NUR 230 Exam 2 - Intrapartum, postpartum and newborn assessments PDF

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Intrapartum, postpartum and newborn assessments...

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NUR230: Exam 2

Labor o Intrapartum Assessment – WNL i. Biophysical profile 1. Test for fetal asphyxia 2. Advise pt to drink 1 qt of water prior to test to fill bladder and stabilize uterus, assist pt into supine position with a small pillow under head and knees 3. Variables: o FHR i. Reactive = 2 ii. Non reactive = 0 o Fetal breathing movements o Gross body movements o Fetal tone o Qualitative amniotic fluid volume: i. Pockets absent or < 2cm = 0 = oligohydramnios o ii. amniotic fluid volume, iii. non stress test, iv. fetal heart rate, v. leopold manuvers (place rolled towel under hip to displace uterus off of vena cava) o BUBBLE-HE etc

i. o Uterine Fundus i. Involution: when uterus returns to normal size ii. Boggy: flaccid iii. Massage: to prevent hemorrhage & stimulate prostaglandin release iv. Midline: palpable between symphysis pubis and umbilicus Lochia vs Hemorrhage  

How much is too much? o More than one pad an hour. You should call your doctor. How long is too long?

NUR230: Exam 2

o it usually lasts 4-6 weeks after birth. Vaginal postpartum bleeding, or lochia, is the heavy flow of blood and mucus that starts after delivery. For about three days after you give birth, lochia is typically dark red in color. Vaginal Exam   

Effacement- is the thinning of the cervix, which is measured in percentages. When your 100 percent effaced, your cervix has thinned enough for your baby to be born Dilation- the action or condition of becoming or being made wider, larger, or more open. Station- The fetal station is the relationship of the presenting part (head/buttocks/feet) to the ischial spines (assessed vaginally). It is measured in centimeters above (-) or below (+) the ischial spines.

Stages of Labor (times) i. First Stage 1. Latent/Early o Nullipara: 7.3-8.6hr o Multipara: 4.1-5.3hr 2. Active/Transition o Nullipara: 6-13.3hr o Multipara: 5.7-7.5 ii. Second Stage 1. Nullipara: 36-57 minutes 2. Multipara: 17-19 minutes o **With epidural i. Nullipara: 336 minutes ii. Multipara: 225 minutes iii. Third Stage 1. 30 minutes or less GROUP-B STREPTOCOCCUS (GBS) 

Symptoms in newborns include fever, trouble feeding, and lethargy. Adults who are immunocompromised may get a urinary tract or blood infection, or pneumonia. Treatment includes antibiotics. Tested around 36-37 weeks

CONTRACTIONS o Frequency: time between the beginning of one contraction and the beginning of the next contraction o Duration: measured from the beginning of one contraction and the beginning of the next contraction o Intensity: the strength of the uterine contraction during acme. Estimated by palpating the contraction. determines whether mild, moderate, or strong by judging amount of indentability of uterine wall during contraction. Can also be measured by intrauterine catheter attached to fetal monitor. Cannot be accurately measured by external monitoring due to maternal weight, specifically amount of adipose tissue

NUR230: Exam 2

POSTPARTUM o Assessment Day 1 i. Vital Signs 1. BP should remain consistent with BP during pregnancy 2. Pulse: 50-90 beats/min 3. May be bradycardia if 50-70 4. Respirations: 16-24/min 5. Temperature: 36.2-38 C (97.1-100.4 F) ii. Breasts 1. General Appearance o Smooth, even pigmentation o One may appear larger 2. Palpation o Soft, filling, full, or engorged 3. Nipples o Supple, pigmentation, intact o Become erect when stimulated iii. Lungs 1. Clear to bases bilaterally iv. Abdomen 1. Musculature o Soft, doughy texture o Rectus muscle intact 2. Fundus o Firm, midline o Following expected process of involution o May be tender when palpated o Cesarean incision dressing dry and in tact 3. Lochia o Scant to moderate amount o Earthy odor o No clots o Normal Progression: RUBRA 4. Perineum o Slight edema and bruising / intact perineum 5. Episiotomy o No redness, edema, ecchymosis, or discharge o Edges well approximated—skin lining up nicely o REEDA 6. Hemorrhoids o None present / if present = small and nontender v. Costovertebral Angle (CVA) Tenderness 1. NONE – if present à kidney infection

NUR230: Exam 2

vi. Lower Extremities 1. No pain upon palpation 2. Negative Homans sign vii. Elimination 1. Urinary Output o Sufficient quantities at least every 4-6 hours o Bladder NOT palpable 2. Bowel Elimination o Should have normal bowel movement by second or third day after birth viii. Psychological Adaptation 1. Passive; preoccupied with own needs 2. May talk about her labor and birth experience 3. Could be talkative, elated, or very quiet 4. By hour 12: beginning to assume responsibility o Eager to learn o Others may be easily overwhelmed ix. Attachment 1. En face position: holds baby close 2. Cuddles and soothes 3. Calls by name 4. Identifies characteristics of family members in baby 5. May be awkward in providing care 6. May initially express disappointment over sex or appearance of baby o Nursing Care POSTPARTUM BLUES VS DEPRESSION  

Blues: feelings of sadness, lack of appetite, sleep pattern disturbances, feeling of inadequacies, crying easily for no apparent reason, restlessness, insomnia, fatigue, headache, anxiety, anger, sadness, crying Depression: feelings of guilt and inadequacies, irritability, anxiety, fatigue persisting beyond a reasonable amount of time, feeling of loss, lack of appetite, persistent feelings of sadness, intense mood swings, sleep pattern disturbance, crying, weight loss, flat affect, irritability, rejection of the infant, severe anxiety and panic attack PREGNANCY COMPLICATIONS

PREECLAMPSIA 

New onset hypertension after 20 weeks with proteinuria

S/S:     

Arteriolar vasocontriction and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field. Hypeactive reflexes of 3+ and 4+. Increased amount of urinary protein that is greater then 500mg in a 24hr specimen. Decreased urine output or oliguria of 20ml or less than 400 to 500ml in 24hrs HTN > 140/90

NUR230: Exam 2

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Both must be present on two occasions greater than 6 hours apart Generalized and/or severe edema is supportive of diagnosis but not in criteria

Risk Factors: nulliparity, maternal age > 40, twin gestation, preeclampsia in prior pregnancy, chronic HTN, chronic renal disease, antiphospholipid syndrome, elevated BMI, diabetes mellitus Prevention: calcium supplementation, low dose aspirin (71-81 mg daily) 

Progresses to eclampsia when seizures occur

Diagnostic Criteria for severe preeclampsia: headaches, visual disturbances, pulmonary edema, hepatic dysfunctions, RUQ or epigastric pain, oliguria, elevated creatinine, proteinuria 5 grams or more in 24 hours, systolic BP > 60 mmHg, diastolic BP > 110 mmHg, thrombocytopenia or hemolysis Management: admit to hospital, monitor closely at bedrest Treatment goals: prevent seizures, lower BP to prevent cerebral hemorrhage, expedite delivery, balancing maternal condition and fetal maturity. __________________________________________________________________________________________ DISSEMINATED INTRAVASCULAR COAGULATION (DIC)   

Imbalance between thrombotic and antithrombotic pathways Bleeding and clotting at the same time Decreased perfusion and SHOCK

Signs: Bleeding, oozing from IV sites, gums, abdominal distention, occult blood loss (stool/GI bleed), petechiae Labs: Increased PT, increased PTT, increased D Dimer, decreased Fibrinogen, decreased Platelets Treatment: RBC transfusion, FFP/Clotting factors, platelets, TRANSFER TO ICU __________________________________________________________________________________________ HELLP   

Hemolysis Elevated liver enzymes Low Platelets

Signs - RUQ pain/tenderness-- liver distension/ N/V / severe edema Labs - thrombocytopenia/ increased liver enzymes/ damaged RBCs Treatment - platelet transfusion/ or delivery of fetus Associated problems: Hypoglycemia, hypocalcemia, asphyxia at birth, meconium aspiration, infection, polycythemia, pulm/cerebral hemorrhage NO increased risk for HTN later in life for these patients __________________________________________________________________________________________ Placental Abruption

NUR230: Exam 2

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is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. a. Partial i. Vaginal bleeding ii. No increase in uterine pain b. Severe i. Vaginal bleeding ii. Extreme tenderness of abdominal area iii. Rigid/board-like abdomen iv. Increase in size of abdomen Occurs after 20 weeks, very dangerous PAINFUL dark red vaginal Bleeding ***** Uterine tenderness, rigidity Contraction Fetal distress- death Hypovolemic shock Testing: H/H, coags, DIC labs, type and cross, Kleinhauer-Betke (blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother's bloodstream.), Ultrasound

 Cocaine use increases the risk of vasoconstriction and possible abruptio placenta __________________________________________________________________________________________ Placental Previa       

occurs when a baby's placenta partially or totally covers the mother's cervix — the outlet for the uterus. Placenta previa can cause severe bleeding during pregnancy and delivery. If you have placenta previa, you might bleed throughout your pregnancy and during your delivery. Painless vaginal bleeding after the 7th month PAINLESS bright red bleeding *** Placenta is close to or grows over the cervical os Can be discovered early and monitored. Usually grows away from cervix and resolves. If still there at term, c section

Gestational Diabetes: is a condition in which your blood sugar levels become high during pregnancy. Substance Abuse

Regular use of some drugs can cause neonatal abstinence syndrome (NAS), in which the baby goes through withdrawal upon birth.  NAS symptoms o Body shakes (tremors), seizures (convulsions), overactive reflexes (twitching) and tight muscle tone, sleep pattern disturbances, increased birth weights 

o Fussiness, excessive crying or having a high-pitched cry. o Poor feeding or sucking or slow weight gain. o Breathing problems, including breathing really fast.

NUR230: Exam 2 o Fever, sweating or blotchy skin.

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Long term effects of drug use o o o o o

birth defects low birth weight premature birth small head circumference sudden infant death syndrome (SIDS)

o What is more common, postpartum hemorrhage or HTN? i. READ THE QUESTION __________________________________________________________________________________________ C-SECTION Risks/Complications 

post surgery infection or fever

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too much blood loss injury to organs emergency hysterectomy blood clot reaction to medication or anesthesia emotional difficulties scar tissue and difficulty with future deliveries death of the mother harm to the baby

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DVT o Diagnostics

o Assessment Findings __________________________________________________________________________________________ NEWBORN ASSESSMENT Vital Signs  

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RR: 30-60 Pulse: 110-160 o If in a deep sleep as low as 70 o If crying as high as 180 Temp: 97.5-99 Bp: 50-70/ 30-25

Skin Traits 

Color should be consistent with ethnic background

NUR230: Exam 2

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Acrocyanosis, circumoral cyanosis, harlequin color change, or Mongolian spots ARE NORMAL!!!!!

APGAR

Reflexes      

Moro: hold infant in semi sitting position and allow head and trunk to fall backward to an angle of at least 30 degrees (should make a c with hands) Tonic Neck: with infant falling asleep or sleeping turn head quickly to one side Babinski: on the sole of the foot stroke upward on lateral aspect of foot then across ball of foot Planter: place thumb firmly on ball of foot Stepping: hold infant vertically allowing one foot to touch table surface Crawling: place newborn on abdomen

Injections – Vitamin K and 1st hep B injection Terminology 

Umbilical cord o Purpose: helps baby receive nourishment and oxygen in the womb through the placenta o Care? the cord will fall off in 7-10 days. it must be kept clean a dry. Make sure to fold the diaper below the stump so its exposed to the air and not to urine (after the stump falls off you make detect a little blood on diaper which is normal). to prevent infection, clean off the base of the stump with a cotton swab or gauze pad dipped in rubbing alcohol with each diaper change. o While waiting for cord to heal, avoid tub baths until it is healed completely (7-10 days after the stump falls off)

NUR230: Exam 2

o Warm weather: keep baby in only a diaper and t-shirt to let air circulate and aid the drying process. avoid bodysuit style tops until the cord falls off o s/s of infection o doesnt fall off in two weeks o bad smell o drainage from bottom of cord o naval and surrounding area become swollen and red o child develops a fever to appears unwell Acrocyanosis 

is blueness of the extremities (the hands and feet)

Respiratory Distress Syndrome S/S  

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Nasal flaring, rapid and shallow breathing, sternal retraction Pallor / Mottling o Poor peripheral circulation due to systemic HYPOtension o Vasoconstriction and pooling of independent areas Cyanosis o Blueish tint o Dependent on: i. Hemoglobin concentration ii. Peripheral circulation iii. Intensity and quality of viewing light iv. Acuity of observer’s color vision 1. Frankly visible in advanced hypoxia

Central Cyanosis: most easily detected in mucous membranes and tongue Cyanosis normal in hands and feet, not in mouth o Resolves with first breath Jaundice 

Metabolic alterations of respiratory distress predispose a newborn to dissociation of bilirubin o Bilirubin deposits in skin and CNS

Edema  

Characteristic in preterm newborns due to low protein concentration Hands and feet – resolve by 5th day

Respiratory System  

Tachypnea: over 60 breaths/minute o Easiest detectable sign of RDS Apnea: non-breathing episode longer than 20 seconds o Decreased oxygen saturation

NUR230: Exam 2

o Respiratory acidosis o Bradycardia Chest  

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Seesaw-like movement Labored respirations indicate severity of retractions o Grunting and nasal flaring o Retractions: inward pulling of soft parts of chest cage upon inspiration o Assisted ventilation may be needed Expiratory Grunt: Valsalva Maneuver in which the newborn exhales against a partially closed glottis o Produces audible groan Nasal Flaring Harsh breath sounds Fine inspiratory rales / rhonchi

Cardiovascular

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o Continuous systolic murmur audible o HR between 110-120 – bradycardia o PMI at fourth to fifth intercostal space/ left sternal border Hypothermia Muscle Tone o Flaccid, hypotonic, unresponsive to stimuli o Hypertonia and/or seizure activity

1st Void and Stool o Meconium: dark green or black material present in the large intestine of full-term newborn. First stool passed by newborn; 24-48 hours after delivery o Lanugo: fine, downy hair found on all body parts of the fetus, with exception of the palms and soles i. After 20 weeks gestation o Vernix: protective, cheese-like, whiteish substance made up of sebum and desquamated epithelial cells that is present on fetal skin o Molding: overlapping of cranial bones under pressure of the powers and demands of labor i. bones of face and cranial base = well fused and essentially fixed ii. frontal, parietal, and occipital bone = not fused iii. allow head to adjust as it passes through maternal pelvis o Sutures: membranous joints in fetal skull that unite cranial bones i. allow for molding of fetal skull ii. allows HCP to identify position of fetal had during vaginal examination o Presentation: determined by fetal lie i. refers to the body part of the fetus that enters the maternal pelvis first ii. MOST COMMON = cephalic iii. presenting part: portion of the fetus that is felt through cervix upon vaginal examination / determines presentation

NUR230: Exam 2

1. said to be “floating/ballotable” when freely moveable 2. malpresentation: breech and shoulder presentation o Engagement (of presenting part): occurs when largest diameter of presenting part reaches/passes through the pelvic inlet i. determined by vaginal examination ii. usually 2 weeks before term Medications 

Vitamin K! Given in vastus lateralis muscle. Babies don’t make vitamin k until 7 days after birth and it’s an important clotting factor

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Instill a prophylactic ophthalmic agent into both eyes of the newborn as prophylaxis against ophthalmia neonatorum up to two hours after the delivery, whether the delivery occurred vaginally or by Cesarean section

Heat Loss Methods 

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Convection: loss from body to cooler air current o Air conditions o Un-warmed o2 mask o Removal of infant heated incubator Radiation: body heat transferred to cooler surfaces and objects not in direct contact with body o Walls of a room o Cold objects placed near the baby Evaporation: loss when water is converted to vapor o After birth o Baths o Expired air o Phototherapy lights Conduction: loss of heat to cooler surface by direct skin contact o Chilled hands o Cool scales

Normal Weight loss for Infants After Birth (%): 5-10% __________________________________________________________________________________________ PRETERM NEWBORN ASSESSMENT 

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Skin: thin and transparent o Veins prominent over abdomen o Greater amount of lanugo Breasts: absent/decreased tissue Ears: relatively shapeless and flat o Little cartilage o Ear folds over onto itself and stays folded Scrotum: few rugae, smooth Testes: palpable in inguinal canal

NUR230: Exam 2

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Clitoris: prominent and labia majora are small and widely separated Vernix: covers newborn, full term baby has no vernix Hair: consistency of wool or fur o Lies in munches o Not silky single strands like full terms Skull: not as firm Square Window Sign: 90-degree angle/ flexing hand toward ventral forearm until resistance is felt Elbow Recoil: elbow has slower recoil and forms greater than 90-degree angle Popliteal Angle (degree of knee flexion): no resistance Scarf Sign: elbow will cross midline of chest Heel-to-Ear Extension: leg remains straight and foot goes to the ear or beyond Ankle Dorsiflexion:45-degree angle ankle to shin Head Lag: total lag Ventral Suspension: some flexion, not fully MEDICATIONS

MAGNESIUM SULFATE

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o Seizure prophylaxis o Loading dose = 4-6 g IV in 250 cc D5/W o Maintenance infusion 2 g/hour o Additional bolus of 2 g can be given over 3-5 minutes o Excretion: through kidneys **Remember** kidney function is often impaired in preeclampsia Contraindications: cardiac damage, heart block, impaired kidney function, and vaginal bleeding Side Effects: Flushing, warmth, H/A, hypotension, sweating, nystagmus, nausea, dry mouth, dysphoria, dizziness, slurred speech, awkward movement, and loss of appetite. Lethargy, sluggishness, pulmonary edema – if woman has preexisting conditions

Signs of Magnesium Toxicity o o o o

Diminished reflexes Decreased respiration rate / shallow Decreased LOC ...