fentanyl and sufentanil which are short-acting opioids that are administered as a motor block into epidural or intrathecal space without anesthesia. These opioids produce regional analgesia providing rapid pain relief while still allowing client to sense contractions and maintain ability to bear down Adverse Effects: - Decreased gastric emptying resulting in nausea/vomiting - Inhibition of bowel/bladder elimination sensations - Bradycardia or tachycardia - Hypotension - Respiratory depression - Allergic reaction and pruritus - Elevated temperature Nursing Actions: - Institute safety precautions like purring side rails up. Patient can experience dizziness and sedation which increases maternal risk for injury - Assess for nausea/emesis and administer antiemetics as prescribed - Monitor maternal vital signs - Monitor for allergic reaction - Continue FHR pattern monitoring

A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? A) "An IUD should be replaced annually during a pelvic exam." B) "I cannot get an IUD until after I've had a child." C) "I should plan on regaining fertility 5 months after the IUD is removed." D) "I will check to be sure the strings of the IUD are still present after my periods."

D) "I will check to be sure the strings of the IUD are still present after my periods."

A nurse is reviewing postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching? A) "I am glad I can have my morning coffee." B) "I should take folic acid to increase my milk supply." C) "I will continue adding 330 calories per day to my diet." D) "I will continue my calcium supplements because I don't like milk."

D) "I will continue my calcium supplements because I don't like milk."

A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is highest priority? A) Initiating breastfeeding B) Performing initial bath C) Giving a vitamin K injection D) Covering newborn's head with a cap

D) Covering newborn's head with a cap

A nurse is planning care for a newly admitted client who reports, "I am in labor and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care? A) Inspect the introitus for a prolapsed cord B) Perform a test to identify the ferning pattern C) Monitor station of the presenting part D) Defer vaginal examinations

D) Defer vaginal examinations

A nurse is completing a newborn assessment and observes small pearly white nodules on roof of newborn's mouth. This finding is a characteristic of which condition? A) Mongolian spots B) Milia spots C) Erythema toxicum D) Epstein's pearls

D) Epstein's pearls

A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which? A) Hold the newborn vertically under arms and allow one foot to touch table B) Stimulate the pads of the newborn's hands with stroking or massage C) Stimulate the soles of the newborn's feet on the outer lateral surface of each foot D) Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backwards

D) Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backwards

A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks. Which of the following instructions should the nurse include in the teaching? A) Use a condom with sexual intercourse B) Avoid bubble bath solution when taking a tub bath C) Wipe from back to front when performing perineal hygiene D) Keep a daily record of fetal kick counts

D) Keep a daily record of fetal kick counts

A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? A) Cover the cord with a small gauze square B) Trickle clean water over the cord with each diaper change C) Apply hydrogen peroxide to cord twice a day D) Keep the diaper folded below the cord

D) Keep the diaper folded below the cord

A nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? A) Iron deficiency anemia B) Poor bone formation C) Macrosomnic fetus D) Neural tube defects

D) Neural tube defects

A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? A) Encourage the parents to touch and explore the neonate's features B) Limit noise and interruption in the delivery room C) Place the neonate at the client's breast D) Position the neonate skin-to-skin on client's chest

D) Position the neonate skin-to-skin on client's chest

A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, feeling of letdown. Which condition are associated with these manifestations? A) Postpartum fatigue B) Postpartum psychosis C) Letting-go phase D) Postpartum blues

D) Postpartum blues

A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it's noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A) Precipitous labor B) Premature rupture of membranes C) Postmaturity syndrome D) Prolapsed umbilical cord

D) Prolapsed umbilical cord

A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding? A) Hand the parent the newborn and suggest that they change the diaper B) Ask the parent why they are so anxious and nervous C) Tell the parent that they will grow accustomed to the newborn D) Provide education about infant care when the parent is present

D) Provide education about infant care when the parent is present

A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? A) Peak of the uterine contraction B) Moderate variability C) FHR acceleration D) Relaxation between uterine contractions

D) Relaxation between uterine contractions

A client calls a provider's office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? A) Braxton Hicks contractions B) Rupture of membranes C) Fetal descent D) True contractions

D) True contractions

A nurse is giving instructions to a parent about how to breastfeed their newborn. Which action by the parent indicates an understanding of the teaching? A) The parent places a few drops of water on their nipples before breastfeeding B) The parent gently removes their nipple from the infant's mouth to break the suction C) When they are ready to breastfeed, the parent gently strokes the newborn's neck with a finger D) When latched on, the infant's nose, cheek, and chin are touching the breast

D) When latched on, the infant's nose, cheek, and chin are touching the breast

Phases Of Maternal Role Attainment:

Dependent (Taking-In Phase): - First 24-48 hr - Focus on meeting personal needs - Rely on others for assistance - Excited, talkative - Need to review birth experience with others Dependent-Independent (Taking-Hold Phase): - Begins on day 2 or 3 - Lasts 10 days to several weeks - Focus on baby care and improving caregiving competency - Want to take charge but need acceptance from others - Want to learn and practice - Dealing with physical and emotional discomforts, can experience "baby blues" Interdependent (Letting-Go Phase): - Focus on family as a unit - Resumption of role (intimate partner, individual)

Transition To Fatherhood Phases:

Expectations & Intentions: - Desires to be deeply and emotionally connected with infant Confronting Reality: - Understands that reality does not always meet expectations. - Commonly expressed emotions including feeling sad, frustrated, jealous. - Can feel like they're unable to talk with the other parent, who is consumed with infant caregiving and their own transition Creating The Role Of The Involved Father: - Decides to become actively involved in the care of the infant Reaping Rewards: - Rewards include infant smiles and a sense of completeness/meaning

Postpartum Infections: Puerperal Infections:

Expected Finding: - Flue-like manifestations (body aches, chills, fever, malaise) - Anorexia/nausea - Elevated temperature of at least 100.4 for 2 or more consecutive days - Tachycardia Nursing Care: - Use aseptic technique for appropriate procedures; perform proper hand hygiene and don gloves for labor, birth, postpartum care - Maintain or initiate IV access - Administer IV broad-spectrum antibiotic therapy (penicillins, cephalosporins, clindamycin, gentamicin) - Provide comfort measures (warm blankets, cool, compresses) Client Education: - Report signs of worsening conditions - Adhere to treatment plan with completion of a full course of antibiotics - Preventative measures include thorough hand washing and good perineal hygiene - A diet high in protein promotes tissue healing

Postpartum Infections: Endometritis:

Expected Finding: - Pelvic pain - Chills - Fatigue - Loss of appetite - Uterine tenderness and enlargement - Dark, profuse lochia - Lochia that is either malodorous or purulent - Temperature greater than 100.4 - Tachycardia Nursing Care: - Collect vaginal and blood cultures - Administer IV antibiotics - Administer analgesics Client Education: - Perform effective hand hygiene - Maintain interaction with the infant to facilitate bonding Medications: - Clindamycin - Cephalosporins, penicillins, getamicin - Antibiotics - Treatment of bacterial infections Client Education: - Take all meds as prescribed - Notify provider of development of watery, bloody diarrhea - Notify provider if breastfeeding

Postpartum Infection: Wound Infection:

Expected Findings: - Wound warmth, erythema, tenderness, pain, edema, seropurulent drainage, wound dehiscence (separation of wound or incision edges) or evisceration (protrusion of internal contents through the separated wound edges) - Temperature greater than 100.4 for 2 or more consecutive days Nursing Care: - Perform wound care - Administer IV antibiotics - Provide or encourage comfort measures (sitz baths, perineal care, warm/cold compresses) Client Education: - Good hygiene techniques include changing perineal pads from front to back and performing thorough hand hygiene prior to and after perineal care

Nursing Care Of Newborns: Complications: Hypoglycemia:

Frequently occurs in first few hours of life secondary to use of energy to establish respirations and maintain body heat: - Newborns of clients who have diabetes mellitus and are small or large for gestational age; less than 34 weeks of gestation; late pre-term newborns are at risk for hypoglycemia. They should have blood glucose monitored within first 2 hr of life Nursing Action: - Monitor for jitteriness; twitching; a weak, abnormal cry; irregular respiratory effort; cyanosis; lethargy; eye rolling; seizures; blood glucose level less than 40 mg/dL by heel stick - Have parent 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

Sources Of Pain During Labor: First Stage:

Internal visceral pain that can be felt as back and leg pain Pain Causes: - Dilation, effacement, stretching of cervix - Distention of lower segment of uterus - Contractions of uterus with resultant uterine ischemia

Common Discomforts Of Pregnancy:

Nausea/Vomiting: Might occur during first trimester. The client should eat crackers or a dry toast before rising in the morning to relieve discomfort. Instruct the client to avoid having an empty stomach and ingesting spicy, greasy, or gas-forming foods. Encourage client to drink fluids between meals. Breast tenderness: Might occur during the last trimester. The client should wear a bra that provides support. Urinary frequency: Might occur during the first and third trimesters. The client should empty bladder frequently, decrease fluid intake before bedtime, and use perineal pads. The client is taught how to perform Kegel exercises to reduce stress incontinence (leakage of urine with coughing/sneezing) Urinary tract infections: Common during pregnancy because of renal changes and vaginal flora becoming more alkaline - UTI risk can be decreased by encouraging client to wipe front to back after voiding, avoiding bubble baths, wearing cotton panties, avoiding tight-fitting pants, consuming plenty of water (8 glasses per day) - The client should urinate before and after intercourse - Advise client to urinate as soon as urge occurs - Advise client to notify provider if their urine is foul-smelling, contains blood, appears cloudy Fatigue: Might occur during the first and third trimesters. The client is encouraged to engage in frequent rest periods Heartburn: Might occur during the second and third trimesters due to stomach being displaced by enlarging uterus and a slowing of gastrointestinal tract motility and digestion brought about by increased progesterone levels. The client should eat small, frequent meals, not allow stomach to get too empty or too full, check with provider prior to using any OTC antacids. Client should not immediately lie down after eating (can exacerbate reflux) Constipation: Might occur during second and third trimesters. Client is encouraged to drink plenty of fluids, eat a diet high in fiber, exercise regularly Hemorrhoids: Might occur during second and third trimesters. A warm sitz bath, witch hazel pads, and application of topical ointments will help relieve discomfort. Backaches: Common during second and third trimesters. Client is encouraged to exercise regularly, perform pelvic tilt exercises (alternately arching and straightening the back), use proper body mechanics by using the legs to lift rather than the back, and use the side-lying position. Shortness of breath: & Dyspnea might occur because of the enlarged uterus, which limits inspiration. Client should maintain good posture, sleep with extra pillows, and contact provider if manifestations worsen Leg cramps: During the third trimester might occur due to compression of lower-extremity nerves and blood vessels by the enlarging uterus. This can result in poor peripheral circulation, as well as an imbalance in the calcium/phosphate ratio. The client should extend the affected leg, keeping the knee straight, and dorsiflex the foot (toes toward head). Application of heat over affected muscle or a foot massage while the leg is extended can help relieve cramping. The client should notify provider if frequent cramping occurs. Varicose veins and lower-extremity edema: Can occur during second and third trimesters. The client should rest with legs and hips elevated, avoid constricting clothing, wear support hose, avoid sitting/standing in one position for extended period of time, and not sit with legs crossed at the knees. The client should sleep in the left-lateral position and exercise moderately with frequent walking to stimulate venous return Gingivitis, nasal stuffiness, epistaxis: Can occur as a result of elevated estrogen levels causing increased vascularity and proliferation of connective tissue. The client should gently brush their teeth, observe good dental hygiene, use a humidifier, and use normal saline nose drops/spray Braxton Hicks contractions: Which occur from the first trimester onward, might increase in intensity and frequency during the third trimester. Inform the client that a change of position and walking should cause contractions to subside. If contractions increase in intensity and frequency (true contractions) with regularity the client should notify the provider. Supine hypotension: Occurs when a client lies on their back and the weight of the gravid uterus compresses the vena cava. This reduces blood supply to the fetus. The client might experience feelings of lightheadedness and faintness. Teach the client to lie in a side-lying or semi-sitting position with the knees slightly flexed.

Prenatal Visit Client Education: Preparing For Pregnancy And Birth:

Nurses provide anticipatory teaching to the pregnant client and their family about: - Physical and emotional changes during pregnancy and interventions that can be implemented to provide relief - Indications of complications to report to provider - Birthing options available to enhance the birthing process - Maternal adaptation to pregnancy and the attainment of the maternal role-whereby the idea of pregnancy is accepted and assimilated into client's way of life- Includes hormonal and psychological aspects: - Emotional lability is experienced by many clients with unpredictable mood changes and increased irritability, tearfulness, and anger alternating with feelings of joy and cheerfulness. This might result from hormonal changes. - A feeling of ambivalence about the pregnancy, which is a normal response, might occur early in pregnancy and resolve before the third trimester. It consist of conflicting feelings (joy, pleasure, sorrow, hostility) about the pregnancy. These feelings can occur simultaneously, whether the pregnancy was planned or not. - The nurse anticipates reviewing prenatal education topics with a client based on their knowledge and previous pregnancy and birth experiences. The client's readiness to learn is enhanced when the nurse provides teaching during the appropriate trimester based on learning needs. Using a variety of educational methods (pamphlets, videos) and having the client verbalize and demonstrate learned topics will ensure that learning has taken place. Fetal movement/kick counts to ascertain fetal-well being: A client should be instructed to count and record fetal movements or kicks daily. There are several different methods to complete kick counts: - One method: Clients should count fetal activity two or three times a day for 2 hr after meals or bedtime. Fetal movement of less than 3 hr or movements that cease entirely for 12 hr indicate a need for further evaluation - Diagnostic testing for fetal well-being (non-stress test, biophysical profile, ultrasound, contraction stress test)

Labor & Delivery: Post-Procedure:

Nursing Assessment During 4th Stage: - Maternal vitals - Fundus - Lochia - Perineum - Urinary output - Maternal/newborn baby-friendly activities Nursing Actions During 4th Stage: - Recommended that blood pressure and pulse be assessed at least every 15 min for first 2 hr afte rbirth and temperature every 4 hr for first 8 hr after birth then at least every 8 hr. - Assess fundus and lochia every 15 min for first hour and then according to protocol - Massage uterine fundus and/or administer oxytocin as prescribed to maintain uterine tone to prevent hemorrhage - Assess client's perineum and provide comfort measures as indicated - Encourage voiding to prevent bladder distention - Promote an opportunity for maternal/newborn bonding - Offer assistance with breastfeeding and provide reasurrance Client Education: - Notify the nurse of increased vaginal bleeding or passage of blood clots

Nursing Care Of Newborns: Patient-Centered Care: Respiratory Complications:

Nursing Care: - Stabilize and/or give resuscitation to newborn Respiratory Complications: - Bradypnea: Respirations less than or equal to 30/min - Tachypnea: Respirations greater than or equal to 60/min - Abnormal breath sounds: Expiratory grunting, crackles, wheezes - Respiratory distress: Nasal flaring, retractions, grunting, gasping, labored breathing Interventions For Stabilization & Resuscitation Of Airway: - Newborn is able to clear most secretions in air passages by cough reflex. Routine suctioning of mouth then nasal passages w/ bulb syringe is done to remove excess mucus in respiratory tract. - Newborns delivered by c-section are more susceptible to fluid remaining in lungs than vaginally born newborns. - If bulb suctioning is unsuccessful, use mechanical suctioning for clearing airway. Institute emergency procedures if airway does not clear - Bulb syringe should be kept with newborn and the family should be instructed on its use. Family members should perform demonstration: - Compress bulb before insertion into one side of mouth - Avoid center of mouth to prevent stimulating gag reflex - Aspirate mouth first, one nostril, then second nostril

Neonatal Substance Withdrawal: Patient-Centered Care:

Nursing Care: - Perform ongoing assessment of newborn using neonatal abstinence scoring system - Elicit and assess newborn's reflexes - Monitor newborn's ability to feed/digest intake. Offer small frequent feedings - Swaddle newborn with legs fixed - Offer non-nutritive sucking - Monitor fluids and electrolytes with skin turgor, mucous membranes, fontanels, daily weights, I/O - Reduce environmental stimuli (decrease lights, lower noise level) Medications: - Morphine sulfate: Opioid - Phenobarbital: Anticonvulsant - Intended effect: Decrease CNS irritability and control seizures for newborns who have alcohol or opioid-withdrawal Nursing Actions: - Assess IV site frequently - Check for any med. incompatibilities - Decrease environmental stimuli - Cluster cares to minimize stimulation - Swaddle newborn to reduce self-stimulation and protect skin from abrasions - Monitor/maintain fluids/electrolytes - Administer frequent, small feedings of high-calorie formula; can require gavage feedings - Elevate newborn's head during and following feedings, and burp newborn to reduce vomiting/aspiration - Try various nipples to compensate for a poor suck reflex - Have suction available to reduce risk for aspiration - For newborns who are withdrawing from cocaine, avoid eye contact and use vertical rocking and a pacifier - Prevent infection - Initiate consult with child protective services - Consult lactation services to evaluate whether breastfeeding is desired or contraindicated to avoid passing narcotics in breast milk. Methadone is not contraindicated during breastfeeding Client Education: - Utilize drug/alcohol treatment center - Understand importance of SIDS prevention activities due to increased rate in newborns of parents who use methadone

Nursing Assessment/Interventions For Nutrition During Pregnancy:

Obtain subjective/objective dietary information: - Journal client's food habits, eating pattern, cravings - Nutrition-related quiestionnaires - Health history, including contraceptive history, previous pregnancies, chronic diseases - Client's weight on first prenatal visit and follow-up visits - Lab findings (Hgb, iron levels) Determine client's caloric intake: Have the client record everything eating during a 24 hr period. The nurse, dietitian, or client can identify the caloric value of each item.

Nursing Interventions For Postpartum Care: Perineal Care/Breast Care:

Perineal Care: Client education: - Cleanse perineal area from front to back with warm water after each voiding and bowel movement - Blot perineal area from front to back - Remove and apply perineal pads from front to back Breast Care: Clients who plan to breastfeed: - Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection Client education: - Wear a well-fitting, non-binding bra if breast support is needed. Do not use an underwire bare, which can cause clogged milk ducts - Allow infant to nurse on demand which would be about 8-12 times in 24 hr. Allow infant to feed until breast softens. Offer second breast to infant before completing the feeding, and start each feeding with a different breast - To relieve breast engorgement take a warm shower or apply warm compresses before breastfeeding to promote letdown and milk flow. Empty each breast completely at feedings, using a pump if needed after the infant has finished feeding. Apply cool compresses after feedings - Apply breast creams as prescribed and wear breast shells in the bra to soften the nipples if they're irritated and cracked - For flat or inverted nipples use a breast shell between feedings - For sore nipples, apply small amount of breast milk to nipple and allow it to air dry after breastfeeding - Drink adequate fluids to satisfy the thirst Clients who don't plan on breastfeeding: - Suppression of lactation is necessary for clients who are not breastfeeding Client Education: - Wear a well-fitting supportive bra continuously for first 72 hr - Avoid breast stimulation and running warm water over breasts for prolonged periods until no longer lactating - For breast engorgement, which can occur on the 3rd or 5th postpartum day, 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 for pain and discomfort for breast engorgement

Causes Of Bleeding During Pregnancy: Third Trimester:

Placenta Previa: Painless vaginal bleeding Abruptio Placentae: Vaginal bleeding, sharp abdominal pain, tender rigid uterus Vasa Previa: Fetal vessels are implanted into the membranes rather than the placenta

Biophysical Profile Indications:

Possible Diagnoses: - Non-reactive non-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

Intermittent Auscultation & Uterine Contraction Palpation: Considerations:

Preparation Of Client: - Based on findings obtained using Leopold maneuvers, auscultate the FHR using listening device - Palpate the uterine fundus to assess uterine activity - Count FHR for 30-60 seconds between contractions to determine baseline rate - Auscultate FHR before, during, after a contraction to determine FHR in response to contractions Ongoing Care: - Identify FHR patterns and characteristics of uterine contractions Interventions: - It's responsibility of nurse to assess FHR patterns and characteristics of uterine contractions, implementing nursing interventions, and report nonreassuring patterns or abnormal uterine contractions to the provider - Cultural considerations as well as emotional, educational, comfort needs of client/family must be incorporated into the pain of care while continuing to assess FHR pattern's response to uterine contractions during labor process

Other Causes Of Bleeding During Pregnancy:

Recurrent Premature Dilation Of The Cervix: Painless bleeding with cervical dilation leading to fetal expulsion Preterm Labor: Bloody discharge, uterine contractions becoming regular, cervical dilation and effacement Hydatidiform Mole: Benign proliferative growth of the placental trophoblast

Cervical Insufficiency (Premature Cervical Dilation):

Risk Factors: - History of cervical trauma (cervical tears from previous deliveries, excessive dilations, curettage for biopsy, surgical procedures involving the cervix), short labors, pregnancy loss in early gestation, advanced cervical dilation at earlier weeks of gestation - In utero exposure to diethylstibestrol, ingested by client during pregnancy - Congenital structural defects of uterus or cervix Expected Findings: - Increase in pelvic pressure or urge to push - Pink-stained vaginal discharge or bleeding - Possible gush of fluid (rupture of membranes) - Uterine contractions with expulsion of fetus - Post-op (cerclage) monitoring for uterine contractions, rupture of membranes, manifestations of infection. Diagnostic/Therapeutic Procedures: - Ultrasound showing a short cervix (less than 25 mm), presence of cervical funneling (beaking), or effacement of cervical os indicates reduced cervical competence - Prophylactic cervical cerclage is surgical reinforcement of cervix with heavy ligature that is placed submucosally around cervix to strengthen it and prevent premature cervical dilation. Best results occur if this is done at 12-14 weeks. The cerclage is removed at 36 weeks or when spontaneous labor occurs. Nursing Care: - Evaluate client's support systems and availability of assistance if activity restriction/bed rest are prescribed - Assess vaginal discharge - Monitor client reports of pressure and contractions - Check vitals Discharge Instructions: - Adhere to activity restrictions/bed rest - Increase hydration to promote relaxed uterus (dehydration stimulates uterine contractions) - Avoid intercourse - Monitor for cervical/uterine changes - Cervical cerclage might be required (indicated for clients who are experiencing singleton pregnancy), often placed at 12-14 weeks and removed 37-38 weeks. Health Promotion/Disease Prevention: - Report findings to provider (preterm labor, rupture of membranes, infection, strong contraction less than 5 min apart, severe perineal pressure, urge to push) - Follow up for observation/supervision

HIV/AIDS Assessment:

Risk Factors: - IV drug use - Multiple sexual partners - Maternal history of multiple STIs Expected Findings: - Fatigue and influenza-like findings - Fever - Diarrhea and weight loss - Lymphadenophathy and rash - Anemia Lab Tests: - Obtain informed maternal consent prior to testing - Testing begins with an antibody screening test, such as enzyme immunoasay (EIA). Confirmation of positive results is confirmed by Western blot test or immunofluorescence assay - Use rapid HIV antibody test (blood or urine sample) for client in labor - Screen client for STIs (gonorrhea, chlamydia, syphilis, hepatitis B) - Obtain frequent viral load levels and CD4 cell counts throughout pregnancy

PostPartum Disorders: Deep-Vein Thrombosis:

Risk Factors: - Pregnancy - Cesarean birth (doubles risk) - Operative vaginal birth - Pulmonary embolism or varicosities - Immobility - Obesity - Smoking - Multiparity - Age greater than 35 - History of thromboembolism Expected Findings: - Leg pain/tenderness - Unilateral area of swelling, warmth, redness - Hardened vein over thrombosis - Calf tenderness Diagnostic Procedures: - Doppler ultrasound scan - CT - MRI Prevention Of Thrombophlebitis: - Maintain compression devices until ambulation established - If bed rest is prolonged longer than 8 hr use active and passive range of motion to promote circulation - Initiate early and frequent ambulation postpartum - Measure lower extremities for fitted elastic thromboembolic hose Client Education: - Avoid prolonged periods of standing, sitting, immobility - Elevate both legs when sitting - Avoid crossing the legs, which reduces circulation - Maintain fluid intake of 2-3 L each day from food and beverage to prevent dehydration which causes bad circulation - Stop smoking Management Of Thrombophlebitis: - Facilitate bed rest/elevation of client's extremity above level of heart. Encourage position changes frenquently - Administer intermittent or continuous warm most compresses - Do NOT massage affected limb - Measure client's leg circumference - Provide thigh-high antiembolism stockings for client at high risk for venous insufficiency - Administer analgesics - Administer anticoagulants Precautions While Taking Anticoagulants: - Avoid taking aspirin/ibuprofen (increases bleeding tendencies) - Use electronic razor for shaving - Avoid alcohol (inhibits warfarin) - Brush teeth gently with soft toothbrush - Avoid rubbing or massaging legs - Avoid periods of prolonged sitting/crossing legs

Placenta Previa Assessment:

Risk Factors: - Previous placenta previa - Uterine scarring (previous cesarean birth, curettage, endometritis) - Maternal age greater than 35 - Multifetal gestation - Multiple gestations - Smoking Expected Findings: - Painless, bright red vaginal bleeding during the second/third trimester - Uterus soft, relaxed, non-tender with normal tone - Fundal height greater than usually expected for gestational age - Fetus in a breech, oblique, or transverse position - Reassuring FHR - Vitals within normal limits - Decreasing urinary output, which can be a better indication of blood loss Lab Tests: - Hgb and Hct for blood loss assessment - CBC - Blood type and Rh - Coagulation profile - Kleihauer-Betke test (used to detect fetal blood in maternal circulation) Diagnostic Procedure: - Transabdominal or transvaginal ultrasound for placement of the placenta - Fetal monitoring for fetal well-being assessment

TORCH Assessment:

Risk Factors: - Toxoplasmosis is caused by consumption of raw or undercooked meat or handling cat feces. Manifestations are similar to influenza or lymphadenopathy - Other infections can include hepatitis A and B, syphilis, mumps, parvovirus B19, varicella-zoster. These are some of most common and can be associated with congenital anomalies - Rubella (German measles) is contracted through children who have rashes or neonates who are born to clients who had rubella during pregnancy - Cytomegalovirus (member of herpes virus family) is transmitted by droplet infection from person to person, through semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. Latent virus can be reactivated and cause disease to fetus in utero or during passage through birth canal - HSV is spread by direct contact with oral or genital lesions. Transmission to the fetus is greater during vaginal birth if client has active lesions Expected Findings: - Toxoplasmosis: Often no manifestations, but client can experience influenza or lymphatdenopathy (malaise, muscle aches, flue-like manifestations). Fever and tender lymph nodes - Rubella: Joint and muscle pain, rash, fever, mild lymphedema - Cytomegalovirus: No manifestations or mononucleosis-like manifesations - Herpes Simplex Infection: Findings consistent of painful blisters and tender lymph nodes Lab Tests: - For herpes simplex, obtain cultures from clients who have HSV or are at or near term Diagnostic Procedures: - TORCH Screen: Immunologic survey used to identify existence of these infections in the mother (to identify fetal risks) or newborn (detection of antibodies against infections) - Prenatal screenings

Postpartum Urinary System & Bladder Function:

Urinary system can show: - Urinary retention secondary to loss of bladder elasticity and tone and/or loss of bladder sensation resulting from trauma, meds, or anesthesia. A distended bladder as a result of urinary retention can cause infection, uterine atomy, displacement to one side, ability of uterus to contract is also lessened - Postpartal diuresis which increased urinary output begins within 12 hr of delivery Assessment: - Assess client's ability to void (perineal/urethral edema can cause pain and difficulty in voiding during first 24-48 hr) - Assess bladder elimination pattern. Excessive urine diuresis (more than 3,000 mL/day) is normal within the first 2-3 days after delivery Assess for evidence of distended bladder: - Fundal height above umbilicus or baseline level - Fundus displaced from midline over to side - Bladder bulges above the symphysis pubis - Excessive lochia - Tenderness over bladder area - Frequent voiding of less than 150 mL of urine is indication of urinary retention with overflow. Patient-Centered Care: - Assist client to void within 6-8 hr after delivery. If unable, catheterize - Encourage client to empty bladder frequently to prevent possible displacement of uterus and atony. - Measure client's first few voidings after delivery to assess for bladder emptying - Encourage client to increase oral fluid intake to replace fluids lost at delivery and prevent or correct dehydration - Catheterize if needed for bladder distention if client is unable to ensure complete emptying of bladder and allow uterine involution

Postpartum Infections: Endometritis, Mastitis, Wound Infections:

Uterine Infection (Endometritis): An infection of the uterine lining or endometrium. It's most frequently occurring puerperal infection. Usually begins on 3rd or 4th postpartum day, generally starting as a localized infection at placental attachment site and spreading to include entire uterine endometrium Wound Infections: Include c-section incisions, episiotomies, lacerations, any trauma wound present in birth canal following labor/birth. Mastitis: Is infection of breast involving the interlobular connective tissue and is usually unilateral. Mastitis can progress to an abscess if untreated: - It can occur as early as 7th postpartum day. It usually occurs during first 6 weeks of breastfeeding, but can occur any time during breastfeeding - Staphylococcus aureus is usually infecting organism Risk Factors: - UTI, mastitis, pneumonia, or history of previous venous thrombus - History of diabetes mellitus, immunosuppression, anemia, malnutrition - History of alcohol/substance use disorder - C-section birth - Prolonged rupture of membranes - Retained placental fragments and manual extraction of placenta - Bladder catheterization - Chorioamnionitis - Internal fetal/uterine pressure monitoring - Multiple vaginal exams after rupture of membranes - Prolonged labor - Postpartum hemorrhage - Operative vaginal birth - Epidural analgesia/anesthesia - Hematomas - Episiotomy or lacerations Lab Tests: - Blood, intracervical, or intrauterine bacterial cultures to reveal offending organism - WBC count: Leukocytosis - RBC sedimentations rate: Distinctly increased - RBC count: Anemia Nursing Care: - Obtain frequent vitals - Assess pain - Assess fundal height, position, consistency - Observe lochia for color, quantity, consistency - Inspect incisions, episiotomy, lacerations - Inspect breasts