maternity

Torch infections

*Toxoplasmosis is caused by consumption of raw or undercooked meat or handling cat feces. The symptoms are similar to influenza or lymphadenopathy. Other infections can include hepatitis A and B, syphilis, mumps, parvovirus B19, and varicella-zoster. These are some of the 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 mothers who had rubella during pregnancy. ●Cytomegalovirus (member of herpes virus family) is transmitted by droplet infection from person to person, a virus found in semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. Latent virus may be reactivated and cause disease to the fetus in utero or during passage through the birth canal. ●The herpes simplex virus (HSV) is spread by direct contact with oral or genital lesions. Transmission to the fetus is greatest during vaginal birth if the woman has active lesions. Subjective Data ◯Toxoplasmosis findings similar to influenza or lymphadenopathy ◯Malaise, muscle aches, (flulike symptoms) ◯Rubella joint and muscle pain ◯Cytomegalovirus has asymptomatic or mononucleosis-like manifestations ●Objective Data ◯Physical assessment findings ■Manifestations of toxoplasmosis include fever and tender lymph nodes. ■Manifestations of rubella include rash, mild lymphedema, fever, and fetal consequences, which include miscarriage, congenital anomalies, and death. ■Herpes simplex virus initially presents with lesions and tender lymph nodes. Fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction. ◯Laboratory Tests ■For herpes simplex, obtain cultures from women who have HSV or are at or near term. ◯Diagnostic Procedures ■A TORCH screen is an immunologic survey that is used to identify the existence of these infections in the mother (to identify fetal risks) or in her newborn (detection of antibodies against infections). ■Prenatal screenings Client Education ■For rubella, vaccination of women who are pregnant is contraindicated because rubella infection may develop. These women should avoid crowds of young children. Women with low titers prior to pregnancy should receive immunizations. ■Because no treatment for cytomegalovirus exists, tell the client to prevent exposure by frequent hand hygiene before eating, and avoiding crowds of young children. ■Emphasize to the client the importance of compliance with prescribed treatment. ■Provide client with emotional support.

cord care

Cord Care ◯Before discharge, the cord clamp is removed. ◯Prevent cord infection by keeping the cord dry, and keep the top of the diaper folded underneath it. ◯Sponge baths are given until the cord falls off, which occurs around 10 to 14 days after birth. Tub bathing and submersion can follow. ◯Cord infection (complication of improper cord care) can result if the cord is not kept clean and dry. ■Monitor for symptoms of a cord that is moist and red, has a foul odor, or has purulent drainage. ■Notify the provider immediately if findings of cord infection are present.

Cephalohematoma

is a collection of blood between the periosteum 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 against the maternal pelvis in a prolonged difficult labor or forceps delivery. It appears in the first 1 to 2 days after birth and resolves in 2 to 3 weeks.

candida albicans

A fungal infection caused by Candida albicans. Risk Factors ●Diabetes mellitus ●Oral contraceptives ●Recent antibiotic treatment Subjective Data ◯Vulvar itching ●Objective Data ◯Physical Assessment Findings ■Thick, creamy, white vaginal discharge ■Vulvar redness ■White patches on vaginal walls ■Gray-white patches on the tongue and gums (neonate) ◯Laboratory Tests ■Wet prep ◯Diagnostic Procedures ■Potassium hydroxide (KOH) prep ■Presence of hyphae and pseudohyphae indicates positive findings. ●Nursing Care ◯Medications ■Fluconazole (Diflucan) ☐Antifungal agent ☐Fungicidal action ☐Over-the-counter treatments, such as clotrimazole (Monistat), are available to treat candidiasis. However, it is important for the provider to diagnosis candidiasis initially. ●Health Promotion and Disease Prevention ◯Client Education ■Instruct the client to avoid tight-fitting clothing. ■Instruct the client to wear cotton-lined underpants. ■Instruct the client to limit wearing damp clothing. ■Instruct the client to void before and after intercourse and avoid douching. ■Instruct the client to increase dietary intake of yogurt with active cultures

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. ■Prepare for actions to prevent respiratory or cardiac arrest. Discharge instructions ■Maintain the client on bed rest, and encourage side-lying position. ■Promote diversional activities. ■Have the client avoid foods that are high in sodium. ■Have the client avoid alcohol and limit caffeine. ■Instruct the client to increase her fluid intake to 8 glasses/day. ■Maintain a dark quiet environment to avoid stimuli that may precipitate a seizure. ■Maintain a patent airway in the event of a seizure. ■Administer antihypertensive medications as prescribed.

Acute and chronic gastritisursing Interventions .

Acute gastritis occurs with excessive use of NSAIDs, bile reflux, ingestion of a strong acid or alkali substance, as a complication of radiation therapy, or as a complication of trauma (burns; food poisoning; severe infection; liver, kidney, or respiratory failure; major surgery). Chronic gastritis occurs in the presence of ulcers (benign or malignant), Helicobacter pylori, autoimmune disorders (pernicious anemia), poor diet (excessive caffeine, excessive alcohol intake), medications (alendronate [Fosamax], perindopril [Aceon]), and reflux of pancreatic secretions and bile into stomach. Clinical manifestations include abdominal pain or discomfort (may be relieved by eating), headache, lassitude, nausea, anorexia, hiccupping (lasting a few hours to days), heartburn after eating, belching, sour taste in mouth, vomiting, bleeding, and hematemesis (vomiting of blood) nursing Interventions ■Suggest that the client avoid eating frequent meals and snacks, as they promote increased gastric acid secretion. ■Tell the client to avoid alcohol, cigarette smoking, aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), coffee, black pepper, spicy foods, and caffeine. ■Monitor the client for vitamin deficiency, especially of vitamin B12.

Vitamin K (Aquamephyton)

Administered to prevent hemorrhagic disorders. Vitamin K is not produced in the gastrointestinal tract of the newborn until around day 8. Vitamin K is produced in the colon by bacteria that forms once formula or breast milk is introduced into the gut of the newborn. ■Nursing Considerations and Client Education ☐Administer 0.5 to 1 mg intramuscularly into the vastus lateralis (where muscle development is adequate) within 1 hr after birth.

aMNioiNfusioN

An amnioinfusion of 0.9% sodium chloride or lactated Ringer's solution, as prescribed, is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. The instillation will reduce the severity of variable decelerations caused by cord compression. ●Indications ◯Potential diagnoses ■Oligohydramnios (scant amount or absence of amniotic fluid) caused by any of the following: ☐Uteroplacental insufficiency ☐Premature rupture of membranes ☐Postmaturity of the fetus ■Fetal cord compression secondary to: ☐Postmaturity of fetus (macrosomic, large body), which places the fetus at risk for variable deceleration from cord compression Nursing Actions Interventions ■Assist with the amniotomy if membranes have not already ruptured. Membranes must have ruptured to perform an amnioinfusion. ■Warm fluid using a blood warmer prior to infusion. ■Perform nursing measures to maintain comfort and dryness because the infused fluid will leak continuously. ■Monitor the 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 the client's uterine contractions. ■Continually monitor FHR. ■Monitor fluid output from vagina to prevent uterine overdistention.

aMNiotoMy

An amniotomy is the artificial rupture of the amniotic membranes (AROM) by the provider using an Amnihook or other sharp instrument. ◯Labor typically begins within 12 hr after the membranes rupture. ◯The client is at an increased risk for cord prolapse or infection. Indications ◯Labor progression is too slow and augmentation or induction of labor is indicated. ◯An amnioinfusion is indicated for cord compression. ●Nursing Actions ◯Ongoing care ■Ensure that the presenting part of the fetus is engaged prior to an amniotomy to prevent cord prolapse. ■Monitor FHR prior to and 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 the time of rupture. ■Obtain temperature every 2 hr.

newborn bathing

Bathing ◯After the initial bath, the newborn's face, diaper area, and skin folds are cleansed daily. Complete bathing is performed 2 to 3 times a week using a mild soap that does not contain hexachlorophene. ◯Bathing by immersion is not done until the newborn's umbilical cord has fallen off and the circumcision has healed on males. Wash the area around the cord, taking care not to get the cord wet. Move from the cleanest to dirtiest part of the newborn's body, beginning with his eyes, face, and head; proceed to the chest, arms, and legs; and wash the groin area last. ◯Teach the parents proper newborn bathing techniques by a demonstration. Have the parents return the demonstration. ◯Bathing should take place at the convenience of the parents, but not immediately after feeding to prevent spitting up and vomiting. ◯Organize all equipment so that the newborn is not left unattended. Never leave the newborn alone in the tub or sink. ◯Make sure the hot water heater is set at 49° C (120.2° F) or less. The room should be warm, and the bath water should be 36.6° to 37.2° C (98° to 99° F). Test the water for comfort on inner wrist prior to bathing the newborn. ◯Avoid drafts or chilling of the newborn. Expose only the body part being bathed, and dry the newborn thoroughly to prevent chilling and heat loss. ◯The newborn's eyes should be cleaned using a clean portion of the wash cloth. Clear water should be used to clean each eye, moving from the inner to the outer canthus. ◯Each area of the newborn's body should be washed, rinsed, and dried, with no soap left on the skin. ◯Wrap the newborn in a towel, and swaddle him in a football hold to shampoo his head. Rinse shampoo from the newborn's head, and dry to avoid chilling. ◯In male newborns, to cleanse an uncircumcised penis, wash with soap and water and rinse the penis. The foreskin should not be forced back or constriction may result. ◯In female newborns, wash the vulva by wiping from front to back to prevent contamination of the vagina or urethra from rectal bacteria. ◯Do not use lotions, oils, or powders, because they can alter a newborn's skin and provide a medium for bacterial growth or cause an allergic reaction. Powder should be avoided because it can cause respiratory problems if inhaled by the newborn.

HELLP syndrome

is a variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory 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/mm3), resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly disseminated intravascular coagulopathy (DIC)

Caput succedaneum

localized swelling of the soft tissues of the scalp caused by pressure on the head during labor) is an expected finding that may be palpated as a soft edematous mass and may cross over the suture line. Caput succedaneum usually resolves in 3 to 4 days and does not require treatment.

basaL body tEmpEratUrE (bbt)

›Temperature can drop slightly at the time of ovulation. This can be used to facilitate conception, or be used as a natural contraceptive. ›A woman is instructed to measure oral temperature prior to getting out of bed each morning to monitor ovulation.

newborn nutrition

Breastfeeding is the optimal source of nutrition for newborns. Breastfeeding is recommended exclusively for the first 6 months of age by the American Academy of Pediatrics. Newborns should be breastfed every 2 to 3 hr. Parents should awaken the newborn to feed at least every 3 hr during the day and at least every 4 hr during the night until the newborn is feeding well and gaining weight adequately. Breastfeeding should occur 8 to 12 times within a 24-hr window. Then, a feed-on-demand schedule may be followed. ●Colostrum is secreted from the mother's breasts during postpartum days 1 to 3. It contains the IgA immunoglobulin that provides passive immunity to the newborn. ●Nursing interventions can help a new mother be successful in breastfeeding. This includes the provision of adequate calories and fluids to support breastfeeding. The practice of rooming-in, allowing mothers and newborns to remain together, should be encouraged as part of baby-friendly initiatives. Lactation consultants can improve the mother's efforts and success in breastfeeding. ●Advantages of breastfeeding - Parents should be presented with factual information about the nutritional and immunological needs of their newborn. The nurse should present information about both breastfeeding and bottle feeding in a nonjudgmental manner. The optimal time to provide newborn nutritional information is during pregnancy, so that the parents make a decision prior to hospital admission

car seat safety

Car Seat Safety ◯Use an approved rear-facing car seat in the back seat, preferably in the middle, (away from air bags and side impact) to transport the newborn. Keep infants in rear-facing car seats until age 2 or until the child reaches the maximum height and weight for the seat. Do not use a used or secondhand car seat.

ChlaMydia

Chlamydia is a bacterial infection caused by Chlamydia trachomatis. It is the most common STI. The infection is often difficult to diagnose because it is typically asymptomatic. According to current guidelines from the Centers for Disease Control and Prevention, all women and adolescents ages 20 to 25 who are sexually active should be screened for STIs Subjective Data ◯Vaginal spotting ◯Vulvar itching ◯Postcoital bleeding and dysuria ●Objective Data ◯Physical Assessment Findings ■White, watery vaginal discharge ◯Laboratory Tests ■Endocervical culture Nursing Care ◯Instruct the client to take the entire prescription as prescribed. ◯Identify and treat all sexual partners. ◯Clients who are pregnant should be retested 3 weeks after completing the prescribed regimen. ●Medications ◯Azithromycin (Zithromax) and amoxicillin (Amoxil) are prescribed during pregnancy. ■Broad-spectrum antibiotic ■Bactericidal action ■Nursing Care ☐Administer erythromycin (Romycin) to all infants following delivery. This is the medication of choice for ophthalmia neonatorum. This antibiotic is both bacteriostatic and bactericidal, thus it provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis. ■Client Education ☐Instruct the client to take all prescriptions as prescribed. ☐Educate the client about the possibility of decreasing effectiveness of oral contraceptives.

Cholecystitis

Cholecystitis is characterized by inflammation of the gallbladder. Clinical manifestations include pain, tenderness, and rigidity in upper right abdomen. Pain can radiate to the right shoulder or midsternal area. Nausea, vomiting, and anorexia also can occur. If the gallbladder becomes filled with pus or becomes gangrenous, perforation can result. ◯Fat intake should be limited to reduce stimulation of the gallbladder ◯Other foods that may cause problems include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods. ◯The diet is individualized to the client's needs and tolerance. ◯Diet modifications are not necessary for healthy people with asymptomatic gallstones.

Circumcision Care

Circumcision is the surgical removal of the foreskin of the penis. ■Circumcision is a personal choice made by the newborn's family for reasons of hygiene, religious conviction (Jewish male on eighth day after birth), tradition, culture, or social norms. Parents should make a well-informed decision in consultation with the provider. ■Contraindications for circumcision include newborns born with hypospadias (abnormal positioning of urethra on ventral undersurface of the penis) and epispadias (urethral canal terminates on dorsum of penis) because the prepuce skin may be needed for surgical repair of the defect. Familiar history of bleeding disorders is also a contraindication. ■Circumcision should not be done immediately following birth because the newborn's level of vitamin K is at a low point, and the newborn would be at risk for hemorrhage. ■Advocates of circumcision state that circumcision promotes a penis with clean glans, minimizes the risk of phimosis later in life, and reduces the risk of penile cancer and cervical cancer in sexual partners. ◯Diagnostic and therapeutic procedures and management ■Anesthesia is required for circumcision. Types of anesthesia include a ring block, dorsal-penile nerve block, and topical anesthetic (eutectic mixture of local anesthetics). Oral sucrose, oral acetaminophen, and nonpharmacologic methods, such as swaddling and nonnutritive sucking, may be employed prior to the procedure. ■Surgical methods for removing the foreskin include the Yellen, Mogen, and Gomco clamps, and Plastibell. ☐The provider applies the Yellen, Mogen, or Gomco clamp to the penis, loosens the foreskin, and inserts the cone under the foreskin to provide a cutting surface for removal of the foreskin and to protect the penis. The wound is covered with sterile petroleum gauze to prevent infection and control bleeding. ☐The provider slides the Plastibell device between the foreskin and the glans of the penis. The provider ties a suture tightly around the foreskin at the coronal edge of the glans. This applies pressure as the excess foreskin is removed from the penis. After 5 to 7 days, the Plastibell drops off, leaving a clean, healed excision. No petroleum is used for circumcision with the Plastibell. ◯ Nursing assessments ■Preprocedure - The newborn should be assessed for: ☐A history of bleeding tendencies in the family (hemophilia and clotting disorders). ☐Hypospadias or epispadias. ☐Ambiguous genitalia (when the newborn has genitalia that may include both male and female characteristics). ☐Illness or infection. ■Postprocedure - The newborn should be assessed for: ☐Bleeding every 15 min for the first hour and then every hour for at least 12 hr. ☐The first voiding. Postprocedure parent teaching ■Teach the parents to keep the area clean. Change the newborn's diaper at least every 4 hr, and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. ■Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. ■A tub bath should not be given until the circumcision is healed. Until then, warm water should be trickled gently over the penis. ■Notify the provider if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the newborn. ■Tell the parents that a film of yellowish mucus may form over the glans by day 2 and it is important not to wash it off. ■Teach the parents to avoid using premoistened towelettes to clean the penis because they contain alcohol. ■Inform the parents that the newborn may be fussy or may sleep for several hours after the circumcision. Provide comfort measures for 24 to 48 hr, to include acetaminophen (Tylenol) as prescribed. ■Inform the parents that the circumcision will heal completely within a couple of weeks

thermoregulation

Conduction - Loss of body heat resulting from direct contact with a cooler surface. Preheat a radiant warmer, warm a stethoscope and other instruments, and pad a scale before weighing the newborn. The newborn should be placed directly on the mother's abdomen and covered with a warm blanket. X Convection - Flow of heat from the body surface to cooler environmental air. Place the bassinet out of the direct line of a fan or air conditioning vent, swaddle the newborn in a blanket, and keep the head covered. Any procedure done with the newborn uncovered should be performed under a radiant heat source. X Evaporation - Loss of heat as surface liquid is converted to vapor. Gently rub the newborn dry with a warm sterile blanket (adhering to standard precautions) immediately after delivery. If thermoregulation is unstable, postpone the initial bath until the newborn's skin temperature is 36.5° C (97.7° F). When bathing, expose only one body part at a time, washing and drying thoroughly. X Radiation - Loss of heat from the body surface to a cooler solid surface that is close to, but not in direct contact. Keep the newborn and examining tables away from windows and air conditioners.

hyPeReMesis gRaviDaRuM

Hyperemesis gravidarum is excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks of gestation and results in a 5% weight loss from prepregnancy weight, electrolyte imbalance, acetonuria, and ketosis. Discharge instructions ■Advance the client to clear liquids after 24 hr if no vomiting. ■Advance the 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, or if vomiting returns, enteral nutrition per feeding tube or total parental nutrition (TPN) may be considered.

CesaReaN biRth

Indications ◯Potential diagnoses ■Malpresentation, particularly breech presentation ■Cephalopelvic disproportion ■Fetal distress ■Placental abnormalities ☐Placenta previa ☐Abruptio placenta ■High‑risk pregnancy ☐Positive HIV status ☐Hypertensive disorders such as preeclampsia and eclampsia ☐Diabetes mellitus ☐Active genital herpes lesions ■Previous cesarean birth ■Dystocia ■Multiple gestations ■Umbilical cord prolapse

laRge foR gestatioNal age NewboRN (lga)/MacRosoMic

Large for gestational age (LGA) occurs in neonates who weigh above the 90th percentile or more than 4,000 g (8 lb, 12 oz). ●Neonates who are LGA may be preterm, postterm, or full-term. LGA does not necessarily mean postmature. ●Newborns who are macrosomic are at risk for birth injuries (shoulder dystocia, clavicle fracture or a cesarean birth, 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 the most common being congenital heart defects, tracheoesophageal fistula, and CNS anomalies.

Erythromycin (Romycin)

Prophylactic eye care is the mandatory instillation of antibiotic ointment into the eyes to prevent ophthalmia neonatorum. Infections can be transmitted during descent through the birth canal. Ophthalmia neonatorum is caused by Neisseria gonorrhoeae or Chlamydia trachomatis and can cause blindness.

lochia

Three stages of lochia ■Lochia rubra - bright red color, bloody consistency, fleshy odor, may contain small clots, transient flow increases during breastfeeding and upon rising. Lasts 1 to 3 days after delivery. ■Lochia serosa - pinkish brown color and serosanguineous consistency. Lasts from approximately day 4 to day 10 after delivery. ■Lochia alba - yellowish, white creamy color, fleshy odor. Lasts from approximately day 11 up to and beyond 6 weeks postpartum. ◯Lochia amount is assessed by the quantity of saturation on the perineal pad as being either: ■Scant (less than 2.5 cm) ■Light (less than 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 for pooled lochia on the pad under the client, which may not be felt by the client. Massaging the uterus or ambulation may result in a gush of lochia with the expression of clots and dark blood that has pooled in the vagina, but should soon decrease back to a trickle of bright red lochia when in the early puerperium.

Heel stick blood samples

Warm the newborn's heel first to increase circulation. ■Cleanse the area with an appropriate antiseptic, and allow for drying. ■A spring-activated lancet is used so that the skin incision is made quickly and painlessly. ■The outer aspect of the 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 the lancet. ■Follow facility protocol for specimen collection, equipment to be used, and labeling of specimens. ■Apply pressure with dry gauze (do not use alcohol because it will cause bleeding to continue) until bleeding stops, and cover with an adhesive bandage. ■Cuddle and comfort the newborn when the procedure is completed to reassure the newborn and promote feelings of safety.

Assess for behaviors that impair and indicate a lack of mother-infant bonding

■Apathy when the infant cries. ■Disgust when the infant voids, stools, or spits up. ■Expresses disappointment in the infant. ■Turns away from the infant. ■Does not seek close physical proximity to the infant. ■Does not talk about the infant's unique features. ■Handles the infant roughly. ■Ignores the infant entirely. ◯Assess for signs of mood swings, conflict about maternal role, and/or personal insecurity. ■Feelings of being "down." ■Feelings of inadequacy. ■Feelings of anxiety related to ineffective breastfeeding. ■Emotional lability with frequent crying. ■Flat affect and being withdrawn. ■Feeling unable to care for the infant.

VaCuuM-assisted deliVeRy

Description of Procedure ◯A vacuum‑assisted birth involves the use of a cuplike suction device that is attached to the fetal head. Traction is applied during contractions to assist in the descent and birth of the head, after which, the vacuum cup is released and removed preceding delivery of the fetal body. ◯Recommendations by the manufacturer should be followed for product use to ensure safety. ◯Conditions for use of a vacuum‑assisted birth ■Vertex presentation ■Absence of cephalopelvic disproportion ■Ruptured membranes ◯Risks associated with vacuum‑assisted births ■Scalp lacerations ■Subdural hematoma of the neonate ■Cephalohematoma ■Maternal lacerations to the cervix, vagina, or perineum ●Indications ◯Maternal exhaustion and ineffective pushing efforts ◯Fetal distress during second stage of labor Nursing Actions ◯Preparation of the client ■Provide the client and her partner with support and education regarding the procedure. ■Assist the client into the lithotomy position to allow for sufficient traction of the vacuum cup when it is applied to the fetal head. ■Assess and record FHR before and during vacuum assistance. ■Assess for bladder distention, and catheterize if necessary. ◯Ongoing care ■Prepare for a forceps‑assisted birth if a vacuum‑assisted birth is not successful. ◯Interventions ■Alert postpartum care providers that vacuum assistance was used. ■Observe the neonate for lacerations, cephalohematomas, or subdural hematomas after delivery. ■Check the neonate for caput succedaneum. Caput succedaneum is a normal occurrence and should resolve within 24 hr.

Coagulopathies (iDiopathiC thRoMboCytopeNiC puRpuRa aND DisseMiNateD iNtRaVasCulaR CoagulatioN)

Disseminated intravascular coagulation (DIC) is a coagulopathy in which clotting and anticlotting mechanisms occur at the same time. Objective Data ◯Physical assessment findings ■Unusual spontaneous bleeding from the client's gums and nose (epistaxis) ■Oozing, trickling, or flow of blood from incision, lacerations, or episiotomy ■Petechiae and ecchymoses ■Excessive bleeding from venipuncture, injection sites, or slight traumas ■Tachycardia, hypotension, and diaphoresis ■Oliguria ●Laboratory Tests ◯CBC with differential ◯Blood typing and crossmatch ◯Clotting factors ■Platelet levels (thrombocytopenia) ■Fibrinogen levels (decreased) ■PT (increased) ■Fibrin split product levels (increased) Nursing assessments for ITP and DIC ■Skin, venipuncture, injection sites, lacerations, and episiotomy for bleeding. ■Vital signs and hemodynamic status. ■Urinary output usually by insertion of an indwelling urinary catheter. ■Transfuse platelets. ■Assist in preparing the client for a splenectomy if ITP does not respond to medical management and provide postsurgical care. ■Nursing interventions for DIC focus on assessing for and correcting the underlying cause (removal of dead fetus or placental abruption, treatment of infection, preeclampsia, or eclampsia). ☐Administer fluid volume replacement, which may include blood and blood products. ☐Administer pharmacologic interventions including antibiotics, vasoactive medications, and uterotonic agents as prescribed. ☐Administer supplemental oxygen. ☐Provide protection from injury.

Normal lochial flow patterns

☐Bright red vaginal drainage for 2 to 3 days. ☐Blood-tinged serous vaginal drainage from days 4 to 10. ☐White vaginal discharge from day 11 to 6 weeks.

newborn feeding/elimination

Feeding/Elimination ◯Mothers who are breastfeeding should be seen by the lactation consultant. ◯The newborn is offered the breast immediately after birth and frequently thereafter. Newborns who are breastfed will average 15 to 20 min per breast and 30 to 40 min for the total feeding. Feedings should be 8 to 12 times in a 24-hr period. Feeding for a newborn who is breastfeeding should be on demand or every 2 to 3 hr. Newborns who are formula fed also should be fed on demand or every 3 to 4 hr. ◯Inform parents that adhering to specific timing of feedings is to be avoided. Parents should be instructed to recognize when the newborn has completed the feeding. No other fluids are offered ◯The mother's milk supply is equal to the demand of the newborn. Eventually, the newborn will empty a breast within 5 to 10 min, but may need to continue to suck to meet comfort needs. ◯Frequent feedings (every 2 hr may be indicated), and manual expression of milk to initiate flow may be needed. ◯Most newborns spit up a small amount after feedings. Keep the newborn upright and quiet for a few minutes after feedings. ◯Newborns should have 6 to 8 wet diapers a day with adequate feedings and may have 3 to 4 stools per day.

gestatioNal Diabetes Mellitus

Gestational diabetes mellitus is an impaired tolerance to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level during pregnancy should fall between 70 and 110 mg/dL. Gestational diabetes mellitus causes increased risks to the fetus including the following: ◯Spontaneous abortion, which is related to poor glycemic control. ◯Infections (urinary and vaginal), which are related to increased glucose in the urine and decreased resistance because of altered carbohydrate metabolism. ◯Hydramnios, which can cause overdistention of the uterus, premature rupture of membranes, preterm labor, and hemorrhage. ◯Ketoacidosis from diabetogenic effect of pregnancy (increased insulin resistance), untreated hyperglycemia, or inappropriate insulin dosing. ◯Hypoglycemia, which is caused by overdosing in insulin, skipped or late meals, or increased exercise. ◯Hyperglycemia, which can cause excessive fetal growth (macrosomia). Laboratory Tests ■Routine urinalysis with glycosuria ■A glucola screening test/1-hr glucose tolerance test (50 g oral glucose load, followed by plasma glucose analysis 1 hr later performed at 24 to 28 weeks of gestation - fasting not necessary; a positive blood glucose screening is 130 to 140 mg/dL or greater; additional testing with a 3-hr oral glucose tolerance test [OGTT] is indicated) ■An OGTT (following overnight fasting, avoidance of caffeine, and abstinence from smoking for 12 hr prior to testing; a fasting glucose is obtained, a 100 g glucose load is given, and serum glucose levels are determined at 1, 2, and 3 hr following glucose ingestion) ■Presence of ketones in urine is tested to assess the severity of ketoacidosis

gestatioNal hyPeRteNsioN

Gestational hypertension (GH), which begins after the 20th week of pregnancy, describes hypertensive disorders of pregnancy whereby the woman has an elevated blood pressure at 140/90 mm Hg or greater recorded at least twice, 4 to 6 hr apart, and within a 1-week period. There is no proteinuria. The presence of edema is no longer considered in the definition of hypertensive disease of pregnancy. The client's blood pressure returns to baseline by 6 weeks postpartum Mild preeclampsia is GH with the addition of proteinuria of greater than 1+. Report of transient headaches may or may not occur along with episodes of irritability. Edema may be present. Severe preeclampsia consists of blood pressure that is 160/100 mm Hg or greater, proteinuria greater than 3+, oliguria, elevated serum creatinine greater than 1.2 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. Subjective Data ◯Severe continuous headache ◯Nausea ◯Blurring of vision ◯Flashes of lights or dots before the eyes ●Objective Data ◯Physical assessment findings ■Hypertension ■Proteinuria ■Periorbital, facial, hand, and abdominal edema ■Pitting edema of lower extremities ■Vomiting ■Oliguria ■Hyperreflexia ■Scotoma ■Epigastric pain ■Right upper quadrant pain ■Dyspnea ■Diminished breath sounds ■Seizures ■Jaundice ■Signs of progression of hypertensive disease with indications of worsening liver involvement, renal failure, worsening hypertension, cerebral involvement, and developing coagulopathies

Discontinue oxytocin if uterine hyperstimulation occurs.

☐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 uterus between contractions

phototherapy

Maintain an eye mask over the newborn's eyes for protection of corneas and retinas. ■Keep the newborn undressed with the exception of a male newborn. A surgical mask should be placed (like a bikini) over the 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 the skin because they absorb heat and can cause burns. ■Remove the newborn from phototherapy every 4 hr, and unmask the newborn's eyes, checking for inflammation or injury. ■Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. ■Check the lamp energy with a photometer per facility protocol. ■Turn off the phototherapy lights before drawing blood for testing. Check the newborn's axillary temperature every 4 hr during phototherapy because temperature may become elevated. ◯Feed the newborn early and frequently - every 3 to 4 hr. This will promote bilirubin excretion in the stools. ◯Encourage continued breastfeeding of the newborn. Supplementation with formula may be prescribed. ◯Maintain adequate fluid intake to prevent dehydration. ◯Reassure the parents that most newborns experience some degree of jaundice. ◯Explain hyperbilirubinemia, its causes, diagnostic tests, and treatment to parents. ◯Explain that the newborn's stool contains some bile that will be loose and green.

newborn elimination

Monitor elimination habits. ■Newborns should void once within 24 hr of birth. They should void 6 to 10 times a day after 4 days of life. ■Meconium should be passed within the first 24 hr after birth. The newborn will then continue to stool 3 to 4 times a day depending on whether he is being breast- or bottle-fed. ■The stools of newborns who are breastfed may appear yellow and seedy. These stools are lighter in color and looser than the stools of newborns who are formula-fed

respiratory complications newborn

Monitor for signs and symptoms of respiratory complications. ■Bradypnea - respirations less than 25/min ■Tachypnea - respirations greater than 60/min ■Abnormal breath sounds - expiratory grunting, crackles, and wheezes ■Respiratory distress - nasal flaring, retractions, grunting, and labored breathing

goNoRRhea

Neisseria gonorrhoeae is the causative agent of gonorrhea. Gonorrhea is a bacterial infection that is primarily spread by genital-to-genital contact. However, it also can be spread by anal-to-genital contact or oral-to-genital contact. It can also be transmitted to a newborn during delivery. Women are frequently asymptomatic. Subjective Data (Male) ◯Urethral discharge ◯Painful urination ◯Frequency ●Subjective Data (Female) ◯Lower abdominal pain ◯Dysmenorrhea Objective Data - Male/Female ◯Physical Assessment Findings ■Urethral discharge ■Yellowish-green vaginal discharge ■Reddened vulva and vaginal walls ■If gonorrhea is left untreated, it can cause pelvic inflammatory disease, heart disease, and arthritis. ◯Laboratory Tests ■Urethral and vaginal cultures ■Urine culture Medications ◯Ceftriaxone (Rocephin) IM and azithromycin (Zithromax) PO for gonorrhea ■One dose prescription ■Broad-spectrum antibiotic ■Bactericidal action ◯Client Education ■Instruct the client to take entire prescription as prescribed. ■Instruct the client to repeat the culture to assess for medication effectiveness. ■Educate the client regarding safe sex practices.

Home Safety infant

Never leave the newborn unattended with pets or other small children. ◯Keep small objects (coins) out of the reach of newborns due to choking hazard. ◯Never leave the newborn alone on a bed, couch, or table. Newborns move enough to reach the edge and fall off. ◯Never place the newborn on his stomach to sleep during the first few months of life. The back-lying position is the position of choice. The newborn can be placed on his abdomen when awake and being supervised. ◯Never provide a newborn with a soft surface to sleep on (pillows and waterbed). The newborn's mattress should be firm. Never put pillows, toys, bumper pads, or loose blankets in a crib. Crib linens should be tight-fitting. ◯Do not tie anything around the newborn's neck. ◯Monitor the safety of the newborn's crib. The space between the mattress and sides of the crib should be less than 2 fingerbreadths. The slats on the crib should be no more than 5.1 cm (2.25 in) apart. ◯The newborn's crib or playpen should be away from window blinds and drapery cords. Newborns can become strangled in them. ◯The bassinet or crib should be placed on an inner wall, not next to a window, to prevent cold stress by radiation. ◯If an infant carrier is placed on a high place, such as a table, always be within arm's reach. ◯Smoke detectors should be on every floor of a home and should be checked monthly to ensure that they are working. Batteries should be changed yearly. (Change batteries when daylight savings time occurs or on a child's birthday.) ◯Eliminate potential fire hazards. Keep a crib and playpen away from heaters, radiators, and heat vents. Linens could catch fire if they come into contact with heat sources. ◯Control the temperature and humidity of the newborn's environment by providing adequate ventilation. ◯Avoid exposing the newborn to cigarette smoke in a home or elsewhere. Secondhand exposure increases the newborn's risk of developing respiratory illnesses. ◯All visitors should wash their hands before touching the newborn. Any individual who has an infection should be kept away from the newborn. ◯Carefully handle the newborn. Do not toss the newborn up in the air or swing him by his extremities. ◯Provide community resources to clients who may need additional and ongoing assessment and instruction on newborn care (adolescent parents

Breast care

Provide breast care for clients who are lactating. ☐Wear a well-fitting, supportive bra continuously for the duration of lactation. ☐Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection. ☐To relieve breast engorgement, have the client completely empty her breasts at each feeding. Allow the infant to nurse on demand, which would be about 8 to 12 times in 24-hr period. Massaging the breasts during feeding can help with emptying. Allow the infant to feed until the breast softens. If the second breast does not soften after the infant's feeding, the breast may be emptied with a breast pump. Alternate breasts with each feeding. ☐For breast engorgement, apply cool compresses between feedings and apply warm compresses, or take a warm shower prior to breastfeeding. These actions will increase milk flow and promote the letdown reflex. ☐For flat or inverted nipples, suggest that the client roll the nipples between her fingers just before breastfeeding to help them become more erect and make it easier for the infant to latch on. Use a breast shield between feedings. ☐For sore nipples, the client should apply a small amount of breast milk to her nipple and allow it to air dry after breastfeeding. ☐Have the client apply breast creams as prescribed and wear breast shields in her bra to soften her nipples if they are irritated and cracked. ☐Promote adequate fluid intake to replace fluid lost from breastfeeding as well as to provide an adequate amount of milk for the infant. ■Breast care for nonlactating clients ☐Wear a well-fitting, supportive bra continuously for the first 72 hr. ☐Suppression of lactation is necessary for clients who are not breastfeeding. Avoid breast stimulation and running warm water over the breasts for prolonged periods until no longer lactating. ☐For breast engorgement, which may occur on the third or fifth postpartum day, apply cold compresses 15 min on and 45 min off. Fresh, cold cabbage leaves can be placed inside the bra. Mild analgesics may be taken for pain and discomfort of breast engorgement.

contraction stress test

Nipple stimulated CST consists of a woman lightly brushing her palm across her nipple for 2 min, which causes the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins. The same process is repeated after a 5-min rest period. ◯Analysis of the FHR response to contractions (which decrease placental blood flow) determines how the fetus will tolerate the stress of labor. A pattern of at least three contractions within a 10-min time period with duration of 40 to 60 seconds each must be obtained to use for assessment data. ◯Hyperstimulation of the uterus (uterine contraction longer than 90 seconds or more frequent than every 2 min) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of both nipples unless stimulation of one nipple is unsuccessful. Interpretation of findings ◯A negative CST (normal finding) is indicated if within a 10-min period, with three uterine contractions, there are no late decelerations of the FHR. ◯A positive CST (abnormal finding) is indicated with persistent and consistent late decelerations on more than half of the contractions. This is suggestive of uteroplacental insufficiency. Variable deceleration may indicate cord compression, and early decelerations may indicate fetal head compression. Based on these findings, the provider may determine to induce labor or perform a cesarean birth.

Dumping syndrome

Normally, the stomach controls the rate in which nutrients enter the small intestine. When a portion of the stomach is surgically removed, the contents of the stomach are rapidly emptied into the small intestine, causing dumping syndrome. ■Early manifestations typically occur 15 to 30 min after eating. Late manifestations occur 1 to 3 hr after eating. ◯Early manifestations include a sensation of fullness, faintness, diaphoresis, tachycardia, palpitations, hypotension, nausea, abdominal distention, cramping pain, diarrhea, weakness, and syncope. ◯Manifestations resolve after intestine is emptied. However, there is a rapid rise in blood glucose and increase in insulin levels immediately after the intestine empties. This leads to hypoglycemia. ◯The client experiences vasomotor symptoms, such as dizziness, sweating, palpitations, shakiness, and confusion. ◯Nursing Interventions ■Recommend small, frequent meals. ■Recommend consumption of protein and fat at each meal. ■Tell the client to avoid food that contains concentrated sugars and to restrict lactose intake. ■Suggest that the client consume liquids 1 hr before or after eating instead of during meals (dry diet). ■Instruct client to lie down for 20 to 30 min to after meals to delay gastric emptying. If reflux is a problem, assume a reclining position. ■Monitor clients receiving enteral tube feedings and report clinical manifestations of dumping syndrome to the provider. ■Monitor the client for vitamin and mineral deficits, such as iron and vitamin B12

A nonreassuring FHR is noted.

Notify the provider. ■Position the client in a side‑lying position to increase uteroplacental perfusion. ■Keep the IV line open and increase the rate of IV fluid administration to 200 mL/hr unless contraindicated. ■Administer O2 by a face mask at 8 to 10 L/min as prescribed. ■Administer the tocolytic terbutaline (Brethine) 0.25 mg subcutaneously as prescribed to diminish uterine activity. ■Monitor FHR and patterns in conjunction with uterine activity. ■Document responses to interventions. ■If unable to restore reassuring FHR, prepare for an emergency cesarean birth.

pRolapsed uMbiliCal CoRd

Nursing Care ◯Call for assistance immediately. ◯Notify the provider. ◯Use a sterile‑gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. ◯Reposition the client in a knee‑chest, Trendelenburg, or a side‑lying position with a rolled towel under the client's right or left hip to relieve pressure on the cord. ◯Apply a warm, sterile, saline‑soaked towel to the visible cord to prevent drying and to maintain blood flow. ◯Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia. ◯Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation. ◯Initiate IV access, and administer IV fluid bolus. ◯Prepare for a cesarean birth if other measures fail. ◯Inform and educate the client and her partner about the interventions.

MeCoNiuM-staiNed aMNiotiC Fluid

Nursing Care ◯Document color and consistency of stained amniotic fluid. ◯Notify neonatal resuscitation team to be present at birth. ◯Gather equipment needed for neonatal resuscitation. ◯Follow designated suction protocol. ■Assess neonate's respiratory efforts, muscle tone, and heart rate. ■Suction mouth and nose using bulb syringe if respiratory efforts strong, muscle tone good, and heart rate greater than 100/min. ■Suction below the vocal cords using an endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and heart rate less than 100/min.

NeoNatal substaNce withdRawal

Physical assessment findings ■Monitor the neonate for abstinence syndrome (withdrawal) and increased wakefulness using the neonatal abstinence scoring system that assesses for and scores the following: ☐CNS - increased wakefulness, a high-pitched, shrill cry, incessant crying, irritability, tremors, hyperactive with an increased Moro reflex, increased deep-tendon reflexes, increased muscle tone, abrasions and/or excoriations on the face and knees, and convulsions. ☐Metabolic, vasomotor, and respiratory findings - nasal congestion with flaring, frequent yawning, skin mottling, tachypnea greater than 60/min, sweating, and a temperature greater than 37.2° C (99° F). ☐Gastrointestinal - poor feeding, regurgitation (projectile vomiting), diarrhea, and excessive, uncoordinated, and constant sucking. ■Opiate withdrawal ☐Can last for 2 to 3 weeks ☐Manifestations of neonatal abstinence syndrome - rapid changes in mood, hypersensitivity to noise and external stimuli, dehydration, and poor weight gain ■Heroin withdrawal ☐Manifestations of neonatal abstinence syndrome - low birth weight and SGA, decreased Moro reflexes (rather than increased), and hypothermia or hyperthermia. ■Methadone withdrawal ☐Manifestations of neonatal abstinence syndrome - an increased incidence of seizures, sleep pattern disturbances, higher birth weights, and higher risk of sudden infant death syndrome (SIDS) ■Marijuana withdrawal ☐Preterm birth and meconium staining. ■Amphetamine withdrawal ☐Clinical findings - Preterm or SGA, drowsiness, jitteriness, sleep pattern disturbances, respiratory distress, frequent infections, poor weight gain, emotional disturbances, and delayed growth and development ■Fetal alcohol syndrome ☐Clinical findings X-Facial anomalies include eyes with epicanthal folds, strabismus, and ptosis; mouth with a poor suck, small teeth, and cleft lip or palate X-Deafness X-Abnormal palmar creases and irregular hair X-Many vital organ anomalies, such as heart defects, including atrial and ventricular septal defects, tetralogy of Fallot, and patent-ductus arteriosus X-Developmental delays and neurologic abnormalities X-Prenatal and postnatal growth retardation X-Sleep disturbances ■Tobacco ☐Clinical findings - prematurity, low birth weight, increased risk for SIDS, increased risk for bronchitis, pneumonia, and developmental delays

Hepatitis B Immunization

Provides protection against hepatitis B. ■Nursing Considerations and Client Education ☐Recommended to be given to all newborns; informed consent must be obtained. ☐For newborns born to healthy women, recommended dosage schedule is at birth, 1 month, and 6 months. ☐For women infected with hepatitis B, hepatitis B immunoglobulin (HBIG) and the hepatitis B vaccine is given within 12 hr of birth. The hepatitis B vaccine is given alone at 1 month, 2 months, and 12 months. ☐It is important NOT to give the vitamin K and the hepatitis B injections in the same thigh. Sites should be alternated.

Nursing Interventions to Promote Successful Breastfeeding

Place the newborn skin-to-skin on the mother's abdomen immediately after birth. Initiate breastfeeding as soon as possible or within the first 30 min following delivery. ◯Explain breastfeeding techniques to the mother. Have the mother wash her hands, get comfortable, and have caffeine-free, nonalcoholic fluids to drink during breastfeeding. ◯Explain the let-down reflex (stimulation of maternal nipple releases oxytocin that causes the let-down of milk). ◯Reassure the mother that uterine cramps are normal during breastfeeding, resulting from oxytocin, which also promote uterine involution. ◯Express a few drops of colostrum or milk and spread it over the nipple to lubricate the nipple and entice the newborn. ◯Show the mother the proper latch-on position. Have her support the breast in one hand with the thumb on top and four fingers underneath. With the newborn's mouth in front of the nipple, the newborn can be stimulated to open his mouth by tickling his lower lip with the tip of the nipple. The mother pulls the newborn to the nipple with his mouth covering part of the areola as well as the nipple. ◯Explain to the mother that when her newborn is latched on correctly, his nose, cheeks, and chin will be touching her breast. ◯Demonstrate the four basic breastfeeding positions: football, cradle or modified cradle, across the lap, and side-lying. ◯Encourage the mother to breastfeed at least 15 to 20 min/breast to ensure that her newborn receives adequate fat and protein, which is richest in the breast milk as it empties the breast. ◯Avoid educating mothers regarding the duration of newborn feedings. Mothers should be instructed to evaluate when the newborn has completed the feeding, including slowing of newborn suckling, a softened breast, or sleeping. ◯Explain to the mother that newborns will nurse on demand after a pattern is established. ◯Show the mother how to insert a finger in the side of the newborn's mouth to break the suction from the nipple prior to removing the newborn from the breast to prevent nipple trauma. ◯Show the mother how to burp the newborn when she alternates breasts. The newborn should be burped either over the shoulder or in an upright position with his chin supported. The mother should gently pat the newborn on his back to elicit a burp. ◯Tell the mother to begin the newborn's next feeding with the breast she stopped feeding him with in the previous feeding. ◯Tell the mother how to tell if her newborn is receiving adequate feeding (gaining weight, voiding 6 to 8 diapers a day, and contentedness between feedings). ◯Explain to the mother that the newborn may have loose, pale, and/or yellow stools during breastfeeding, and that this is normal. ◯Tell the mother to avoid nipple confusion in the newborn by not offering supplemental formula, pacifier, or soothers. Supplementation can be provided using a small feeding or syringe feeding, if needed. ◯Tell the mother to always place her newborn on his back after feedings. ◯Promote rooming-in efforts. ◯Offer referral to breastfeeding support groups. ◯Contact a lactation consultant to offer additional recommendations and support, especially to mothers who have concerns about adequate breast milk or mothers who have been unsuccessful with breastfeeding in the past. ◯Herbal products, such as fenugreek, and prescription medications, such as metoclopramide (Reglan), have been reported to increase breast milk production. There is insufficient data to confirm or deny their effect on lactation. Mothers should check with the provider before taking over-the-counter or prescription medications.

Endometritis

☐Uterine tenderness and enlargement ☐Dark, profuse lochia ☐Lochia that is either malodorous or purulent ☐Temperature greater than 38° C (100.4° F) typically on the third to fourth postpartum day ☐Tachycardia Nursing interventions for endometritis ■Collect vaginal and blood cultures. ■Administer IV antibiotics as prescribed. ■Administer analgesics as prescribed. ■Teach the client hand hygiene techniques. ■encourage client to maintain interaction with her infant to facilitate bonding.

RuptuRe oF the uteRus

Subjective Data ◯Client reports sensation of "ripping," "tearing," or sharp pain. ◯Client reports abdominal pain, uterine tenderness. Objective Data ◯Physical assessment findings ■Nonreassuring FHR with signs of distress, bradycardia, variable and late decelerations, and absent or minimal variability ■Change in uterine shape and fetal parts palpable ■Cessation of contractions and loss of fetal station ■Manifestations of hypovolemic shock: tachypnea, hypotension, pallor, and cool, clammy skin Patient-Centered Care ●Nursing Care ◯Administer IV fluids. ◯Administer blood product transfusions if prescribed. ◯Prepare the client for an immediate cesarean birth, which may involve a laparotomy and/or hysterectomy. ◯Inform the client and her partner about the treatment

uRiNaRy tRaCt iNfeCtioN

Subjective Data ◯Reports of urgency, frequency, dysuria, and discomfort in the pelvic area ◯Fever ◯Chills ◯Malaise ●Objective Data ◯Physical assessment findings ■Change in vital signs, elevated temperature ■Urine (cloudy, blood‑tinged, malodorous, sediment visible) ■Urinary retention ■Pain in the suprapubic area ■Pain at the costovertebral angle (pyelonephritis) ◯Diagnostic procedures ■Urinalysis for WBCs, RBCs, protein, bacteria Nursing Care ◯Obtain either a random or clean‑catch urine sample. ◯Administer antibiotics and teach the client the importance of completing the entire course of antibiotics as prescribed. ◯Teach the client proper perineal hygiene, such as wiping from front to back. ◯Encourage the client to increase her fluid intake to 3,000 mL/day to dilute the bacteria and flush her bladder. ◯Recommend that the client drink cranberry and prune juice to promote urine acidification, which inhibits bacterial multiplication.

Chorionic villus sampling (CVS)

assessment of a portion of the developing placenta (chorionic villi), which is aspirated through a thin sterile catheter or syringe inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance and analyzed. ◯CVS is a first-trimester alternative to amniocentesis with one of its advantages being an earlier diagnosis of any abnormalities. CVS can be performed at 10 to 12 weeks of gestation. ●Indications for the use of CVS during pregnancy ◯Potential diagnoses ■Women at risk for giving birth to a neonate who has a genetic chromosomal abnormality (cannot determine spina bifida or anencephaly) ◯Client education ■Instruct the client to drink plenty of fluid to fill the bladder prior to the procedure to assist in positioning the uterus for catheter insertion. ■Provide ongoing education and support.

Blood loss during childbirth

average blood loss is 500 mL in an uncomplicated vaginal delivery and 1,000 mL for a cesarean birth

Hypoglycemia

frequently occurs in the first few hours of life secondary to the use of energy to establish respirations and maintain body heat. Newborns of mothers who have diabetes mellitus, are small or large for gestational age, are less than 37 weeks of gestation, or are greater than 42 weeks of gestation, are at risk for hypoglycemia and should have blood glucose monitored within the first 2 hr of life. Follow facility protocols regarding frequency of assessing blood glucose levels. ◯Nursing Actions ■Monitor for jitteriness; twitching; a weak, high-pitched cry; irregular respiratory effort; cyanosis; lethargy; eye rolling; seizures; and a blood glucose level less than 40 mg/dL by heel stick. ■Give formula immediately or have the mother breastfeed to elevate blood glucose. Brain damage can result if brain cells are depleted of glucose.

Group B streptococcus ß-hemolytic (GBS)

is a bacterial infection that can be passed to a fetus during labor and delivery. Physical Assessment Findings ■Positive GBS may have maternal and fetal effects, including premature rupture of membranes, preterm labor and delivery, chorioamnionitis, infections of the urinary tract, and maternal sepsis. ◯Laboratory Tests ■Vaginal and rectal cultures are performed at 36 to 37 weeks of gestation. Medications ◯Penicillin G or ampicillin (Principen) is most commonly prescribed for GBS. ■Administer penicillin 5 million units initially IV bolus, followed by 2.5 million units intermittent IV bolus every 4 hr. The client may be prescribed ampicillin 2 grams IV initially, followed by 1 g every 4 hr. ■Bactericidal antibiotic is used to destroy the GBS.

episiotomy care

promote measures for the client to help soften her stools. ◯Educate the client about proper cleansing to prevent infection. ■The client should wash her hands thoroughly before and after voiding. ■The client should use a squeeze bottle filled with warm water or antiseptic solution after each voiding to cleanse the perineal area. ■The client should clean her perineal area from front to back (urethra to anus). ■The client should blot dry, not wipe. ■The client should sparingly use a topical application of antiseptic cream or spray. ■The client's perineal pad should be changed from front to back after voiding or defecating. ◯Promote comfort measures. ■Apply ice packs to the client's perineum for the first 24 to 48 hr to reduce edema and provide anesthetic effect. ■Encourage sitz baths at a temperature of 38° to 40° C (100° to 104° F)or cooler at least twice a day. ■Administer analgesia, such as nonopioids (acetaminophen [Tylenol]), nonsteroidal anti-inflammatories (ibuprofen [Advil]), and opioids (codeine, hydrocodone), as prescribed for pain and discomfort. ■Opioid analgesia may be administered via a PCA (patient-controlled analgesia) pump after cesarean birth. Continuous epidural infusions may also be used for pain control after cesarean birth. ■Apply topical anesthetics (Americaine spray or Dermoplast) to the client's perineal area as needed or witch hazel compresses (Tuck's Pads) to the rectal area for hemorrhoids.

Amniocentesis

the aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client's uterus and amniotic sac under direct ultrasound guidance locating the placenta and determining the position of the fetus. It may be performed after 14 weeks of gestation. ●Interpretation of findings ◯Alpha-fetoprotein (AFP) can be measured from the amniotic fluid between 16 and 18 weeks of gestation and may be used to assess for neural tube defects in the fetus or chromosomal disorders. May be evaluated to follow up a high level of AFP in maternal serum. ■High levels of AFP are 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 may be present with normal multifetal pregnancies. ■Low levels of AFP are associated with chromosomal disorders (Down syndrome) or gestational trophoblastic disease (hydatidiform mole).

intraUtErinE dEviCE (iUd)

›A chemically active T-shaped device that is inserted through a woman's cervix and placed in the uterus by the provider. Releases a chemical substance that damages sperm in transit to the uterine tubes and prevents fertilization. ›The device must be monitored monthly by clients after menstruation to ensure the presence of the small string that hangs from the device into the upper part of the vagina to rule out migration or expulsion of the device.

diaphragm and spErmiCidE

›A female client should be fitted with a diaphragm properly by a provider. ›A client must be refitted by the provider every 2 years, if there is a 7 kg (15 lb) weight change, full-term pregnancy, or second-term abortion. ›Requires proper insertion and removal. Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim. The diaphragm must remain in place for at least 6 hr after coitus. ›Spermicide must be reapplied with each act of coitus. ›A client should empty her bladder prior to insertion of the diaphragm

injECtabLE progEstins (dEpo-provEra)

›An intramuscular injection given to a female client every 11 to 13 weeks. ›Start of injections should be during the first 5 days of a client's menstrual cycle and every 11 to 13 weeks thereafter. Injections in postpartum nonbreastfeeding women should begin within 5 days following delivery. For breastfeeding women, injections should start in the sixth week postpartum. ›Advise clients to keep follow-up appointments. ›A client should maintain an adequate intake of calcium and vitamin D.

transdErmaL ContraCEptivE patCh

›Contains norelgestromin (progesterone) and ethinyl estradiol, which is delivered at continuous levels through the skin into subcutaneous tissue. ›A client applies the patch to dry skin overlying subcutaneous tissue of the buttock, abdomen, upper arm, or torso, excluding breast area. ›Requires patch replacement once a week. ›Patch is applied the same day of the week for 3 weeks with no application of the patch on the fourth week.

mastitis

■Painful or tender, localized hard mass, and reddened area usually on one breast ■Chills ■Fatigue Nursing interventions for mastitis ■Provide the client with education regarding breast hygiene to prevent and manage mastitis. ☐Instruct to thoroughly wash hands prior to breastfeeding. ☐Instruct to maintain cleanliness of breasts with frequent changes of breast pads. ☐Encourage allowing nipples to air‑dry. ☐Teach proper infant positioning and latching‑on techniques, including both the nipple and the areola. The client should release the infant's grasp on the nipple prior to removing the infant from the breast. ☐Instruct the client about completely emptying her breasts with each feeding to prevent milk stasis, which provides a medium for bacterial growth. ☐Encourage using ice packs or warm packs on affected breasts for discomfort. Instruct the client to continue breastfeeding frequently (at least every 2 to 4 hr), especially on the affected side. Instruct the client to manually express breast milk or use a breast pump if breastfeeding is too painful. ☐Instruct the client to begin breastfeeding from the unaffected breast first to initiate the letdown reflex in the affected breast that is distended or tender. ☐Encourage rest, analgesics, and fluid intake of at least 3,000 mL per day. ☐Encourage the client to wear a well‑fitting bra for support. ☐Tell the client to report redness and fever. ☐Administer antibiotics, and teach the client the importance of completing the entire course of antibiotics as prescribed.

Celiac disease

◯Celiac disease is also known as gluten-sensitive enteropathy (GSE), celiac sprue, and gluten intolerance. ◯It is a chronic, inherited, genetic disorder with autoimmune characteristics. Clients who have celiac disease are unable to digest the protein gluten. They lack the digestive enzyme DPP-IV, which is required to break down the gluten into molecules small enough to be used by the body. In celiac disease, gluten is broken down into peptide strands instead molecules. The body is not able to metabolize the peptides. If untreated, the client will suffer destruction of the villa and the walls of the small intestine. Celiac disease may go undiagnosed in both children and adults. ◯Clinical manifestations vary widely. Children who have celiac disease have diarrhea, steatorrhea, anemia, abdominal distention, impaired growth, lack of appetite, and fatigue. Typical manifestations in adults include diarrhea, abdominal pain, bloating, anemia, steatorrhea, and osteomalacia. ◯Treatment for celiac disease is limited to avoiding gluten. However, eliminating gluten, which is found in wheat, rye and barley, is difficult because it is found in many prepared foods. Clients must read food labels carefully in order to adhere to a gluten-free diet. Some gluten-free products are unappealing to clients, and many are more expensive that other products. Prognosis is good for clients who adhere to a gluten-free diet. ◯Nursing Interventions ■Encourage clients to eat foods that are gluten-free: milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh poultry, meats and fish, dried beans. ■Remind clients to read labels on processed products. Gravy mixes, sauces, cold cuts, soups, and many other products have gluten as an ingredient. Advise clients to read labels on nonfood products, which also may have gluten as an ingredient.

Diverticulosis and diverticulitis

◯Diverticula are pouches protruding through the muscle of the intestinal wall, usually from increased intraluminal pressure. They occur anywhere in the colon, but usually in the sigmoid colon. Unless infection occurs, diverticula cause no problems. ◯Clinical manifestations of diverticulitis include abdominal pain, nausea, vomiting, constipation or diarrhea, and fever, accompanied by chills and tachycardia ◯A high-fiber diet may prevent diverticulosis and diverticulitis by producing stools that are easily passed, thus decreasing pressure within the colon. ◯During acute diverticulitis, a clear liquid diet is prescribed until inflammation decreases, then a high-fiber, low-fat diet is indicated. ◯Instruct the client to avoid foods with seeds or husks (corn, popcorn, berries, tomatoes). ◯Clients require instruction regarding diet adjustment based on the need for an acute intervention or preventive approach.

Gastroesophageal reflux disease (GERD)

◯GERD occurs as the result of the abnormal reflux of gastric secretions up the esophagus. This leads to indigestion and heartburn. ◯Long-term GERD can cause serious complications including adenocarcinoma of the esophagus and Barrett's esophagus. ◯Clinical manifestations include heartburn, retrosternal burning, painful swallowing, dyspepsia, regurgitation, coughing, hoarseness, and epigastric pain. Pain may be mistaken for a myocardial infarction. ◯Nursing Interventions ■Instruct the client to avoid situations that lead to increased abdominal pressure, such as wearing tight-fitting clothing. ■Advise the client to avoid eating 2 hr or less before lying down. ■Advise the client to elevate the body on pillows instead of lying flat and to avoid large meals and bedtime snacks. ■Encourage weight loss for overweight clients ■Suggest that the client avoid trigger foods (citrus fruits and juices, spicy foods, carbonated beverages). ■Instruct the client to avoid items that reduce lower esophageal sphincter (LES) pressure, including fatty foods, caffeine, chocolate, alcohol, cigarette smoke and all nicotine products, and peppermint and spearmint flavors

Pancreatitis

◯Pancreatitis is an inflammation of the pancreas. ◯The pancreas is responsible for secreting enzymes needed to digest fats, carbohydrates, and proteins. ◯Nutritional therapy for acute pancreatitis involves reducing pancreatic stimulation. The client is prescribed nothing by mouth (NPO), and a nasogastric tube is inserted to suction gastric contents. ◯TPN may be used until oral intake is resumed. ◯Nutritional therapy for chronic pancreatitis usually includes a low-fat, high-protein, and high-carbohydrate diet. It may include providing supplements of vitamin C and B-complex vitamins.

Nursing interventions to facilitate sibling acceptance of the infant

◯Take the sibling on a tour of the obstetric unit. ◯Encourage the parents to: ■Let the sibling be one of the first to see the infant. ■Provide a gift from the infant to give the sibling. ■Arrange for one parent to spend time with the sibling while the other parent is caring for the infant. ■Allow older siblings to help in providing care for the infant. ■Provide the preschooler with a doll to care for.

Liver disease

◯The liver is involved in the metabolism of almost all nutrients. ◯Disorders affecting the liver include cirrhosis, hepatitis, and cancer. ◯Malnutrition is common with liver disease. ◯Protein needs are increased to promote a positive nitrogen balance and to prevent a breakdown of the body's protein stores. ◯Carbohydrates are generally not restricted, as they are an important source of calories. ◯Caloric requirements may need to be increased based upon an evaluation of the client's stage of disease, weight, and general health status. ◯Multivitamins (especially vitamins B, C, and K) and mineral supplements may be necessary. ◯Alcohol, nicotine, and caffeine should be eliminated