Ch 28 Care of the Mother and Newborn
a mother delivered at midnight, its now 9am. she wants to sleep and asks the nurse to take care of the baby. what is this considered?
"taking in" stage is a normal response of new mothers. she may be passive for a couple days and needs supportive care
newborn assessment finding for the newborn hygiene
(body temp must be stabilized) bathing; provides complete cleansing, observation of infant's condition
Postpartum Maternal Danger Signs
- Fever with or without chills - Malodorous vaginal discharge - Excessive amount of vaginal discharge - Bright red vaginal bleeding after it has changed to pink or brown (rust). -Edema; erythmatous or painful area on the legs - Pain or burning sensation with urination or an inability to void - Breast changes, such as localized pain, heat, edema, or malodorous drainage - Pain in the perineal or pelvic area
Atonic uterus
- literally a uterus without tone - Most common reason for post-partum hemorrhage
Which client behavior indicates that a woman needs further teaching regarding breastfeeding her newborn? 1 She leans forward to place her breast in the infant's mouth. 2 She holds the infant level with her breast while in a side-lying position. 3 She touches her nipple to the infant's cheek at the beginning of the feeding. 4 She puts her finger in the infant's mouth to break the suction after the feeding.
1 She leans forward to place her breast in the infant's mouth.
Which drug would be excluded from the prescription of a lactating mother being treated for heart problems? 1 Tenormin 2 Labetalol 3 Metoprolol 4 Propranolol
1 Tenormin
A client with a habit of smoking while on estrogen therapy is at risk for developing which condition? 1 Thrombosis 2 Gastrointestinal upset 3 Endometrial cancer 4 Decreased effectiveness of estrogen
1 Thrombosis
the umbilical cord will generally fall of when?
10-14 days after birth
normal newborn HR?
120-160
Passages of vesicles (grapelike clusters) may occur around which weeks of gestation?
16 weeks
How much sleep does a newborn need?
16-20 hours a day
Estrogen levels in nonlactating women begin to rise when after birth?
2 weeks after birth & the levels are higher by postpartum day 17 than in women who breast-feed
What kind of milk do you give a baby after 2 years old?
2% milk
Normal bowel elimination should resume within ____ to ____ days after delivery.
2-3 days
Episiotomy takes how long to heal?
2-3 weeks. Sutures are absorbed by the body
Blood volume is reduced to nonpregnant levels by _________ weeks after delivery.
2-4 weeks
Neurological assessment is done when on newborn?
24 hours after birth
a perineal laceration extending through the muscle of the perineum is called what
2nd degree laceration
Colostrum production begins when?
2nd trimester. Continues for about 2 days after delivery, when true milk production begins
Why would the use of baby powder on an infant be avoided? 1 Skin irritation 2 Skin infection 3 Lung irritation 4 Respiratory infection
3 Lung irritation
Which drug impairs fertility when administered along with fertility drugs? 1 Clomiphene 2 Menotropins 3 Promethazine 4 Choriogonadotropin alfa
3 Promethazine
A client who is scheduled for an amniocentesis tells the nurse, "I'm glad this test will be able to tell me whether or not my baby is well." How would the nurse respond? 1 "Research has shown that this is an excellent test." 2 "A normal amniocentesis result is a reliable indicator of a healthy baby." 3 "This test is useful in detecting potential defects caused by chromosomal errors." 4 "An amniocentesis is a valuable tool for detecting congenital defects in the developing fetus."
3 "This test is useful in detecting potential defects caused by chromosomal errors."
May need to assess for PIH up to
3 days
Lochia serosa is?
3-7 days, discharge thins & becomes pink to brown.
New Born Respiratory Rate Range?
30 to 60 breaths/min with brief periods of apnea.
Normal respiratory rate for newborn?
30-60 min with brief periods of apnea.
Blood loss during delivery/C-Section?
300-500mL if delivery 600-800ml if C section
Which dietary information would the nurse emphasize when reinforcing a dietary program for a pregnant client with diabetes? 1 The need to increase high-quality protein and decrease fats 2 The need to increase carbohydrates to meet energy demands and prevent ketosis 3 The need to eat a low-calorie diet that maintains the current insulin coverage and helps prevent hyperglycemia 4 The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary
4 The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary
A nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. Which part of the foot is the best site to use for the puncture? 1 Big toe 2 Foot pad 3 Inner sole 4 Outer heel
4 Outer heel
Resumption of sexual intercourse may begin when?
6 weeks after delivery
Abdominal muscle tone returns & joint stabilization occurs over a ______week period after delivery.
6-8 weeks
Return of the cervix, vagina, & perineum takes how long?
6-8 weeks
in a pregnancy that an excessive amount of weight is not gained how long will it take the mother to reach pre-pregnancy weight after birth
6-8 weeks
Average BP for a newborn?
60-80/40-50
Jaundice disappears when?
7-10 days
Average newborn size?
7lbs 8oz 20 inches long head circumference 13-14 inches Chest circumference 12-13 inches
axillary temperature for newborn?
97.6-98.6 (36.4-37)
Baby's Normal body temperature ranges?
97.6° to 99°F (36.4° to 37.2°C)
What happens to cardiac output pp?
= increases slightly for about 1 hour pp and then will decline
What pulse rate is considered normal after delivery?
A pulse rate between 50 and 70 beats/min is considered
Lochia alba is?
After the 7th day, the drainage is slightly yellow to white. Continues for another 10-14 days.
Jaundice - physiologic
Appears between 72-96 hrs PP, starts on face/eyes, can extend down trunk. Refer for bili-check if extends to limbs or past umbilicus with very yellow/orange/squash look or prior with other s/sx (lethargy, difficulty nsg, not passing stool, dark urine, light/chalky stool)
Fontanelles
Areas where the infant's skull has not fused together; usually disappear at approximately 18 months of age.
Episiotomy
Asses patient and look for hemorrhoids.
PT care of umbilical area
Avoid getting cord wet, use alcohol or other substances to promote drying and inhibit microbial growth
BUBBLE-HE
BREAST, UTERUS, BLADDLER, BOWEL,LOCHIA,EPISIOTOMY, HORMAN'S SIGN, EMOTIOANL STATUS,
Pathologic jaundice
Begins in the first 24 hours and may require treatment with phototherapy
Decreased estrogen levels are associated with?
Breast engorgement & with the diuresis of excess extracellular fluid
How long can breast milk be refrigerated?
Breast milk can be safely stored in a refrigerator for 24 to 48 hours.
Transitional milk
Breastmilk produced between colostrum and mature milk, during the first 4-10 days postpartum.
Lochia rubra
Bright red, clots, 1-2 days after delivery
Strawberry birthmarks
Capillary hemangiomas. May continue to increase in size for several months. Usually disappear early in childhood
newborn assessment finding for the newborn skin color
Caucasian-pink to slightly reddish African-American; pink or yellowish brown Spanish- olive tint or a slight yellow Asian- rosy or yellowish tan American indian- light pink to dark, reddish brown
How should the cord be cared for?
Check for bleeding or oozing during early hours after birth Cord must be clamped securely with no skin caught in it Purulent drainage, edema, or redness indicates infection Maybe treated with triple-dye solution, antibiotic ointment, or alcohol 3 times a day or allowed to dry naturally. When soiled, it should be cleaned with water
Women who are not breastfeeding should do what to help with engorgement?
Cold compresses & analgesics
The first secretion of the breasts is called ?
Colostrum; milk is watery, thin, slightly yellow. Rich in protein, calories, antibodies, lymphocytes
Ophthalmia Neonatorum
Conjunctivitis of a newborn; caused by presence of Neisseria gonorrhoeae, or Chlamydia trachomatis in the birth canal, which can infect the baby during birth Treated using silver nitrate drops, or tetracycline
When does the cord fall off?
Cord becomes brownish black within 2-3 days & falls off in about 10-14 days
Sequence of events in hypovolemic shoc,
Decreased B/V Decreased Venous return Decreased stroke volume Decreased cardiac output Decrased tissue perfusion
Milia
Distended sebaceous glands which appear as tiny white spots on the baby's face. occluded sebaceous gland -> disappears on own
How is blood volume reduced to nonpregnant levels?
Diuresis Diaphoresis
Stepping (walking)
Elicit by holding the newborn upright with feet touching a flat surface. the newborn responds with stepping movement. Disappears 3-4 weeks and replaced with deliberate movement
Palmar grasp
Elicit by placing examiner's finger in palm of newborn's hand. The newborn's fingers curl around examiner's fingers. Expected age: Lessen's between 3 and 4 mths.
Plantar grasp
Elicit by placing examiners's finger at base of newborn toes. the newborn responds by curling toes downward. Expected age: birth to 8 mths.
Babinski reflex (plantar)
Elicit by stroking outer edge of sole of the foot, moving up toward toes. toes will fan upward and out. Expected age: Birth to 1 year!...
How long does it take for an episiotomy take to heal?
Episiotomy heals in approximately 3 weeks (when the lochia has stopped).
Which hormone stimulates the growth of the milk ducts to prepare for lactation?
Estrogen
How long should mother breast feed in each breast?
Feed for 10 to 15 minutes from each breast.
Where does milk accumulation begin?
Filling of the breast with milk usually begins in the axillary region, so palpate the body and the tail of the breast.
Want occurs in an ectopic pregnancy when the fallopian tube ruptures?
If the fallopian tube has ruptured, she may have vaginal bleeding, referred shoulder pain, and abdominal rigidity. The risk for hypovolemic shock is present.
A woman who gave birth to an unwanted baby may have?
Impaired bonding
Signs of psychosocial problems?
Inability or refusal to discuss labor/birth experience Refusal to interact/care for baby Refusal to attend infant care classes Refusal to discuss contraception Calls self ugly/useless Excessive preoccupation with self Marked depression Lack of support system Partner/Family reacts negatively to baby Expression of disappointment over baby gender View of baby as messy or unattractive Baby reminds mom of person she does not like
Which hormone changes breast size?
Increased amounts of estrogen
Coagulation pp
Increased levels clotting factors/fibrinogen during pregnancy remain elevated a few days after delivery to protect against hemorrhage
Aquamephyton (Vitamin K)
Indication: prevention of hemorrhagic disease in neonate. Required for hepatic synthesis of blood coagulation factors. Administered IM - 0.5 mg within the first hour of life.
You should inspect the nipples for?
Inflammation, fissures, & tenderness. Nipples should be kept soft & supple
Parent-child attachment (bonding)
Initial phase in a relationship characterized by strong attraction and a desire to interact.
When does the colostrum become milk?
Its production continues for about 2 days after delivery, when true milk production begins.
Stage 2 postpartum period
Last about 6 weeks most changes are reverse.
When can mother take pain medications when breast feeding?
May take a mild analgesic 1 hour before nursing.
A women who have experienced a molar pregnancy must avoid becoming pregnant for how long?
One year.
a newborn is jaundiced over the bony prominence of the face and mucous membranes within the first 24hrs of birth. this represents what?
Pathologic jaundice; caused by too much bile pigments called icterus neonatorum.
Test perform to newborn
Phenylketonuria (PKU) , biotinidase, thyroid
Black newborn is usually what color?
Pinkish or yellowish brown
White newborn is usually what color?
Pinkish to slightly reddish
How to clean breasts and nipples?
Plain water and air drying may prevent problems. Some physicians recommend allowing the nipples to dry after feeding without removing the milk residue. If additional moisturizer is needed, small amounts of unscented lanolin or a nipple cream may be used to soften and soothe dry, tender nipples.
let-down reflex.
Prolactin, a hormone secreted by the anterior pituitary gland, is responsible for stimulating milk production in the mammary alveolar cells. Stimulation of the nipples, particularly by the infant's sucking, causes the release of oxytocin from the posterior pituitary gland. Oxytocin stimulates contraction of the mammary ducts, and milk is ejected from the breast.
Pull to sit (Traction) Reflex
Pull infant up by the wrist from supine position with head in midline. Head lags until infant is in upright position, then head is held in the same place with chest and shoulder momentarily before falling forward; infant will attempt to right head.
What will help with engorgement of a mom who isnt breast feeding?
Put cold packs in her bra
newborn assessment finding for the newborn VS
RR- 30-60 bpm with brief periods of apnea (if>60 could have fluid in airway) P- 120-160 bpm BP- 60-80/40-50 mm Hg AxTemp- 97.6-98.6F
Administration of Rho(D) immune globulin (RhoGAM) is indicated for those women who are?
Rh negative.
Asian newborns are usually what color?
Rosy or yellowish color
diastasis recti
Separation of the longitudinal muscles of the abdomen (rectus abdominis) during pregnancy.
Desquamation
Shedding of epithelial elements; chiefly of the skin in scales or sheets
Lochia is?
Shedding of uterine lining; bloody discharge
Simean crease
Single palmar crease; seen in Downs syndrome
Epstein's pearls
Small, white blebs found along the gum margins and at the junction of the hard and soft palates; commonly seen in the newborn as a normal manifestation.
S/S of hypovolemic shock
States she feels weak, lightheaded, funny, sick to stomach, or sees stars Becomes anxious or exhibits air hunger Skin turns ashen or grayish Skin feels cool & clammy Pulse rate increases BP declines
Moro (startle) reflex
Sudden jarring or change in equilibrium causes extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a C shape, followed by flexion and adduction of extremities; legs may weakly flex; infant may cry.
Engorgement
Swelling of the breasts resulting from increased blood flow, edema, and the presence of milk.
How many sitz should the mother take after vaginal delivery?
Take sitz baths two or three times daily with vaginal delivery.
Acrocyanosis is?
Temporary cyanotic condition, usually in newborns resulting in a bluish color at the extremities. Lasts 7-10 days
Mature milk
The breastmilk after colostrum and transitional milk, typically beginning 2 weeks postpartum.
The newborn should void within how many hours of delivery?
The newborn should void within 24 hours of delivery.
How long does the puerperium last?
The puerperium lasts about 3 to 6 weeks
Milk stool
These usually appear by the fourth day. In breastfed infants, stools are yellow to golden, are pasty in consistency. Formula fed smells worse than breastfed
Murmurs are common in newborns. True or False?
True
How long can breast milk be frozen?
Two weeks
Most common infections in pregnant women ?
UTI Masitis
How to clean umbilical cord?
Use alcohol on cord stump daily. (Be careful to prevent alcohol from dripping down to perineal area.) • Keep area dry; fold diaper down with plastic side on outside to prevent moisture retention. • Sponge bathe for 7 to 10 days until umbilical cord comes off. (Do not soak in bath water.)
Pseudomenstruation
Vaginal bleeding in the newborn, resulting from withdrawal of placental hormones.
When a cesarean delivery has been performed and the use of anesthesia was used, when can the mother start eating solid foods again?
Verify the presence of bowel sounds before giving solid food.
Women who are breastfeeding should do what to help with engorgement?
Warm shower/warm packs & manual expression
Dry breasts (engorgement, fluid intake)
Wear supportive, well-fitting bra. • Avoid breast stimulation (warm showers). • Apply ice bags for 20 minutes four times a day. • Suppression of lactation takes about 5 days. • Do not drink excessive amounts of fluids (normal: six to eight 8-ounce glasses).
Tonic neck reflex( fencing)
With newborn in supine, neutral position, examiner turns newborn's head quickly to one side.. the newborn's arm and leg on that side extend and opposing arm and leg flex.
spina bifida
a congenital defect that occurs during early pregnancy when the spinal canal fails to close completely around the spinal cord to protect it
what may interfere with the complete contraction of the uterus, potentially causing hemorrhage
a full bladder (mother should void within 4-6 hrs after delivery; an indwelling cath may be used 1-2 days after a cesarean birth)
Prolactin is what?
a hormone that stimulates milk production
Mottling
a lacy pattern with dilated vessels on pale skin
when assessing the perineum after an episiotomy is performed would be
a lateral position with the upper leg toward the chest; perineum should be approximated and tissue may appear edematous
when pain in the calf when the ankle is dorsiflexed and the knee bent is know as
a positive homans sign (indicates inflammation of the blood vessels of the leg and could indicate possible thrombophlebitis
what is colostrum
a thin, watery, slightly yellow substance that is first produced in lactating mothers; rich in protein, calories, antibodies, lymphocytes and has high levels of immunoglobins; present for 2-4 days after delivery.
hip dysplasia
abnormal development of the pelvic joint causing the head of the femur and the acetabulum not to be aligned properly
microcephaly
abnormal small head.
2nd degree tear
additionally muscles of the perineum but not the rectal sphincter
what should you do to help a mother who has a 3rd degree laceration and is afraid to have a BM
administer stool softener as prescribed; encourage fluids and bulk in the diet.
when can you give a baby milk?
after 1 years
discharge instructions that should be given concerning circumcision at discharge?
apply sterile petroleum gauze after each diaper change
Mongolian spots
areas of deep bluish-gray pigmentation most commonly on the sacral aspect of a newborn
newborn assessment finding for the newborn extremities
arms and hands generally flexed against body; arms should move evenly; legs should be same length; hips move freely; hands and feet should be assessed for syndactyly/polydactyly (fused/webbed digits, too may digits)
bowel
assess for bowel sounds, encourage activity, and adequate fluid.
if a new mother had spinal anesthesia during a c-section, desires to get up and go to the bathroom to void, and can wiggle her toes, what should the nurses' response be?
assist the pt to ambulate to the bathroom
witch hazel (Tucks pads)
astringent for hemorrhoids (reduces itching)
vernix caseosa
at birth the skin is covered with a yellowish white cream cheese-like substance. It protect the newborn form the amniotic fluid.
a uterus that feels soft/boggy is termed
atonic uterus; should be massaged to increase contractility
the self ingestion that occurs in tissue/cells by enzymes in the cells themselves and contributes to involution is?
autolysis
bladder.
be alert of sigh of infection after urination . Note for dysuria or urinary retention.
Lochia rubra is?
bright red blood (first day or two). some small clots may be passed
stool of baby that is bottle fed
brown more formed
what may put a mother at risk for thrombus
cardiac output declines rapidly; d/t high platelets in early postpartum
newborn assessment finding for the newborn face
chin is receding cheeks full and round oral cavity should be intact with a closed palate Epstein's pearls may be observed (white, epithelial inclusion cysts in the midline of the palate)
what should be included in the demonstration of newborn bathing?
cleanse perineum from front to back, umbilical cord care, bath water temp, safe methods of holding and positioning, do not scrub to vigorously
first secretion produced by the breast
colostrum
Three interrelated factors of engorgement
congestion, increased vascularity, and the accumulation of breast milk
Caput succedaneum
diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days feels spongy crosses suture lines
causes of fluid loss during delivery
diuresis, diaphoresis, and blood loss in delivery
gynecomastia
either sex may have enlarged breast. it is result of maternal hormones.
sucking and rooting
elicit by stroking the cheek or edge of mouth. Newborn turns the head toward the die that is touched and starts to suck. Expected age: Usually disappears after 3 to 4 mths.
a result of venous and lymphatic stasis that happens during lactation is called
engorgement (seen about 3 days after delivery and usually resolves in about 48hrs)
what are some potential evaluations of psychosocial aspects of new parents?
engrossement (preoccupation, absorption, and interest in the infant), how they will provide, will I be a good parent, insufficient knowledge, self-perception is common for new mother. "taking in" stage may happen the first couple days and will need supportive care. Mood swings are common d/t stresses, fatigue and rapid hormonal changes. cognitive and perceptual issues; controlling pain is important i.e. episiotomy pain, cramping or if cesarean birth, the incision site. PT for care of self and newborn is important throughout the stay in the hospital.
hydrocephalus
excessive cerebral fluid within the brain cavity surrounding the brain.
newborn assessment finding for the newborn eyes
eyelids may appear edematous strabismus (cross-eyed) nystagmus (abnormal movement of the eyes) nearsightedness
newborn assessment finding for the newborn genitals
female may be edematous pseudo menstruation (in female infants) scrotum may be enlarged and edematous, indicating a hydrocele penis inspected for position of the urethral meatus
Lanugo?
fine, soft hair, especially that which covers the body and limbs of a human fetus or newborn. from 20 weeks on
newborn assessment finding for the newborn head
fontanels should be palpable may have molding caput succedaneum (localized edema on the newborn scalp) cephalohematoma (localized effusion of blood beneath the periosteum of the skull; does not cross suture line unlike cs; is firmer than edema like a water filled balloon)
lactation
function of secreting milk or period during which milk is secreated.
NI for the fundus for the first 2hrs after delivery
fundus and lochia are checked q15min; fundus should remain contracted, firm and at the midline; if not severe bleeding may occur; encourage mother to empty bladder before fundus palpation d/t bladder displacing fundus and preventing fundus from contracting.
Postpartum headaches may be caused by which various conditions?
gestational hypertension stress leakage of cerebrospinal fluid into the extradural space during placement of the needle for epidural or spinal anesthesia.
newborn assessment finding for the newborn skin appearance
good turgor and tissue elasticity
harlequin sign
half of the newborn's body appears deep red and the other half appears pale as a result of vasomotor disturbance, with some vessels constricting while others dilate.
newborn assessment finding for the newborn characteristics of body size and shape
head disproportionately large for its body the abdomen is prominent, with a smaller chest and narrow hips average weight-3400g (7lbs, 8oz) average length- 20 inches (50cm) head circumference- 13-14 inches (33-35.5cm)
What will help with engorgement of a mom who is breast feeding?
hot shower
teaching regarding breast engorgement
if breastfeeding; manual expression of milk, application of warm, moist heat (like a hot/warm shower), cabbage leaves inside the bra has been known to alleviate symptoms. If non breastfeeding; wear snug/comfortable bra for compression, wrapped ice packs and analgesics prn
How long does the fudus take to return to the pelvis?
in 10 days.
If a native American mother tells the nurse when she goes home, her mother-in-law will be caring for the baby while she rests. would this be concerning? if so, what should the nurse do?
in certain cultures it is acceptable for the mother to completely rest and let family members take care of the baby. it is important for the nurse to initiate and observe mother/baby bond while in the facility to ensure there is as much interaction as possible between mother and baby
telangienctatic nevi
in newborn skin " stork bites" are flat, pink or red marks often seen on the eyelids, nose, or nape of the neck. These are dilated capillaries that becomes more vivid when the infant cries. . they are not significant to the healthy of the infant and disappear at 1 to 2 years of age.
nevus flammeus
in newborn skin- Port wine stain- is a capillary angioma below the surface of the skin that is purple or red, varies in size and shape, is commonly seen on the face, and does not blanch or disappear.
Diuresis
increased formation and secretion of urine/fluid
newborn assessment finding for the newborn rest and sleep
infants sleep 16-20hrs/day usually time awake is spent crying, eating or in quiet alertness most infants do not exceed 5hrs of sleep for some months; can disrupt the mother's need for sleep
mastitis
inflammation of the breast; most commonly occurs in women who are breastfeeding
uterus
inspect top of uterus, the fundus. if not firm, muscle are not contracting and or has placental fragment. predispose for hemorrhage. Gently massage the uterus.
3rd degree tear
into the rectal sphincter
term for a postpartum uterus' return to a pregravid state
involution
Cephalohematoma
is a collection of blood between the peritoneum and the skull bone that it covers. It does not cross the suture line. It results from trauma during birth such as pressure of the fetal head again the maternal pelvis in a prolonged difficult labor or forceps delivery. It appears in the first 1 to 2 days after birth and resolve in 2 to 3 weeks.
What causes autolysis to occur after birth?
is a result of the sudden withdrawal of estrogen and progesterone, which releases proteolytic enzymes into the endometrium.
Tolbutamide
is an oral hypoglycemic agent used in the treatment of type 2 diabetes mellitus. It is known to have teratogenic effects like neonatal hypoglycemia.
What's the color of lochia the first three days after delivery?
is dark red
PT care of the circumcision;
keep clean/assess for bleeding, sterile petroleum gauze may be applied to the penis after diaper change/baths.
Native American newborns are usually what color?
light pink to a dark, reddish brown. Depends on tribe
vaginal discharge that occurs immediately following delivery
lochia
yellow/whitish discharge that may continue 7 days to 2 weeks after birth is
lochia alba
bright red discharge during 1-3 days after birth
lochia rubra
pink/brown discharge after birth that lasts up to 7 days is
lochia serosa
Ileus
loss of peristalsis with resulting obstruction of the intestines
metabolic issues of newborn; hypothermia
maint of body temp is critical for newborn care large surface area of newborn and limited amount of adipose tissue can contribute to low body temps. heat is lost through RADIATION; heat loss d/t transfer from body to cooler surfaces/objects not in contact with body (NI; keep infant wrapped; work quickly to avoid exposure; use radiant warmer, locate crib away from outside wall) EVAPORATION: loss when water is converted to vapor (NI; dry infant thoroughly after bath_ CONDUCTION: loss of heat to cooler surface via direct skin contact (NI; pad surfaces under infant, warm other equipment I.e. stethoscope before use) CONVECTION: loss of heat to cooler air currents (NI; reduce drafter from open doors, window, or air conditioner; wrap newborn to protect from cold)
newborn assessment finding for the newborn activity and exercise
maintaining a clear airway is critical to the newborn; may need to suction to remove mucus from nose and mouth infants are obligate nose breathers and the nasal passageway must be kept open and free of mucus (use blue bulb prn) crying is the only means of communication for the infant; indicates hunger, pain or simply the need for attention
observed mom and infant interactions which indicate bonding
makes eye contact and talks with infant; cuddles with infant; says infants name when speaking to or about infant; interactive with the care of the infant
polydactyly
malformation of digits, commonly seen as webbing or fusion of two or more digits to form extra digits
syndactyly
malformation of digits, commonly seen as webbing or fusion of two or more digits to form one structure.
first stool is called
meconium
where should the fundus be located right after birth
midway between the umbilicus and symphysis pubis
plan of acre for a newly circumcised infant would include?
monitor for bleeding during the first 12hrs
the normal reflex that is seen in newborns who jerk around when their position is changed
moro reflex; ext and abduction of extremities and fanning of fingers, with index finger and thumb forming a c shape, followed by flexion and adduction of extremities, legs may weakly flex and infant may cry
test that detects inborn errors of metabolism in newborns
newborn screening test, PKU, phenylketonuria
what is the purpose for the administration of vit k to the newborn?
newborns are not able to synthesize vit k in the colon until they have adequate intestinal flora
what diet should a lactating/nonlactating mother maintain
nonlactating mothers should maintain a pre-pregnancy diet. lactating mothers should increase 300-500 ca;/day and 2-3L of fluids/day is recommended for lactating mother to maintain an adequate diet for breastfeeding
during the immediate postpartum period, mom has a temp of 100.2F, pulse of 52, RR of 18 and BP of 138/84. What should the nurse do? is this normal?
normal but fever should not persist for more than 2 consecutive days
know how to measure lochia discharge
observable on pad: scant is about an 1 inch stain light is 1-4 inch stain moderate is about 4-6 inch stain heavy is saturated in 1 hour
When is jaundice considered pathologic?
occurs sooner than 48 hours after birth
used after delivery of the placenta to contract and compress blood vessels of the uterus where the placenta separated from the wall?
ocytocin
Spanish newborns are usually what color?
olive tint or slight yellow cast
Which hormone causes the uterus to contract?
oxytocin
Homans' sign
pain in the calf which indicates inflammation of the blood vessels of the leg and possible thrombophlebitis.
Telangiectatic nevi (stork bites)
pale pink or red spots; frequently found on the eyelids, nose, or nape of the neck. Usually fade by the second birthday.
normal characteristics of a breastfed infants stools
pale, yellowish and sweet smelling, sometimes with small curds in it
BREAST
palpate for engorgement or nodules. Inspect nipples for pressure, soreness, cracks, or fissures
assessment for parent-child attachment
parent should have a strong attraction; a desire to interact with infant if bonding doesn't occur it would be difficult to maintain energy required to meet newborn's needs early contact is important to establish bonding nurse should encourage early and frequent interaction between baby and parent.
1st degree tear
perineal skin vaginal mucus membrane without muscle involvement
normal findings in the newborn during initial assessment?
persistant high pitched cry
What kind of gauze is used to for circumcision?
petroleum gel gauze
erythema toxicum
pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks. elevated hive-like rash may result white vesicles -> not contagious, no tx, resolves on own
What color is the lochia after 4 or 5 days after delivery?
pinkish brown.
Mummification
producing a dry, hard mass
uterine involution increases
proteinuria
measures to help prevent infant abduction
recognize facility id badges do not give infant to anyone not wearing this badge respond to electronic sensor alarm never leave the infant unattended
the hormone that "relaxes hip and joints to prepare the body for birth
relaxin
Nutritional needs of the newborn
requires approx. 120 cal/kg/day breast milk and formulas are balanced for newborn needs fluid need; 140-160 mL/kg/day frequency of feeding depends on type of feeding: breastfed babies may tend to eat more frequently that formula fed newborns d/t the fluctuation of lactation or factors that may affect breast feeding.
NI for the postpartum mother
risk for deficient fluid volume risk for infection impaired urinary elimination constipation nutrition; less than the body requires nutrition; more than the body requires pain, acute impaired tissue integrity disturbed sleep pattern deficient knowledge anxiety risk for impaired parenting interrupted family processes impaired parenting situation low self esteem
newborn assessment finding for the newborn reflexes
rooting sucking gag swallow blink burp hiccup sneeze moro reflex aka startle reflex
How long does it take for a mother to return to prepregnate weight?
she usually returns to her prepregnant weight in 6 to 8 weeks without significant dietary restrictions.
newborn assessment finding for the newborn elimination:
should void within 24 hrs; usually voids small amounts of poorly concentrated urine (as fluid intake increases, kidney function improves, urination becomes more frequent) bm within 24 hours; odorless, black-green color, sticky (meconium) initially; when infant begins to taking nourishment the stool changes to greenish and loose. or breastfed babies tend to pass stool frequently; pale yellow and sweet-smelling sometimes with curds.
newborn assessment finding that can suggest a chromosomal disorder
simian crease (of hand); (also low set ears can be indicative of chromosomal abnormalities)
can reduce discomfort and promote healing of the perineum
sitz bath
normal findings in a 1-day postpartum pt?
slightly elevated temp up to 100.4F, light to moderate discharge of lochia rubra, perineum tenderness, constipation, tender/sore/engorged breasts, but fever should not persist for more than 2 consecutive days. (indicative of puerperal infection)
Lochia alba
slightly yellow to white This drainage continues for another 10 days to 2 weeks.
newborn assessment finding for the newborn spine
straight w/o curves
what NI should be carried out immediately following the delivery of a newborn?
suction the nose and mouth for airway patency
Circumcision
surgical removal of the foreskin
appropriate suggestions for quieting a fussy newborn
swaddle; prewarm crib sheets; suckle breast/pacifier; movement such as a car ride/stroller/carriage/rocking or cradle; skin to skin contact; soothingly talking with infant; or infant may need stimulation like repositioning or bring into the room with the rest of the family
which reflex should be assessed before allowing the initial feeding of an infant?
swallow reflex
Rubin's Restorative Phases
taking in, taking hold, letting go
bonding
the itnitial phase in a relationship characterized by strong attraction and a desire to interact.
meconium
the newborn initial stools are odorless, black-green, and sticky. It is made of vernix, strands of lanugo, mucus, and other substances form the amniotic fluid.
involution
the pelvic decrease size to the non pregnant size of 2 ounces.
Lochia
the postpartum vaginal discharge that typically continues for 4-6 weeks after childbirth
diaphoresis
the secretion of sweat, especially when profuse, cold sweat, circulation has started to decrease
autolysis
the self dissolution or self-digestion that occurs in tissue or cells by enzymes in the cells themselves. is the results of withdrawn of estrogen and progesterone, which release proteolytic enzymes into the endometrium.
puerperium
the stage that lasts from the time of placenta delivery to when reproductive organs return to nonpregnant size and position
cryptorchidism
the testicles are normally descended in term infants. in preterm infants they may not be descended.
Where is the uterine fundus after delivery?
the uterine fundus is about midway between the umbilicus and the symphysis pubis or slightly higher. Should decend 1 cm per day.
When is Rhogam administered?
they must receive RhoGAM within 72 hours of delivery.
transitional stool
thin, brown to green
what should a nurse encourage the mother to do to prevent contamination/infection
thorough handwashing and perineal care with a squirt bottle after voiding and defacating.
4th degree tear
through the sphincter and into rectal mucosa
latch-on
to grip; to fasten onto
12 hours post delivery, where would you expect to palpate the fundus?
umbilicus
newborn assessment finding for the newborn ears
upper insertion of the pinna should be even with theouter canthus of the eye
appropriate way to assess the fundus of the postpartum pt
use one hand on the lower uterine segment and the other hand to palpate the fundus for size and position
NI and assessment for the newborn
verify and identify security bracelets to parent PT handwashing for before infant care PT safety practices to reduce injury to infant state laws require certain diagnostic tests on newborns (PKU) aka newborn screening
what are the NI for a mother during the recovery stage (1-4hrs after placenta delivery)
vs should be monitored q15min for the first 2hours (vs should stabilize during the first 2 hours)
what is vernix caseosa and its purpose?
white cream-like substance that is on the surface of the infant to protect in the environment within the amniotic fluid
newborn assessment finding for the newborn umbilical cord
whitish blue-gray with 3 vessels (two arteries, 1 vein) contain a gelatinous tissue called whartons jelly (gives structure and prevents vessels from injury) if little to no whartons jelly could signal congenital abnormalities
pre-pregnant blood level with return to normal within
within 2-4 weeks
Vital signs normally stabilize within how many hours after delivery?
within the first 2 hours after delivery
color of baby stool when breast fed ?
yellow colored, more often
within the 1st hour following a vag delivery, you find the fundus is firm and there is a trickle of bright red blood. is this normal?
yes, lochia rubra can last 1-2 days postpartum
Nutrition (Nursing, Dieting)
• Continue prenatal vitamins until gone. • Nursing: need 500 kcal more than prepregnant diet; need increased protein, 400 mg calcium each day, 8 to 10 glasses of fluid each day; avoid onions, cabbage, chocolate, spices, and foods that may distress infant; no dieting during breast-feeding.
Emotions (Bonding, "Baby Blues")
• Mother may be tearful or anorexic and have difficulty sleeping. • Hormonal factors and fatigue are often responsible. • Notify primary care practitioner if prolonged, increased, or unmanageable.
Hypovolemic Shock Nursing Intervention
• Notify primary health care provider. • If uterus is atonic, massage gently and expel clots to cause uterus to contract; compress uterus manually, as needed, with two hands. Add oxytocic agent to IV drip, as ordered. • Give oxygen via face mask or nasal prongs at 8 to 10 L/min. • Tilt the woman to her side or elevate the right hip; elevate her legs to at least a 30-degree angle. • Provide additional or maintain existing IV infusion of lactated Ringer's solution or normal saline solution to restore circulatory volume. • Administer blood or blood products, as ordered. • Monitor vital signs. • Insert an indwelling urinary catheter to monitor perfusion of kidneys. • Administer emergency drugs, as ordered. • Prepare for possible surgery or other emergency treatments or procedures. • Chart incident, medical and nursing interventions instituted, and results of treatments.
Hypovolemic Shock symptoms after birth
• Woman has persistent significant bleeding (perineal pad soaked within 15 minutes); this bleeding may not be accompanied by a change in vital signs or maternal color or behavior. • Woman states she feels weak, lightheaded, "funny," or "sick to my stomach" or she "sees stars." • Woman begins to act anxious or exhibits air hunger. • Skin turns ashen or grayish. • Skin feels cool and clammy. • Pulse rate increases. • Blood pressure declines.
Hygiene post partume?
▪Excessive perspiration normal ▪Lochia has musty odor ▪Encourage bathing ▪May have vertigo (due to vascular fluid shift) -> supervise 1st shower ▪No baths x 6 weeks ▪Sitz baths encouraged if available