Maternal Newborn ATI exam study guide PDF

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ATI Maternal Newborn study guide, basic and advanced knowledge of topics....

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VEAL CHOP: Variable decelerations→ Cord compression Early deceleration→ Head compression Acceleration→ Okay Late deceleration → Placental insufficiency Effleurage- gently stroke upper thighs Newborn1. Respiratory 2. Dry 3. feed(within 1st hour) After 1st hour-Vitamin K -Erythromycin in the eyes -Wristband on ( don’t hand baby over to anyone without ID band) AVA- 2 arteries and 1 vein, umbilical cord… congenital issues possible. Jerky eye movement in newborn, lack of muscle development in the eyes. True labor-cervical change Newborn highest risk for meconium in amniotic fluid- SGA because of all stress the baby went through and can aspirate. Post term babies, past 40 weeks because placenta is beginning to die and body wants to poop Skin of a postmature baby is leathery, cracked, dry. Hypertonicity Lanugo- hair soft, mostly preterm babies Vernix- white cheesy goo, preterm has ton of it, post term have none even in the creases Cord prolapse is an emergency, cord is coming out of moms vagina. Priority action is to put glove on and lift the baby's head off the cord. Tocolytic therapy stops contractions- nifedipine, iv magnesium sulfate, terb. It is safe to give to preterm and contracting often (every 2 minutes).

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Can have vaginal birth after c-section depending on the scar LOW TRANSVERSE, vertex or breach baby. Uterine rupture can occur for other scars. Pee and poop- day 1: at least 1, day 2: at least 2, day 3: at least 3 Day 4 : 6 to 8 wet diapers. 1st pee after delivery should be 24hours, 1st poop within 48hours of life. Black and tarry poop (meconium) has vernix, lanugo, vanishing twin. Temp in newborn- 100.4 F 38C (no fever allowed) call pediatrician and sign of infection. Mom can have temp up 100.4F 38C due to dehydration the first 24hours postpartum. NewBorn assessment- respiratory rate, especially c-section because they didn’t have the squeeze coming out of the birth canal. Preterm newborn biggest concern is #1 hypothermia, #2 hypoglycemia. Milk comes in between 3 to 5 days after delivery, milk engorgement feed the baby from both breasts, cold cabbage leaves or cold compress 15min on 45 min off, warm compress when its time to feed baby vasodilation. Never give a set time, it's always until baby is satisfied. Go back and forth 5 min each breast. 30 to 60 newborn respiratory rate. SGA- #1 hypoglycemia, #2 hypothermia Umbilical cord care- Keep the cord dry, fold the top of the diaper underneath it. Laboring breathing fast, hand and feet are tingly, have her breathe in a paper bag so she won’t lose too much co2 or breathe into her hand. Encourage mom to take long deep breaths. O2 WILL NOT HELP. don’t give oxygen. Gait control theory of pain- effleurage- touch, counterpressure, feeling pressure over pain. Use senses! Things that smell nice, massage OP- occiput posterior position- lower back pain EXTREMELY, long labor, pushing a long time. Put hands and knees position or knee chest position will help rotate baby. APPLY counter pressure on lower back/sacrum to relieve pressure and pain! Occiput anterior is the ideal position for baby birth. FUNDAL ASSESSMENT COMES AFTER BABY IS BORN. FUNDUS IS TOP PART OF UTERUS. BLADDER DISTENTION IF FUNDUS NOT MIDLINE (assist pt to empty 2

bladder). PRETERM BABY NEED TO REDUCE STIMULATION BECAUSE OF THIN VESSELS AND CAN BLEED EASILY. CRYING, EXCESSIVE MOVEMENT, ETC… CLUSTER CARE, DO EVERYTHING AT ONCE KEEP LIGHTS LOW BLOOD PRESSURE: Q15 for the first 2 hours after birth PULSE: Q15 for the first 2 hours after birth TEMPERATURE: Q 4hour for the first 8 hours after birth, then Q8hour Vital signs: Temperature elevations should last for only 24 hours – should not be greater than 100.4°F Temperature of 100.4 F for 24 hours after delivery? Wait, isn’t that a maternal fever? Not in the first 24 hours of the PP period. Dehydration in the 1st 24 hours after delivery may cause a temp no greater than 100.4 for approximately 24 hours. Bradycardia rates of 50 to 60 beats per minute occur during first 6 to 10 days due to decreasing blood volume. Mom no longer needs the massive amount of circulating blood volume. Think about it, she’s no longer feeding the uterus/placenta/fetus with massive amounts of blood; therefore, she has loads of circulating blood volume that she no longer needs. So, as her circulating blood volume decreases (returns to her normal pre-pregnancy state) she experiences bradycardia. Once mom’s blood volume returns to prepregnancy levels, her pulse returns to her normal, prepregnant baseline. PROMOTE FLEXION PKU- TYPE OF PROTEIN, BABY NEED TO BE 24HOURS OLD AND EATING NEWBORN HAVE SHORT APNEA 5 TO 10 SECONDS.

Lochia = blood mucus, tissue vaginal discharge •lochia rubra (bright red color, small clots, smells like human flesh; lasts 1-3 days PP). •lochia serosa (pinkish brown color, day 4 to 10 PP) •Lochia alba (Yellow/creamy discharge; day 11 to 8 weeks PP)

What other Lochia assessments are necessary? 3

Assess amount, odor, consistency (clots) •Must move from Rubra to Serosa to Alba--NEVER in the opposite direction. •If blood collects and forms clots within uterus, fundus rises and becomes boggy (uterine atony)

If soaking 1 or > pads /hour, assess uterus, notify health care provider Resume menstrual cycle within 6 – 8 weeks, breastfeeding moms might be 3 months or greater 1.) 2.) 3.)

WANTING TO DISCUSS BIRTHING EXPERIENCE AND WANTS HELP. DEPENDENT NEEDS ACCEPTANCE FROM OTHERS--CAN EXPERIENCE BABY BLUES. Provide education at this time!!! DEPENDENT-INDEPENDENT RESUMING RELATIONSHIP WITH PARTNER--FAMILY UNIT AS A WHOLE ENTITY. Not really interested in a lot of education; mother typically feels like she has this new part of her life somewhat under control. INTERDEPENDENT

If the fetus is Rh positive, the mother will receive Rhogam within 72 hours of birth. What if the fetus is Rh negative? Then the mother does NOT need to have Rhogam administered PP.

Massage the FUNDUS!!!!! EXCESSIVE BLEEDING AND SOAKED PADS If the fundus is NOT midline--you take her to the bathroom to empty her bladder. An extended bladder (full of urine) increases likelihood of postpartum hemorrhage (PPH)

● Expected vital sign alterations ○ Normal fetal heart rate 110 to 160 ● (Betamethasone)- help with baby lungs ● Biophysical Profile- ultrasound ● Lung test to 2 to 1 or 2.5 3 to 1 diabetic patient ● Cervical change is true labor ● Assess fetal heart rate, water

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● Ambiculus down to the spine, prolonged labor, position ● Prolapse- stick fingers push against head and relieve pressure on cord, keep fingers there until birth ● Dystocia-difficult period ● Occiput posterior, lower back pain intense ● Amniotic fluid embolism- PE, ● lochia , the most it can be is one soaked pad in 15 minutes, blood clots up to a quarter ● Cardiovascular System and fluid and hematologic status- dehydration, temp, loses blood, weight loss, high WBC to prevent infections ● Perineal care, wipe front to back, well fitting bra, before feeding warm breast or warm shower, after feeding fifteen minutes on and forty five minutes off cool compress, avoid breast stimulation. ● Vaginal 500ml, c section 1000ml blood loss ● Postpartum- a year , delirium two three weeks after birth

AMNIOCENTESIS) page 33-34 Obtain FHR PRIOR to procedure. ● Amniocentesis is a prenatal test. Is the sampling of amniotic fluid using a hollow needle inserted into the uterus, to screen for developmental abnormalities in a fetus. ● Prescribed for a pt. who is at increased risk of having a baby with a birth defect or genetic condition. ● An ultrasound transducer is used to show a baby's position in the uterus on a monitor prior to procedure. ● It may be performed after 14 weeks of gestation. Patient Education ● Instruct client to empty her bladder prior to procedure ● During the procedure slight pressure will be felt, keep breathing. ○ The diaphragm is lowered when pt holds the breath. Nursing Interventions ● With Rh negative will be given Rho(D) immune globulin, to protect against Rh isoimmunization. ● Monitor FHR after the procedure for 30mins ● Notify provider for leakage, bleeding on site, pressure, contraction ULTRASOUND EDUCATION: () page 29 ● instruct patient to have full bladder. “Drink 1 quart of water prior to the procedure ● put the Wedge UNDER the right buttuck to prevent supine hypotension. NONSTRESS TEST: NURSING INTERVENTIONS: page 31 ● “What are you looking at while you monitor my baby?”

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○ “This test monitors the response of your baby’s FHR to fetal movement.” Which trimester can this noninvasive test be performed? 3rd, 32 weeks Let's look at 2 strips to determine reactive vs. non reactive. ○ Let’s go over the reactive definition AGAIN! ○ Nonreactive, baby is sleeping, Opioid and nicotine(smoking) can cause baby to relax which can cause a false nonreactive NST Why do we ALSO need to connect the client to the Toco transducer during this test? ○ If an acceleration occurs at the same time as a contraction it does not count Best Maternal Position during this exam? ○ High fowler’s or left side ○ Supine with wedge under hip What is the ‘normal’ range for the FHR? (page 86) ○ 110 -160 bpm ○ After birth: 100 - 160 bpm

NONSTRESS TEST: RESULTS:)-third trimester Done twice a week at 28-32 weeks gestation, IF HIGH RISK PREGNANCY (PAGE 31, BOTTOM LEFT under Client Presentation.) ● Reactive (good): FHR normal baseline with moderate variability. Accelerates at least 15 beats for 15 sec and it occurs twice during 20 mins ● Remember, it’s not counted as an acceleration IF it occurs DURING a contraction!!! ● Non-reactive: no demonstration of 2 qualifying accelerations in 20 mins ● Some medications, like Opioids & Nicotine can cause non-reactive results. ○ Stimulate baby for 3 sec, give food or drink OJ ○ Reffered to get BPP (biophysical profile) or CST (contraction stress test) ● False non-reactive NST when baby is asleep (sleep periods 20-30 mins), if Pt is on opioids (dilaudid) or is a smoker (page 31) ● Moderate variability with a minimum of 2 accelerations ● What is the definition of an acceleration? ○ 15 bpm above the fetal baseline and lasts for 15 seconds during a 20 minute period. (I say, “it’s a 15 by 15”) ○ Less than 32 weeks = 10 bpm, lasts 10 seconds Identification of Prolonged Decelerations: ● Decrease in FHR is 15 beats/min or more BELOW THE BASELINE and lasts for at least 2 min but less than 10 if sustained for 10 min its a baseline change. Nursing interventions for Prolonged Decelerations: ) ● Notify provider ● Stay with patient’ ● Reposition pt. (Turn on side)--always least invasive action first!!! ● Maternal Oxygen--facemask at 8-10L/min ● IV fluid bolus

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Assessing Fetal Lung maturity (prior to birth): )--PAGE 34 ● Preterm baby lungs are not mature and minimal surfactant. ● Amnio for L/S RATIO AND PG presence. --page 34 ○ L/S Ratio- 2:1 ratio indicates fetal lung maturity (2.5:1 or 3:1 for a client with diabetes) Its ration should be higher than standard. ○ Absence of PG (phosphatidylglycerol) = respiratory distress : WANT PG for lung maturity ○ Obtained via amniocentesis ● Mom at risk of preterm delivery will receive 2 doses of betamethasone (corticosteroid)

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Enhance fetal lung maturity Doses 24 hrs apart Prolong labor so you can to give both doses Can’t give betamethasone after 37 weeks of gestation

Expected Lab findings:

● BUN ○ First trimester: 7-12 mg/dL ○ Second trimester: 3-13 mg/dL ○ Third trimester: 3-11 mg/dL ● Hematocrit: 30-40 % ● Hemoglobin: 11-15 g/dL ● Platelets: 150,000-400,000 ● Liver enzymes (ALT and AST): pregnancy level to decreased is normal ● Protein is NEVER normal in urine

Describe fetal Late deceleration: ★ Fetal heart rate slows after contraction has started and returns to baseline well after contraction has ended. Causes of late decel. ● Uteroplacental insufficiency causing inadequate fetal oxygenation. Interventions

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Side lying position first action or knee chest position Increase rate of IV fluid Discontinue oxytocin Administer oxygen 8-10 L via nonrebreather face mask Prepare for assisted vaginal birth or cesarean

Pitocin (Oxytocin) ● No more than 5 contractions in 10 minutes ● No more than 7 contractions in 15 minutes ● Contraction longer than 90 seconds is hyper-contraction and leads to fetal distress ○ D/c or lower the dose ○ A prolonged contraction duration (greater than 90 seconds) or too frequent contractions (more than five in a 10-min period) without sufficient time for uterine relaxation (less than 30 seconds) in between can reduce blood flow to the placenta. This can result in fetal hypoxia and decreased FHR GBS: patient education regarding screening: ● screen at 35 weeks to 38 weeks, and if positive, antibiotic treatment will be given during labor/after SROM HOW DO YOU EXPLAIN THIS TO YOUR CLIENT ● Natural bacteria sometimes leaks out and babies can be exposed during vaginal birth. ○ Can cause neurological issues (cerebral palsy) ○ Give antibiotic q4hrs IV while in labor; stop antibiotics once baby is born. ○ Client does NOT need antibiotics if she’s going to have a c-section. Teach client about hysterosalpingography: ● outpatient radiological procedure in which dye is used to assess the patency of fallopian tubes for imaging. ● Assess for history of iodine and seafood allergies prior to procedure (because of the contrast dye) ● If allergic to shellfish and needs procedure done, pt will premedicated with Diphenhydramine(Benadryl) Evaluating lab values for a client with Preeclampsia: pg 60 UA= protein 1-2 is mild, +3 is severe At risk for HELLP Hemolysis: results in anemia and jaundice Elevated Liver enzymes Low Platelets : less than 100,000 results in bleeding Labs: 1. Elevated ALT and AST (liver enzymes) 2. CBC- platelets 150,000- 400,000 under 100,000

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Hyperemesis Gravidarum: ● Signs and symptoms ○ Excessive vomiting, nausea, increased pulse, decreased BP ○ Results in 5% weight loss, electrolyte imbalances, acetonuria, ketosis ● Nursing Interventions ○ Monitor I&O. ○ Assess skin turgor and mucous membranes. ○ Monitor vital signs. ○ Monitor weight. ○ Monitor lab for ketone and acetone in urinalysis, electrolytes and hemoconcentration in CBC ○ Administer IV LR, supplements, antiemetics as ordered ○ Advance the diet as tolerated ● Education ○ Small frequent meals ○ Fluids between meals ○ Crackers at bedside in the morning ○ Encourage gatorade ○ Notify Provider ■ Can’t hold anything down for 12 hrs (@ risk for dehydration-uterus to contract) Expected vital sign changes during pregnancy: BP: ● 1st trimester: B/P measurements are within the prepregnancy range ● Systolic slight or no increase from pre pregnancy levels ● Diastolic: slight decreases around 24-32 weeks ● Will gradually return to prepregnancy level by the end of pregnancy Pulse ● Increases 10-15/min around 32 weeks of gestation and remain elevated throughout the remainder of the pregnancy Respirations ● Unchanged or slightly increased (+2) ● Shortness of breath may occur due to expanding uterus Circumcision site care: client education ● Apply gauze lightly to penis if there’s bleeding ● Fan fold diapers to prevent pressure on area ● Change diapers at least every 4 hours and clean penis with warm water each change ● Avoid tub baths until healed; trickle warm water on penis (DO NOT WIPE) ● Film of yellowish mucus may appear-do not wash it off ● Avoid pre-moistened towelettes to clean the penis because it may contain alcohol ● Clamp procedure: apply petroleum jelly each diaper change for at least 24 hours after

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circumcision Plastibell circumcision: client education ● Provider will tie a suture tightly around the foreskin & with pressure the excess foreskin is removed. ~5-7 days the plastibell drops off leaving clean circumcision. ● NO bottle feeding for 2-3 hours prior to procedure to prevent vomiting/aspiration. (Those who are breastfed can nurse up until the procedure) ● AVOID alcohol towelettes. ● DO NOT give a tub bath until circumcision is healed. ● Change diaper ~4 hours & clean with WARM water. ● Notify of S/S of infection. A film of yellow mucus can form over glans (it is part of the healing process Give acetaminophen as prescribed ● EDUCATE MOM TO CALL PROVIDER ○ Color of penis changes reddish, bluish ○ Excess amount of bleeding ○ If plastibell falls off before 5 days ○ Unresolvable pain (grimacing and excessive crying) ○ Any discharge, swelling, strong odor, tenderness, ○ decrease in urination (how many wet diapers are normal each day? 6 or more page 177) ○ Fever 100.4 F (38 C) and above Your c-section client begins to hemorrhage when you arrive in the recovery room, describe the top 3 nursing actions and why those are the top 3: Call provider 1. Firm massage fundus, monitor v/s, assess for source of bleeding. 2. Assess fundal height , firmness and position (should be midline). If uterus is boggy, massage fundus to increase muscle contraction. 3. Assess lochia and other clinical findings of bleeding such as lacerations, episiotomy or hematoma. 4. Maintain or initiate isotonic fluids, ( LR or 0.9 Sodium Chloride) Colloid volume expanders such as albumin and blood products (packed RBC’s and fresh frozen plasma) 5. Provide O2, 2-3 L min per nasal cannula and monitor O2 sat. Elevate pt legs 20-30 degrees to promote venous return. If hypoperfused due to blood loss there will be VS changes: HR increased, BP decreased, Urinary output decrease, SPO2 decreased

Priority nursing assessment (top 3) after Epidural placement: 1. Maternal VS’s: B/P- at risk for B/P to drop and HR (fyi: nausea = Low BP) 2. FHR 3. Pain- was epidural successful ? 4. Temp at risk for infection (CLE & Foley)-maternal fever 100.4 F 5. FALL RISK

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Specific labs drawn during prenatal care and : ): (Rubella, ABO, RH factor, etc.) ● During prenatal care, Obtain initial laboratory tests, including hemoglobin, hematocrit, WBC, blood type and Rh (rhogam) , rubella titer, urinalysis(protein, ketones, WBC) renal function test, Pap test, cervical cultures, HIV antibody, hepatitis B surface antigen, toxoplasmosis, and RPR (syphilis) or VDRL. ● Rh-negative and not sensitized, the indirect Coombs’ test is repeated between 24 and 28 weeks of gestation ● Group B Streptococcus (GBS): Obtain a vaginal/anal culture at 35 to 38 weeks of gestation to assess for GBS infection. ● One-hour glucose tolerance (oral ingestion or IV administration of concentrated glucose with venous sample taken 1 hr later [fasting not necessary]): Identifies hyperglycemia; done at initial visit for at-risk clients and at 24 to 28 weeks of gestation for all pregnant women (greater than 140 mg/dL requires follow up).

Glucose Testing: prenatal ● 1hr initial visit ○ 24-28 wks gestation fasting is not necessary ○ 50 grams oral glucose loaded, followed by plasma glucose analysis 1 hour later ○ Positive glucose screening is 130-140 or greater additional testing with a 3 hour oral glucose tolerance test is indicated Oral glucose tolerance test (3 hour); ● Following overnight fasting , no caffeine, and abstinence of 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 1,2,3 hr following glucose ingestion ○ Total of 4 blood draws (fasting and one every hr for 3 hrs) ○ Two elevations are required to be diagnosed with gestational diabetes Prenatal Screening: client education: Done w/in the first 12 weeks. Determine estimated due date. Obtain medical and nursing history to include social supports. Perform physical assessment to include pt baseline weight, v/s and pelvic exam. LABS- Blood type, RH factor, and presence of irregular antibodies. ● Indirect Coombs to identify pt sensitized to RH + blood. ● CBC to detect anemia, ● Hgb electrophoresis ( identifies sickle cell and thalassemia) Rubella titer, Hep B, ● Urinalysis to check pregnancy, HCG, DM, HTN, renal disease, infection. Pap test and vag/cervical culture. ● PPD (tuberculosis screen) ● VDRL ( test for syphilis), HIV, screen for TORCH, a...