NUR316 final sg s combined PDF

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FINAL SG’S Introduction to Maternity Nursing ● Review AWHONN’s role in establishing Standards of Care that influence nursing interventions; o Association for Women’s Health, Obstetrical, and Neonatal Nurses o Set the Standards of Care for maternity and gynecological nursing ● Transcultural question on appropriate cultural sensitivity, and nutritional practices. o As nurses, we must assess the client and family for specific requests they have, taboos, rituals, etc. that need to be integrated into the plan of care to foster cultural competence ▪ How can we adapt our care practices to give certain cultures what they need o Be careful with wording ● Infant mortality rates: what does it mean, what factors increase the risk for higher rates o Infant mortality rate: number of deaths during the first year of life per 1000 births o Risk factors: ▪ Low birth weight ▪ Preterm birth: improper prenatal care such as improper diet, drugs, chemicals ▪ Weight gain during pregnancy o NO: co-sleeping (parents, siblings, etc), sleeping in bed with baby, sleeping with toys in crib ▪ Baby needs to sleep with nothing in crib, on back o Morbidity= illness ● Review the goals of healthy People 2020—reflect on the nurse’s role in advocating for their achievement. Informed consent. o Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; o Achieve health equity, eliminate disparities, improve the health of all groups; o Create social and physical environments that promote good health for all; o Promote quality of life, healthy development, and healthy behavior across all life stages o Maternal specific-- prenatal care vitamins, going to doctor, doing everything someone should while pregnant-▪ Decrease infant mortality rate-- teach safe practices for parents ▪ Decrease preterm births ● Increase prenatal care ● Reducing low birth weight and preterm babies ▪ INCREASE AMOUNT OF WOMEN THAT ARE BREASTFEEDING and how long they breastfeed (6 months LOWEST- 1 year) ▪ Reduce C-section deliveries ● No vaginal squeeze ▪ Decrease alcohol and drug use ● Most women don’t know they are pregnant until 6-8 weeks o First 8 weeks is most important for fetal development ▪ Back to sleep; no co-sleeping; sleeping on flat surfaces with no toys, items in crib

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● Back and alone Informed consent: nurse’s goal is to assess understanding of patient as well as witness signature (informed consent is required for anything invasive// also need consent to give shots like vitamin K and hepatitis B; circumsion) ▪ 2 parents involved: informed consent must be agreed upon

Postpartum Physiology and Nursing Care: ● Normal expectations for BUBBLEHEAD assessment—all parts. o Normals after delivery ▪ white blood count can be up to 25,000-30,000 ▪ hemoglobin will drop slightly after birth (give iron if below 10) ▪ if someone is hemorrhaging their pulse will go up and their blood pressure will go down o Normal changes in fundus after delivery (expectations). ▪ Uterus decreases from 1 kg- 60/ 80 grams at 6 weeks with the fundal height steadily descending into the pelvis approximately 1 fingerbreadth (cm) ▪ By 24 hrs postpartum- uterus is same size as it was at 20 weeks gestation ▪ Should be at umbilicus and remain that way 24 hr after birth ▪ Fundus (top of uterus) descends 1-2 cm or 1-2 fingerbreadths every 24 hrs ▪ By 2 weeks postpartum that uterus has descended into the true pelvis ▪ Normally- U/U; over 2-3 weeks it goes down over pelvis ▪ We want fundus to be rock hard and firm ▪ If the fundus is soft and mushy (boggy), massage uterus to make it contract ▪ Fundus should be located midline; if it’s left or right, pt will need to void and then be reassessed for placement ▪ Cramping caused by involution of the uterus (afterpains) ▪ Increases with greater number of pregnancy ▪ Breastfeeding increases cramping ▪ Encourage patients to go to the bathroom every 2 hours; encourage them to breastfeed to increase oxytocin (causes the uterus to cramp, decreasing the bleeding); encourage pts to massage own uterusshow new mother how to find the top of her uterus and explain how it will decrease in size (especially those who bleed more) o Expected changes in lochia. ▪ Lochia contains blood, mucus, and uterine tissue ▪ Rubra: bright red color; bloody consistency; fleshy odor; contains small clots; transient flow increases during breastfeeding and upon rising; lasts 1-3 days after delivery (beyond day 3= possible retained placental fragments) ▪ Serosa: pinkish brown; serosanguineous consistency; lasts from day 4- 10 postpartum ▪ Alba: yellowish white cream color, fleshy odor; lasts from day 11- 4-8 weeks postpartum

● Flow of serosa or alba beyond normal amount of time could indicate possible endometritis esp. if accompanied by fever, infection, abdominal tenderness ▪ First few days= heavy; progresses to moderate—light ▪ Can have bleeding for up to 6 weeks after delivery (not excessivedoes change color) ● Scant= less than 2.5 cm ● Light= 2.5-10 cm ● Moderate= more than 10 cm ● Excessive= one pad saturated in 15 min or less, or pooling of blood under buttocks (can indicate hemorrhage if prolonged) ▪ Foul odor= infection ● Nursing interventions for common postpartum discomforts (can be discomfort or pain depending on perception) and prevention of complications, and nursing actions for complications. o What interventions- ice packs, massage uterus, dermoplast (benzocaine numbing spray) o Milk coming in can hurt o After labor pains - muscle tightness - give motrin (drug of choice), MASSAGE MAKES PAIN WORSE but it does help decrease bleeding, if in pain take her to use the bathroom (her bladder could be pushing and causing pain), heated blanket o If they have an episiotomy - give witch hazel pads, ice, lidocaine/benzocaine spray (caine=numbing), sitz bath, spray with warmed peri bottle, doughnut pillow (bottom won’t be directly on surface), may put ice pack in donut hole ● Expected changes in vital signs and appropriate nursing interventions, labs and general systems o Greatest risks during postpartum period: hemorrhage, shock, infection o VS: bleeding- increased pulse, decreased BP (hemorrhaging) ▪ Possible orthostatic hypotension within first 48 hours ▪ Elevated pulse, stroke volume, and cardiac output within first hour postpartum and then gradually decreases to baseline by 8-10 weeks ▪ Elevation of temp to 38 degrees resulting from dehydration after labor-- should return to normal within 24 hours postpartum ▪ VS should remain about the same ▪ VS (BP and pulse) should be checked at least every 15 minutes for the first 2 hours after birth; temperature should be assessed every 4 hours for the first 8 hours after birth and then at least every 8 hours o Lab tests: CBC monitoring Hgb, Hct, WBC, platelet counts ● Anticipatory guidance for self-care of the postpartum patient. o Care of episiotomy in the postpartum period-ice vs heat etc. ▪ For stitches and swelling o Thrombophlebitis prevention, afterbirth pain, ▪ SCDs, up and ambulating (especially C-section mom) ▪ Cramps- breastfeeding from the uterus contracting ● Pain is worse for moms who have many babies (uterus works harder to move down) ● IBUPROFEN o Rubella-patient education and administration

▪ Subq injection post- birth; can breastfeed but can’t get pregnant before 1-3 months ● Psychological Adaptation: Attachment process for both mom and dad, Taking In and Taking Hold characteristics o dad can start feeling the pain mom is going through (sympathy illness) ● Newborn discharge teaching. o Circ care, normal infant temps, falls, baby sleeps on back, if the baby has color changes/ rapid breathing, baby isn’t eating, looks yellow, not waking up for feedings o Care plan in maternal book has more info o Feeding - feed on a schedule, around 8 times a day (about every 3 hours), if baby goes over 5 hours it will have a hard time feeding, diabetic babies, small babies and premature babies (before 37 weeks) need a feeding schedule o How to hold a baby - en face, keep head higher than feet o Don’t leave them alone with bottle, don’t heat up milk, twirl the milk in bottles, use nursery water until they are old enough to use tap water in their area, properly sterilize and clean the bottle and its parts o Breast pumps - sterilize pump periodically, use clean technique when washing it o How to change a diaper, wipe front to back o Types of poop ▪ meconium - thick and tarry ▪ add other kinds

Adaptation to Extrauterine life & Initial Newborn Care ● Assessment parameters that differentiate full-term and preterm neonates Criteria for Full term, Preterm by gestational age. o JANESSA- creases on feet (more= full term); vernix (less vernix= full term); breast bud development; posture and tone; linugo; ears (floppy ears= premee) ● Ballard gestational age assessment scoring criteria. ● Review newborn reflexes. o Suction, startle, babinski’s, stepping reflex—tests neurological function and intact ● Review newborn assessment guide for normal variations in the newborn—eg. Vernix, Epstein pearls, caput succedaneum, mottling, acrocyanosis, central cyanosis o Vernix - White, cheesy coating on skin o Epstein pearls- white, yellow cysts on gums and mouth (painless and normal)

Caput succedaneum- doesn’t grow in size; pushes past suture line; scalp against the cervix ▪ Disappears within a few hours or days o Cephalohematoma- caused by hemorrhage; increases in 2-3 days; doesn’t push past suture line; increased risk for intracranial bleeding ▪ Vacuum babies o Mottling: lacy network of blood vessels; cold temps produce vasospasm o Acrocyanosis: hands and feet turn blue; painless; hands and feet are the last to get circulation o Central cyanosis: reduced O2 saturation; after 10 minutes of age= abnormal; check pulse ox and breathing (initially, is normal) Signs and symptoms of jaundice o Yellow- tan skin; whites of eyes get yellow; lethargic; don’t want to eat or wake up o Look at bilirubin levels—when baby poops really good, they are releasing the bilirubin Thermoregulation—four types (causes) of heat loss, understanding cold stress, ways of producing heat in the neonate o Infants have decreased adipose tissue; try to conserve functioning when they are cold—won’t eat o Lots of skin to skin or warmer; lethargic babies are more likely to eat when they are warm Circulatory changes in the newborn adapting to extrauterine life o Duct may not have closed before until after birth; causes murmurs Sleep awake states; normal newborn vital signs and characteristics of pulse and respirations at birth. o Fetal vital signs norms: ▪ Temp: 97.5- 100.4--- keep baby warm, not too warm ● Irradiant warmer, naked except diaper ▪ HR: 110-160 ▪ RR: 30-60 ▪ BP: 80/60- 40/30-- 64/41 is normal ▪ Strong, lusty cry o Periodic breathers, fast heart rate Review what is essential to know BEFORE baby is born if you are to be the nurse resuscitating the baby and what has immediate implications for nursing care. o Gestational age o Meds that mom has; med history; meconium fluid; how long has mom been ruptured; fetal distress on monitor; does mom have fever; is mom beta strep positive o Warmer on, stethoscope, pulse ox, oxygen, someone who knows how to do resuscitation Understand steps in immediate newborn care, what is first, what is priority. o Airway, breathing, circulation, warmth Review priorities of care in the delivery room and appropriate nursing interventions in the delivery room for the baby. o Ready for baby o Keeping them warm and dry APGAR Scoring o

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APGAR= appearance, pulse, grimace, activity, respirations ▪ Appearance-- color ● 0= blue, pale; 1= pink body, cyanotic hands, and feet (acrocyanosis), 2= completely pink ▪ Pulse-- HR ● 0= absent; 1= slow, less than 100/ min; 2= greater than 100/min ▪ Grimace-- reflex irritability ● 0= none; 1= grimace; 2= cry ▪ Activity-- muscle tone ● 0= flaccid; 1= some flexion in extremities; 2= well-flexed ▪ Respirations=RR ● 0= absent; 1= slow, weak cry; 2= good cry ▪ 8-10 = good ▪ 5-7= need little bit of O2 ▪ 3-4= baby may need compressions, more O2 ▪ 1-3= baby is getting WORKED

● Newborn prophylaxis medications used, dosage, and rationale for administration. ● What is the newborn metabolic screening (includes the PKU). o Test after 24 hours- state mandated test (PKU test) o Metabolic disorders that could cause serious issues ● Anticipatory guidance for parents of newborn re: safety, positioning, bathing, basic infant care, proper circumcision care, when to notify pediatrician. Newborn bonding.skin to skin, mom and dads both involved in care o Reduce risk of SIDs, don’t overheat the baby, check water temps, don’t need bathed every day (DRY SKIN), don’t bath until after umbilical cord falls off ● Proper bottle feeding techniques; differences between human milk and formula. o Bottle: don’t lay head flat; propped up and upwards ▪ Bottle filled- nipple filled ▪ Tilted a certain way so the baby doesn’t take in air ▪ Burp them every so often ▪ Don’t need a huge amount of formula at once (5 cc and increase) o Breast: decreased risk for SIDS ▪ Easier to digest ▪ Less health risks ▪ Better brain development ▪ Antibodies ▪ At least one year of breastfeeding ▪ Colostrum- contains antibodies to prevent infections ▪ Gain weight faster Hemolytic Disease of the Newborn: ● Know ● ● ●

the pathophysiology and the role of Rho-Immune Globulin (Rhophylac,Rhogam). How mother can develop antibodies if the baby is positive blood type Any negative blood- mom gets blood drawn If the baby is positive, give the mom rho gam!!

● RHo (D) immune globulin is administered within 72 hours to women who are RH-

negative and gave birth to infants who are RH- positive to prevent sensitization in future pregnancies ● Kleihauer- Betke test determine amount of fetal blood in maternal circulation if a large fetomaternal infusion is suspected; if 15 mL or more of fetal blood is detected, the mother should receive increased Rho (D) immune globulin dose ● Know the lab tests indicated for detection of Hemolytic Disease in both the mother and the baby. Know the nurse’s role in administration of Rho-Immune Globulin and how it works ● Know symptoms and complications of erythroblastosis and hydrops.

Extra Notes ● ● ● ● ● ● ● ● ● ● ●

Premature - born before 37 weeks Neonate - birth until 28 days Infant - birth until a year old Once baby is born - know what to assess, what they should look like (apgar, newborn assessment) Babies pee very little first day, then about 25 times a day for a few days, then evens out to about 6-8 times a day Give baby a ritual (ex. change diaper, then get milk, then hold - if you mix up this order the baby will be confused and won’t be as happy) Decrease SIDS - DO NOT put baby on back to sleep, don’t have anything in the crib (no stuffed animals, no blankets (can do WRAPPED blankets), no bumper pads) Don’t smoke around kids Pacifier after a week of ago Light fan or air flow should be in babies room Understand different cultures may have certain things they want to do (sometimes only the father can sign things, in indian cultures the mom might need to be hand fed by grandma, majority of jewish can’t eat shellfish, etc)

Review Session 2/7/2019 ● ●

Discharge teaching found in care plan in book Feeding ○ 8 times a day or so ■ May not be on a perfect schedule but if you make a baby wait too long their blood sugar will drop and they will have trouble coordinating ■ If a baby is on glucose protocol, they need to eat every 3 hours ● diabetic babies, preemies (under 37 weeks), babies that are large for gestational age, small for gestational age ○ Don’t prop and walk away ○ Hold head above feet ○ Don’t microwave milk or formula ○ Don’t shake human milk

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Use nursery water for formula until they reach the age that is appropriate for their city ○ Clean bottle after every use ■ All the parts ■ Let it air dry Pumping - make it as clean as possible, wash your hands ○ Think about the fact that you’re preparing someone’s food Diaper changes ○ What to expect in the diapers Meconium - first poop ○ Bad if it happens while they’re in utero ■ Will stain fluid Prebirth - Want to know color of fluid, age of gestation, maternal risk factors Once baby is born - are they breathing, is their color okay, how is their muscle tone First day or two low urine output ○ Once mom’s milk is in (day 3-5) should have 6-8 wet diapers per day Newborn - not exact, just their first few days or weeks Neonate - up to 28 days old Infant - up to a year Babies like consistency ○ Kevin and the love channel SIDS Prevention ○ On back to sleep ○ Nothing in bed ○ No smoking around baby ○ Should be in a room with good air circulation Postpartum ○ Mom’s WBC can be up around 25,000 ○ Hemoglobin will have a slight drop ■ If it goes below 10 give iron ○ Hemorrhage ■ Pulse goes up ■ BP goes down ○ Cramping is both the uterus clamping to prevent bleeding and also working to get down to its original size ○ Discomforts depend on the person ■ Milk coming in ■ Cramping ● Ibuprofen is drug of choice ● Massage makes cramping worse but helps bleeding ● Emptying bladder will help with cramping ● Heat - warm blankets ■ Perineal tear ● Witch hazel ● Lidocaine/Benzocaine spray ○ Numbing ● Peri bottle with warm water spray ● Sitz bath - constantly flowing water ● Donut pillow to keep their bottom off the mattress ○ Ice or cooling pad ○ Taking In (1st)

■ more worried about self than baby - hungry, thirsty, survival tactics Taking Hold (2nd) ■ Teach me about the baby, how do we handle this when we get home ● Attachment for dad ○ Couvida - sympathy illness ■ Mom has nausea, dad may feel it too ○ Mom feels pregnant early, dad usually doesn’t really feel it until he can hear a heartbeat ● Don’t give rubella to mom, because it’s a live virus, until after pregnancy, shouldn’t get pregnant again for 3 months ○ Titer of less than 1:8 is administered subq injection of MMR during the postpartum period to protect a subsequent fetus from malformations ● Normal vitals for baby ● Ballard - gestational age scoring ○ Look at trends, don’t memorize each score ● Immediate newborn care ○ Dry and stimulate before anything - skin to skin or warmer ○ Suction mouth, then nose ● Rh stuff ○ Rh Neg mom gets RhoGam ● Mom gets TDAP vaccine while pregnant (ideally third trimester, to cross antibodies to baby when it’s born) ○ Recommended to get TDAP with each pregnancy to protect the baby ○ TDAP hurts a lot after the fact, arm gets stiff ● erythroblastosis ○

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Rh Neg mom blood interacts with Rh Pos baby, she becomes sensitized ■

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Antibodies will be sent to break open fetal blood cells, which will release bilirubin and cause jaundice

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Baby’s blood count will drop and cause him to become anemic

hydrops ○

Edema (little michelin man)

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Swelling around heart and organs will kill them ■

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Her next pregnancy will be affected

Abdomen will swell up

May also cause swelling in head, but the fontanelles leave some wiggle room

Anterior fontanelle closes first, around 1 year to 18 months

Adaptation to Extrauterine life & Initial Newborn Care  Review Newborn Assessment Study Guide o Vocab Terms

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Acrocyanosis: bluish discoloration of the hands and feet from sluggish circulation to the periphery  Normal right after birth. Assess for acrocyanosis a few hours later to make sure it goes away. Barlow’s Maneuver: Used to rule out congenital hip instability; done by flexion of legs, abduction of the hips, then downward pressure is exerted while ADDUCTION the thighs Caput Succedaneum: collection of fluid in the soft tissues of the scalp that may cross over the suture lines; caused by pressure on the head from pressing against the cervix dur...