Upgrade to remove ads
Only $35.99/year

Semester II, Exam I

Terms in this set (221)

What do Hbg and Hematocrit levels look like if mom has iron deficiency anemia?
Hgb < 11.0g/dl and Hematocrit < 33%
How much does a pregnant woman's blood increase by?
By 50% or 1500mL
Women develop hypercoagulation naturally during pregnancy. Name a benefit as well as a risk with this
Benefit: Decreased risk of PP hemorrhage
Risk: Increased risk of DVT
What are some musculoskeletal problems that are common in pregnant woman?
Low back pain, lig stretching, difficulty walking (preggo waddle), and leg cramps
Presumptive signs of pregnancy (subjective, perceived by woman)
Amenorrhea, nausea/vomiting, fatigue, urinary frequency, breast changes, quickening (1st time mom feels baby move)
Probable signs of pregnancy (objective)
-Chadwick's sign (Bluish discoloration of vaginal mucosa
-Goodell's sign (Softening of cervix upon palpation by MD)
-Uterine and Abdominal growth
-Skin hyperpigmentation
-Positive pregnancy test (NOT CONSIDERED DIAGNOSTIC TEST! THEREFORE IS PROBABLE)
Positive signs of pregnancy (objective but can only be attributed to the fetus)
-FH auscultation (as early as 4 wks)
-Fetal movement and palpation noted by provider
-Visualization thru ultrasound
WEEK TO WEEK- 1st Trimester, 2nd Trimester, 3rd Trimester
-1st Trimester = Conception-12 wks
-2nd Trimester = 13 wks-27 wks
-3rd Trimester = 28 wks to 40 wks
-Calculation of Gravida and Para

-What does Gravida mean?

-What does Para mean?

-What does the acronym "TPAL" stand for?
GTPAL
G= Number of times pregnant
Para= Births after 20 weeks gestation
T = # of term births
P= # of Pre-Term births
A = # of Abortions
L= # of children currently living
1. Nulligravida
2. Primigravida
3. Multigravida
1. Never been pregnant
2. Pregnant for the first time
3. Pregnant 2 or more times
Why is it important for a pregnant woman to have folic acid?
Prevents neural tube defects such as spinal bifida
How frequently are prenatal visits for women with uncomplicated pregnancies?
-Conception to 28 wks = every 4 wks
-29 wks to 36 wks = every other wk (q 2wks)
-37 wks to delivery = every week
What is the main goal of prenatal care?
-To maintain maternal/fetal health
-To gain an accurate determination of gestational age
-Implement appropriate interventions
-Build rapport
Initial Prenatal Assessment- What do we check (not including labs)
BP, weight, OB history, menstrual, contraceptive, medical and surgical, family health, psychosocial health
What labs do we obtain at initial prenatal assessment?
CBC, blood grouping, Rh Factor, VDRL (syphilis), Rubella Titer, Genetic screening for sickle cell and Tay-Sachs, Hep B Antigen, HIV, PPD, Urinalysis, Pap Smear, cevical cultures for Gonarrhea and Chlamydia
What are we checking for when we perform the urinalysis?
Protein, glucose, and keytones
At what time during pregnancy is the 1 hour glucola performed? What is a normal reading?
Glucola performed between 24-28 wks. Normal reading is < 140 (test is 1hr and is non-fasting)
At what time during pregnancy is the GBBS culture done (for group B beta strep?)
GBBS culture performed between 35-37wks
During normal return prenatal visits, what are we checking everytime?
Ultrasound, BP, weight, urinalysis, fundal height, Leopald's maneuver
What is a normal fetal heart rate?
110-160 BPM
When during pregnancy is a Maternal Serum Screen for Birth Defects (MSSBD)? It's a "quad screen", what serums are we checking?
-Alpha-Fetoprotein (produced by fetus)
-hGG
-Estriol
-Inhibin
What does a MSSBD test screen for?
Down Syndrome (trisomy 21) and Neural tube defects
If baby is suspected to have Down Syndrome, will Alpha-fetoprotein be high or low?
LOW
If baby is suspected to have Neural Tube defect will Alpha-fetoprotein be high or low?
HIGH
What are tests are performed to test fetal status and well being during 3rd Trimester (by mom and by MD)
-Kick counts: 1x/day; 4 movements in 1hr or 10 movements in 2hrs
-Nonstress Test: FH accelerations in respect to movement
-Vibroacoustic Stim Test: Only used if non stress test is non-reactive
If we have accelerations during a NST, what does that tell us?
That the baby has adequate oxygenation
What criteria are we looking for in a REACTIVE NST?
Need at least 2 accels; FHR must increase 15BPM x 15 seconds within 20 minutes
What is considered a NON REACTIVE NST?
Baby did not meet reactive critera within 40 mins
When is a vibro accoustic test performed? What are the risks?
-Vibro acoustic is performed if NST is non reactive.
-Risks: Potential fetal hearing loss
Prolonged fetal tachycardia
Spontaneous Abortion SAB
s/s: uterine bleeding or spotting, uterine contractions, cramping, pain
tx: conservative mgmt or D&C dilation and vacuum
What are you as the nurse responsible for doing if patient has SAB?
-Monitor bleeding; color, amount, odor
-Provide psychological support
Ectopic Pregnancy
Implantation of fertilized egg in area outside uterus
s/s: abdominal pain, delayed menses, vaginal bleeding/spotting 6wks p last menstrual period
What type of women are at risk for ectopic pregnancy?
Women who've had: h/o previous ectopic pregnancies
h/o PID
h/o surgery of reproductive organs
What are the nursing actions if patient has experienced ectopic pregnancy?
Offer explanations and reassurance related to the plan of care, ensure stabilization of cardiovascular status, and provide support related to the pregnancy loss.
What dangers are associated with ectopic pregnancy?
Hemorrhage related to rupture of fallopian tube, and decreased or sterile fertility
Hyperemesis Gravidarum
-It's persistant uncontrollable vomiting during pregnancy that leads to dehydration, weight loss, and acid-base imbalance.
If you suspect hyperemesis gravidarum, what would your assessment findings be?
Dry mucous membranes, poor skin turgor, malaise, and low BP
What are you as the nurse responsible for doing if patient has hyperemesis gravidarum?
-Assess emesis; amount, color, consistancy, odor
-Daily weight
-I&O
-Monitor electrolytes
-Maintain NPO
-BP
-IV fluids
-Assess mucous membranes, skin turgor
-Can administer vitamin B6 and antiemetics (zofran)
-Eliminate odors
-Provide oral hygeine
Gestational Trophoblastic Disease (Hydatiform Mole)
A benign proliferating growth of a trophoblast (it's a non viable pregnancy)
What would the assessment findings be if you were assessing for a Hydatiform Mole?
-Vaginal bleeding
-Hyperemesis (because of the excessive hCG levels)
What are the nursing actions if your patient experiences Hydatiform Mole?
-Offer emotional support related to pregnancy loss
-Explain to pt that hCG levels need to be monitored for 6 months b/c of risk of choriocarcinoma
Incompetent Cervix
Painless dilation of a defective cervic in absence of contractions
What are some risks the pregnant woman faces if she has an incompetent cervx?
-Repeated 2nd Trimester losses
-Preterm delivery
-Rupture of membranes
-Infection
How does the doctor test to see if the cervix is incompetent, and what does he do if it is?
Transvaginal ultrasound is performed to evaluate length and funneling of cervix. If it's incompetent, MD will place Cerlage (pursed string suture to reinforce cervix)
What are your nursing actions if mom has Cerlage placed to keep the cervix closed?
-Monitor uterine activity
-Monitor vaginal bleeding/leaking fluid
-Monitor for infection (lab values)
-Administer tocolytics as ordered
Rh Isoimmunization
What's injected? Who gets it? When is it given?
-Rhogam
-Rh negative pregnant women with negative antibodies
-Given at 28 weeks
Sometimes a woman needs an additional Rhogam shot after delivery. Who would be a candidate for this, and how long after delivery is it given?
- Mom needs additional shot of Rhogam if BOTH:
*baby is Rh positive
*Coomb's test is negative (screens for antibodies)
-Repeat injecion within 72 hrs after birth
Placenta Previa
When the placenta is implanted in the low segment of the uterus, near or over the cervix. Can be low lying, partial, or total
What are the clinical manifestations of placenta previa?
PAINLESS, BRIGHT RED uterine bleeding
Can a vaginal exam or pelvic exam be performed if you suspect placenta previa?
NO! A serile vaginal exam is contraindicated in ALL pregnant women with extensive vaginal bleeding until the source of bleeding is identified.
If a woman has placenta previa, what kinds of complications is she at risk for? What are the risks for the fetus
Mom: Hemorrhage and hypovolemic shock
Fetus: anemia, hypoxia, and death
What are the nursing actions during placenta previa?
-Insert large bore IV (anticipate blood replacement)
-Assess vaginal bleeding
-Monitor vital signs (risk of hypovolemia; decreased BP, tachycardia)
-Monitor uterine and fetal activity
-Maintain bedrest
-Administer corticosteroids if ordered (for lung mat.)
-Monitor CBC, platelets, and clotting studies
-Anticipate blood transfusion adn cesarean delivery
Abruptio Placenta **LEADING CAUSE OF DEATH
-MATERNAL AND FETAL
Partial or total separation of the placenta after 20 weeks but before the delivery (usually in 3rd trimester).
Classic Manifestations of Abruptio Placenta
-Sudden onset of severe abdominal pain
*uterine contractions
*uterine tenderness
*dark red vaginal bleeding (may or may not be visible)
What type of women are at risk for having Abruptio Placenta happen to them during pregnancy?
-Women with previous abruption
-Hypertensive disorders of pregnancy
-An abdominal trauma
-Women who use cocaine/cigs during pregnancy
What kinds of scary things can happen to a woman experiencing abruptio placenta?
-Hemorrhagic shock
-Disseminated intravascular coagulation
-Hypoxic damage to organs such as kidneys and liver
-Postpartum hemorrhage
What are your nursing actions for a woman who experiences Abruptio Placenta?
-Monitor vaginal bleeding/abdominal pain
-Palpate uterus for contractions/tenderness/distension/hypertonus
-Monitor maternal hypotension & tachycardia
-Monitor CBC & clotting studies
-Assess FHR and activity
-Offer emotional support
What are some hypertensive disorders of pregnancy?
Preeclampsia and Eclampsia
Preeclampsia
Hypertensive disease accompanied by proteinuria developing after the 20th week of gestation
Eclampsia
A convulsive stage of preeclampsia disease
What is the cause of preeclampsia?
Cause is unknown
What type of women are at risk of developing preeclampsia during pregnancy?
-Nulliparity
-Younger than 19 or older than 35
-Obesity
-Multiple gestation
-History of preeclampsia
-Preexisting hypertension
-Kidney disease
-diabetes
What is the cure for preeclampsia-Eclampsia?
DELIVERY!
Classic Manifestations of Preeclampsia
-BP 140/90 or greater
-Proteinuria (1+ or greater)
-Epigastric pain
-CNS changes
*headache
*visual changes
*DTR's (hyperreflexia)
What is the goal when treating preeclampsia?
To control BP and to prevent seizures!
What are the nursing actions for a pregnant woman who has preeclampsia?
-Monitor BP while in a sitting position
-Obtain daily weight
-Assess edema
-Strict I&O
-Perform fetal monitoring as ordered
-Maintain bedrest in lateral recumbent position
*DOC may order anticonvulsant (magnesium sulfate) or an antihypertensive (beta blocker)
What is HELLP syndrome? How do we diagnose?
Hemolysis (RBC destruction/anemia/jaundice), Elevated Liver enzymes (liver damage), Low Platelets
It's a complication of severe preeclampsia. We diagnose by lab results
If a pregnant woman has cardiac disease, what extra precautions are taken?
-Frequent office visits to OB and cardiologist, b/c exacerbation of cardiac disease can occur due to normal cardiac changes in pregnancy
What are some signs that a pregnant patient with cardiac disease is having a problem?

(Pre term delivery and/or C-Section may be indicated)
-Dyspnea -thromboembolic changes
-Orthopnea -palpitations
-Syncope -fluid retention
-Chest pain w/ activity
What are risks a pregnant woman w/ Pregestational Diabetes faces?
-infection (related to hyperglycemia)
-spontaneous abortion
-preterm labor
-polyhydramnios/oligohydramnios
-hypertensive disorders and preeclampsia
NEWBORN HAS INCREASED INCIDENCE OF CARDIAC AND CNS ANOMALIES
If a woman fails her glucose screening, gestational diabetes is suspected. We have to do further testing to diagnose. How do we test and what are results if woman is positive for GDM?
Perform 3 hour glucose tolerance test. If 2 or more results are elevated, a dx of Gestational diabetes is made.
What are your nursing actions for a pregnant woman who has gestational diabetes (GDM)?
TEACHING
-self-monitoring blood glucose
-self-administration of insulin
-dietary management
-exercise needs
-identifying s/s of hypoclycemia and hyperglycemia
What does TORCH stand for?
***THESE CAN ALL CROSS THE PLACENTA AND HAVE TERATOGENIC TO THE FETUS
Toxoplasmosis
Other (Hepatitis B)
Rubella
Cytomegalovirus
Herpes simplex virus
What is Group B Strep (GBS)?
It's an asymptomatic bacteria that colonizes in the rectum, vagina, cervix, and urethra
When do we test pregnant woman for group b strep, and how is testing performed?
Woman is tested at 35-37wks, and is done by vaginal and rectal cultures
Transmission rate of GBS is low, but what dangers does the neonate face if it's transmitted?
-Sepsis
-Pneumonia
-Meningitis
Let's say a pregnant woman has GBS. What do we give her during labor?
Penicillin is administered during labor as a prophylactic.
How is HIV transmitted to the fetus during pregnancy?
Through the placenta
Why do we avoid amniocentesis and episiotomy in woman with HIV?
To avoid the risk of maternal blood exposure
Why is fetal monitoring and forceps contraindicated in pregnant mom's who have HIV?
To avoid the risk of fetal bleeding.
What is Chorionic Villus Sampling (CVS)? When is it performed?
It's an aspiration of a small amount of placental tissue (chorion) to detect fetal abmormalities, DNA testing, and metabolic testing to diagnose cystic fibrosis. CVS is done between 10-12 weeks gestation. NOT recommended before 10wks.
What types of pregnant women usually need to have a CVS test?
Pregnant women who are of advanced maternal age, and also high risk pregnancy patients.
What are the risks of having a CVS?
Fetal loss and bleeding
What are the post procedure nursing actions you will perform if a woman has a CVS?
-Instruct patient to report abdominal pain/cramping/leaking of fluid, bleeding, fever, or chills
-Administer rhogam if mother is Rh negative
What does an amniocentesis test for? When is this test usually performed?
It's a diagnostic test that is used to diagnose genetic disorders, fetal lung maturity, hemolytic disease of the fetus, and intrauterine infection. Whis is performed at different times during 2nd and 3rd trimester depending on the reason.
What are some advantages of an amniocentesis?
-It's a simple procedure which is relatively safe and painless
-Identifies genetic disorders
What are some disadvantages of an amniocentesis?
-They're performed late in pregnancy
-Results take 2 weeks to come in
What are the risks of amniocentesis?
-Low risk of spontaneous abortion
-May cause uterine contractions
What are your nursing actions when amniocentesis will be occuring?
-Obtain baseline maternal BP and FHR
-continue to monitor fetal and maternal well being for 30-60 mins after procedure
-Instruct pt to report cramping, leakage of fluid, bleeding, fever, chills, decreased fetal movement
-Administer Rhogam to Rh negative woman post procedure as ordered
What do bacterial infections do to a pregnant woman's chorioamniotic membranes?
Bacterial infections weaken membranes leading to rupture.
PROM has 2 meanings in regards to ruptured membranes. What are they?
Premature Rupture of Membranes (rupture of chorioamniotic membranes before the onset of labor)
Prolonged Rupture of Membranes (membranes that have ruptured for prolonged period of time >24 hrs)
Define PPROM
Preterm Premature Rupture of Membranes: Rupture of membranes @ <37 weeks gestation
What types of pregnant women are at risk for PPROM (preterm premature rupture of membranes)?
-Previous PPROM -Previous preterm delivery
-Bleeding during pregnancy -Multiple gestation
-STDs -Cigarette smoking
What risks does a woman face if she has a PPROM (preterm premature rupture of membranes)?
-Chorioamnionitis -Preterm labor or preterm birth
-Neonatal Sepsis
-Increased probability of C-Section
If a woman has PPROM (preterm premature rupture of membranes), what should your nursing actions be? (What kinds of things are you monitoring)
*Monitor for infection; Signs of infection:
-Fever -Maternal and fetal tachycardia
-Foul smelling vaginal discharge
*Monitor for labor
-Monitor for fetal compromise
-Administer antibiotics as ordered
Preterm Labor Diagnosis
gestation age must be greater than 20 weeks but less than 37 weeks. 6 or more uterine contractions per hour PLUS ONE OF THE FOLLOWING:
-Rupture of membranes
-Cervical change (1cm or more dialated OR 80% effaced)
What types of pregnant women are at risk for preterm labor?
-Multiple gestation (twins, triplets, etc)
-genitourinary infection
-Uterine/cervical abnormalities
-Preterm rupture of membranes
-Domestic violence
- <17 or >35 years of age
Preterm Labor Care
-vaginal and urine cultures
-tocolytic drugs to suppress contractions (focus is to delay delivery at least 72 hrs to facilitate fetal lung maturity from steroids
-corticosteroids to accelerate lung maturity
-IV hydration
-bedrest
You are responsible for teaching a pregnant who was in for PTL (pre-term labor). Baby is still in utero. You need to review what warning signs need to be reported immediately. What are they?
Call MD IMMEDIATELY if:
-Bag of water breaks
-Baby stops moving
-Contractions
-Low back pain, menstrual cramps, pelvic pressure
-Fever > 100.4 degrees
-Feel like "something isn't right"
What is an Apgar Score?
The Apgar score is a rapid assessment of 5 physiological signs that indicate the physiological status of the newborn
What are the 5 physiological signs assessed during Apgar? At what time intervals is this assessment made?
-HEART RATE (auscultated)
-RESPIRATORY RATE (observe movement of chest)
-MUSCLE TONE (based on degree of flexion and movement of extremities)
-REFLEX IRRITABILITY (based on response to tactile stimulation)
-COLOR (based on observation)
*performed @ 1min p birth and @ 5 mins p birth by RN
What is a good Apgar Score (requires no intervention)
Final Apgar Score of 7 or greater requires no intervention
What is a bad Apgar Score (requires intervention)
Less than 7 requires intervention
What is the normal temperature of a newborn?
97.7 - 99 degrees Fahrenhight (axillary)
(36.5 - 37.2 degrees celcius)
What is the normal pulse of a newborn?
120-160BPM
What is the normal respiration rate for a newborn?
30 - 60 breaths per minute (count for a full minute)
What else are you looking at when assessing RR of newborn?
Observe color, especially lips (tachypnea, apnea)
What is a normal BP for a newborn?
Systolic: 50-75 Diastolic: 30-45
When we palpate a newborns peripheral pulses, we palpate for presence, quality, and equality. What pulses are used, which is best?
FEMORAL IS BEST! Can also check brachial and pedal.
**CHECK FOR WARMTH IN EACH FOOT!
What is the normal weight of a newborn?
2500-4000 grams (5lbs. 8oz - 8lbs. 13oz.)
Why is it normal for babies to lose up to 10% of their birth weight within the first few days?
-Burning calories to stay warm
-Eliminating waste
-Feeding (baby is learning to eat, no longer gets nutrition directly from placenta).
By how many days old should the baby be back to it's birth weight after losing a little?
Baby should be back to birth weight within about 10 days
What are the normal measurements for a baby's head, chest, and length?
(Circumferences)
-Head: 33-35.5cm (13-14in.)
-Chest: 30.5-33cm (12-13in.)
-Length: 45-53cm (19-21in.)
-Abdominal girth (varies)
Normal newborn Posture
-Extremities flexed
-Hands clenched
-Symmetrical movements
-Slight tremors on crying
What are some possible causes of a newborn's limbs being outstretched?
-Premature birth
-Neurological problems
-Effects of meds given to mom during labor
-Drug withdrawl
-Too much tone
What strategies can a nurse suggest for parents to prevent shaken baby syndrome/abusive head trauma?
-Have someone come over to help
-Get support
-NEVER pick up the baby if you feel frustrated!
What is Vernix?
Vernix is a protective substance that covers the fetus during pregnancy. It looks white and cheesy. Presence of vernix on term baby mostly found in auxiliary and genital areas (premies have more)
What is Lanugo?
Fine downy hair taht gradually falls out. Abundant lanugo may be a sign of prematurity or genetic disorder.
When inspecting a baby's skin, what are you assessing and looking for?
-Color: Pink/tan with acrocyanosis (temp of skin will be warm, also check texture of skin)
-Intactness
-Birthmarks
-Rashes
-Bruises
-Vernix in creases at term
Small amounts of lanugo on shoulders, sides of face, forehead, upper back
Small amount of desquamation
What is Milia?
Exposed sebacious glands (white papules on face) more frequently seen on nose and chin. They resolve on their own. Teach parents to leave them alone.
What is Erythema toxicum?
It is a rash w/ red macules that have white papules in the center, surounded by reddened skin. This rash appears in different areas of the body, but usually the trunk area. This is baby's reaction to getting used to the environment.
What time frame does Erythema toxicum appear in a newborn?
Within 24 hours of birth and up to 2 weeks. (Disappears without treatment).
What is a hemangiome (Stork Bite)
It is a red spot (composed of dilated blood vessels) that will either go away on it's own or form a birthmark.
What is mottling?
This is a response to cold environment (blotchy skin; pink and white)
What are mongolian spots? Do they need to be documented?
Flat bluish discolored area on lower back or butt. More common in black, asian, Latin, and Native American babies. Resolves by school age. DOCUMENT size and location.
What is a Nevi, or cafe au lait spot?
It's a birthmark
What should you do during newborn assessment when inspecting head?
-Inspect the shape of the head, palpate the fontanels
-Sutures will be slightly seperated
-Anterior fontanel is diamond shaped; 2.5-4cm, soft and flat
-Posterior fontanel is triangle shaped; 0.5-1cm, soft and flat
-Hair will be silky, soft, curly, or straight
Is facial bruising normal in a newborn?
Can be normal from going thru birth canal.
Why might a newborn have a circular mark on his/her head?
If a scalp electrode was used during labor.
What is molding?
An elongation of the fetal head as it adapts to the birth canal. Resolves in 1 week.
What does Caput Succedaneum mean, and why does it occur?
Caput Succedaneum is a soft tissue edema of the scalp which feels spongy, and can cross the suture lines. Results from prolonged pressure of the head against the cervix during labor. Resolves within first week of life.
What is a Cephalhematoma and why does it occur?
A Cephalhematoma is unilateral hematoma on the baby's head. It appears within a few hours of birht and can increase over the next few days. Has well defined outline, and does not cross suture line. Related to trauma to the head due to prolonged labor, forceps delivery, or vacuum. Resolves within 3 months.
When we are assessing the newborns ears, what are we looking for?
Inspect for position, shape, drainage. Top of pinna is located @ level of outer canthus of eye. Skin tags are common. If ears are low set, can be developmental.
How do we know baby can hear if she hasn't had a hearing test yet?
Will display positive startle reflex to loud noises.
If there is a problem with baby's ears (positioning, shape, etc) what organ do we perform a focused assessment on?
Kidneys
When does a baby's eye color become permanent?
6 months of age
When assessing the newborn's eyes, what are we looking for?
-Assess for symmetry, color of sclera, pupil size and reaction
-Iris should appear blue-grey
-Scera will be bluish white
-Should follow object w/in 12 inches from face
When does a baby start to cry with tears?
No tears until 2 months
Transient strabismus
Cross eyes. Babies need a little time to focus. They're brand new!
When assessing the newborns nose, what are we looking for?
-Observe shape, and inspect nares for openings
-Test patency by closing mouth and pressing against 1 nostril at a time
What is a sign of newborn under respiratory distress?
Nasal flaring is a sign of respiratory distress.
When assessing the newborns mouth, what are we looking for?
-Inspect lips, gums, tongue, palate, mucus membranes
-Tongue should be pink and move freely
-Lips and palates should be intact
-Sucking pads present
-Positive rooting, sucking, swallowing, and gag reflexes
What does Epstein's Pearls mean?
It's a little cyst of epitheleal cells around lips or in lips and goes away within first 2 weeks.
When assessing the newborns neck, what are we looking for?
-Lift the chin to assess neck area
-Should have short neck with skin folds
-Turns head easily from side to side
-Raises head when prone
-Clavicles in tact
-Check for crepitus
-Positive tonic neck reflex
When inspecting the newborns chest, what are we looking for?
-Inspect shape, symmetry, chest excursion. Should be cylindrical/barrel-shapped, symmetrical.
-Nipples and breast buds present; breast engorgement/drainage may be present b/c of mom's hormones (will go away)
-Auscultate breath sounds
-Lungs should sound clear, and equal. Crackles are normal within the first few hours of birth
-Heart sounds, S1, S2 murmurs
When inspecting the newborns abdomen, what are we looking for?
Inspect shape and size
Should be round and soft
Should have positive bowel sounds
Umbilical cord- note 3 vessels, whitish-blue color, there should be no drainage.
If there are only 2 vessels in umbilical cord present, what might that mean?
Possible GI/GU abnormality
Can you put a baby in a tub bath before cord falls off?
NO! That's a risk of infection. Teach mom signs of infection
When inspecting a female newborn, how do we inspect the genitals, and what are we looking for?
-Inspect genitalia by placing thumbs on either side of labia and separate tissue
-Labia majora will be dark, and covor the clitoris and labia minora
-Clear/whit gavinal discharge present'
-Urinary meatus and vagina present at midline
What is pseudomenstruation?
Sometimes baby girl will have a little blood down there, but it is not menstruation.
What do you teach mom about changing baby's diaper?
How to change diaper, cleaning front to back, wash hands after changing.
Do you as a nurse need to wear gloves when changing baby's diaper?
YES!
A newborn infant is not circumsized yet. Should you retract the forskin to inspect it underneath?
NO! Do NOT retract the foreskin of the newborn baby boy.
When inspecting a male newborn, how do we inspect the genitals, and what are we looking for?
-inspect penis, position of meatus
-Meatus should be located at tip of penis
-Inspect and palpate scrotum
-Scrotum will be large and pendulous
-Rugae present on scrotum
-Testes within the scrotal sac.
What does hypospadias mean?
A congenital condition in males in which the opening of the urethra is on the underside of the penis. (hole isn't at tip like it should be).
What does epispadias mean?
a congenital condition in males in which the opening of the urethra is on the top side of the penis.
What is a hydrocele?
an accumulation of serous fluid, which sometimes occurs in a male infant. Sometimes the RN will shine a light thru it, b/c if it's usually translucient. If a dark spot is seen, it may be a clot or something else in there.
What are the 3 types of tools used for circumcision?
-Gomco Clamp
-Mogen Clamp
-PlastiBell
Care after circumcision
-Petroleum ointment/Vaseline applied to dressing and wrapped around incision for first 24 hours (unless bell)
-NO ointment for use of Plastibell
What should you be keeping track of after circumcision? What do you teach mom?
-Monitor for voiding, bleeding, and signs of infection. Demonstrate gauze dressing for circumcision.
How soon should a newborn void after birth?
Within 24 hours (should void 1-2x's)
What counts as a void?
-A little yellow spot will be on diaper. Urate crystals on diaper also counts as a void.
How do we document output on a newborn since we can't measure it?
Document voiding by counting wet diapers
How many wet diapers are we wanting baby to have per day?
About 6-8 wet diapers per day.
What does meconium mean?
It's the baby's first stool which is sticky, blackish, and tarry.
When inspecting newborn's rectum, what should it look like?
Inspect for patency. Sphincter should be tightly closed.
After the first stool (meconium), baby has transitional stool. What color is that?
Greenishblack/brown/yellow
How many stools should an infant have per day?
1-3 stools per day
What does a breast fed baby's stool look like and smell like?
Yellow, sour smelling, pasty/soft stool
What does a formula fed baby's stool look like and smell like?
Pale yellow/brown, more formed stool, unpleasant odor.
If newborn has hip displasia, what would we find in extremities?
either knee hight will be different, or gluteal and thigh folds will be unequal
How many creases should be in the babies palms?
Normally, there are 2 creases in human hands. If baby only has one crease, this is abnormal and is a concern. May be developmental issue like Down's.
What is it called when a baby only has one crease in its hands?
"Simian Crease"
What does polydactyly mean?
Extra fingers or toes
What does syndactyly mean?
Webbing of fingers (can be just a couple or all)
What is Ortolani's Maneuver, and do nurses asses?
this is a maneuver where the MD rocks the hips back and forth to make sure they're in place.
When inspecting the newborn's back, what are you looking for?
-Inspect and palpate spine, should be straight
-there should be no openings observed or palpated in vertibral column
-There should be no dimpling or tufts of hair
What is a Pilonidal dimple?
A condition that can occur anywhere along the crease between the buttocks, which runs from the bone at the bottom of the spine (sacrum) to the anus. If there is an opening there, it's a sign of a non-intact spinal column.
What if you are testing the neonate for palmer grasp reflex and response is absent or weak; what can this mean?
Absent or weak response indicates possible CNS defect; or nerve or muscle injury
Name some baby reflexes!
Palmer Grasp- grasps finger when you touch palm
Moro/Startle- baby jumps then cries when hearing loud noise
Tonic Neck- With baby in supine position, turns head side to side so that the chin is over the shoulder
Babinski Reflex- run finger from heel up to toes on lateral side, and baby will hyperextend and fan toes
Stepping or dancing- Neonate steps up and down in place.
What if you are testing neonate for Moro/Startle reflex and response is absent or weak; what can this mean?
Slow response for preterm infants pr sleepy neonates is normal. If baby does NOT react, possible deafness or neurological deficit. If response is asymmetrical, may be temporary or permanent injury to clavicle, humerus, or brachial plexus.
How long does a neonate's tonic neck reflex last?
Birth to about 6 months
What if a baby older than 6 months still displays tonic neck? What can this mean?
Response after 6 months may indicate cerebral palsy.
How long does the stepping and dancing reflex last?
Birth to 3-4 weeks
What if you are testing neonate for stepping and dancing reflex and response is diminished?
Diminished response may indicate hypotonia
What if you are testing a neonate for the Babinski reflex and response is absent or weak; what can this mean?
Absent or weak response may indicate neurological defect.
How do you test a baby's rooting reflex?
Brush side of cheek at corner of mouth, and baby will turn it's head toward your finger
What if you are testing neonate for rooting reflex and response is absent or weak; what can this mean?
May not respond if recently fed. Prematurity or neurological defects may cause weak or absent response.
How do you test a baby's plantar reflex
Place thumb firmly against the ball of the infant's foot; toes flex down in a grasping motion
What if you are testing a neonate for plantar grasp reflex and response is absent or diminished; what can this mean?
Weak or absent may indicate possible spinal cord injury
Why do we administer erythromycin ointment to a baby's eyes?
Just in case the baby has gonococcal or chlamydial eye infections
Explain route, dose, and procedure of the erythromycin ointment to eyes?
Hold application tube 1/2 inch from eye. Apply a 1/4 inch bead of ointment to lower eyelid of each eye.
Why do we give newborn's an injection of vitamin K?
To prevent hemorrhagic disease in neonates
Explain route, dose, and procedure of vitamin K injection to neonate
Injection is given IM, in middle third of leg. 0.5-1mg is giving with a 5/8 inch needle 25 gauge within first hour of birth
Neonate is congested and you need to use bulb syringe. Explain how you would do this.
Squeeze bulb prior to inserting. Always do mouth first, then nose. (just think clean to dirty; and nose has more germs)
Explain feeding a newborn> how often? how much? and when to burp.
Feed every 3-4 hours, start with 0.5 to 1 ounce (15-30 ml), burp half way and end of feeding. Elevate HOB for 20-30 mins after.
How many wet diapers a day and how many poopy diapers a day are normal?
6-8 wet diapers, and at least 1 poopy diaper per day.
If you were teaching mom about breastfeeding: explain a good latch
Before baby latches, her mouth will be wide open, and the lips will be flanged. She will see lower jaw movement and may hear audible swallowing.
If mom feels pain when baby starts to feed, how long will the pain last?
Latch pain should last no longer than 10 seconds. Pain beyond this is a sign of poor latch.
How can you provide comfort to mom while she's breastfeeding?
-Positioning (of mom and baby)
-Arms and back should be supported
-Use of pillows
-Provide privacy
-Provide positive reinforcement
Mom is ready to be discharged. You need to teach her about potential signs of illness in her newborn. What do you tell her?
-Behavior change; increased irritability, excessive crying without cause, extreme sleepiness or floppy arms and legs
-Loss of appetite
-Decrease in wet diapers
-Fontanels sunken or bulging
-Jaundice
-Skin rash
-Bleeding and/or foul odor from circa. or cord site
-Congested coug, running eyes or running nose
-Lethargy
-Watery, green stools
-Vomiting
-blue lip color or blue and pale colored skin.
What are the signs of a hungry baby?
-Awake -Licking lips, sticking tongue out
-Rooting -Turns toward breast while held
-Hand to mouth activity
-Fussing/crying...try to feed baby before this happens!
When performing a post partum assessment, we are systematic in using the "BUBBLE" acronym. What does BUBBLE stand for?
Breasts, uterus, bladder, bowel, loch, episiotomy/extremeties/emotional education
Explain what you are assessing during the "B" (breast assessment)
-Size and shape should be symmetrical. Assess the nipples. They should be everted; flat is still okay, inverted may be abnormal. Look for redness blisters, cracking and ask about PAIN!
How will you explain position of uterus in relation to umbilicus. Ex: fundus is 1cm above umbilicus or funds is 1cm below umbilicus
U +1
U -1
Explain what you are assessing during the "U" (uterus) assessment.
-Fundal height and tone; hight will descend 1cm/day (1 finger breath)**At umbilicus or below is good
-Consistency; Firm or boggy. If firm, should feel like an apple or a fist.
Explain what you are checking during the bladder assessment.
***You will only feel the bladder if it is distended. Normal=nonpalpable
-Assess amount, frequency, and difficulty initiating voiding 6-8 hrs after delivery
-Mom should have 300-400ml's per void
-Urin should be clear, yellow
If bladder is full, how does this displace the uterus? How can you tell the uterus is displaced?
If the bladder is full, the fundus is displaced from the midline
How can a full bladder affect bleeding? What are some signs of urinary retention?
If uterus is displaced, excessive lochia may occur.
Frequent voids of less than 150ml's at a time may indicate urinary retention.
It is normal for a woman's bladder and urethra to be edematous immediately postpartum. What can you do to promote urination?
-Early ambulation
-Use nursing tricks to stimulate voiding
What if mom doesn't void within 6-8 hours after birth? What may we have to do at that point?
-Bladder scan to assess whether straight cath may be needed.
What are we looking for during our bowel assessment for mom?
-Abdomen should be soft
-Assess bowel sounds (may be hypoactive if C section)
-Ask about flatus
-Check for hemorrhoids
-Ask date of last BM
**Ask about pain or discomfort while pooping
**Teach her how to prevent constipation
Explain what you are checking for during the loch assessment.
-Assess color, amount, and any clots
-If clots, assess size and consistency)
-Assess odor; should smell fleshy or musty. You will only smell a bad odor if there's an infection
When you are assessing the perineum, there are 3 options we are gonna have to pick from when we look down there. Hint: "intact"
Episiotomy (note if midline, R mediolateral, or L mediolateral)
Laceration
Intact perineum
When assessing perineum, we are going to see if there are any signs of REEDA. What does REEDA stand for?
Redness
Edema
Echimosis (bruising)
Drainage
Approximation
How will we position the woman when we are assessing the perineum?
Have mother lay on her side, and lift upper buttock to visualize perineum
What are we assessing if we are inspecting the incision site of a mom who had a C-Section
-Staples/Stitches (REEDA)
-dressing (change per MD order)
If mom didn't have an episiotomy, but ripped (got a lac during birth), how do we chart that laceration?
First degree= Superficial
Second degree= Skin into muscle
Third degree= To anal sphincter
Fourth degree= Through anal sphincter to rectal mucosa
Name some things to teach mom about perineal care.
-Use peri bottle of warm water, spraying front to back with each void and BM. Pat dry
-Ice to perineum first 24 hours
-Sitz baths 24 hours after delivery
-Analgesia per orders
-Topical anesthetic per MD order: Tucks, dermaplast spray, etc.
DON'T forget that "E" also stands for extremities! Explain what you are checking for in regards to mom's extremities.
-Assess lower legs for redness, selling, or warmth
-B pedal edema
-Deep tendon reflexes
-Assess sensation and motion of extremities if epidural/spinal was given in labor/delivery
-Orthostatic hypotension when OOB first time is common, especially w/ heavy bleeding or c-section.
-ASK PT IF SHE'S DIZZY!
Pretend you have a woman who just gave birth. What do you immediately begin to monitor and assess?
-Obtain vitals q 15 mins for the first 1-2 hrs
-Check the funds and loch every 15 mins (2x), and then every 2-3 hrs, then q 4 to 8 hrs. (This will go on for days)
-Generalized shaking and chattering of the teeth may occur (it's hormonal for most women)
-Pain assessment (ask patient to rate pain and describe type of pain)
-Assess motion and sensation of extremities if epidural/spinal was given in labor/delivery.
Sets found in the same folder