Reproductive System

Female
MALE External genitalia
External genitalia ❖ mons pubis
❖ Penis: reproductive and urinary elimination. ❖ labia majora and minora
❖ Scrotum: External sac that houses testes. ❖ Clitoris
Protects the testes from trauma & testicular ❖ Vestibule
temperature regulation. ❖ perineum
Internal reproductive organs
Internal reproductive organs ❖ Vagina: muscular tube that leads from the vulva to the
❖ Testes: produce male sex hormone and from uterus
spermatozoa ❖ Cervix: dips into the vagina and forms fornices, which are
❖ Ductal system: “ vas deferens” the tube in which arch-like structures or pockets.
sperm begin the journey out of the body. ❖ Ovaries :two sex glands homologous to the male testes,
❖ Accessory glands: The seminal vesicles are are located on either side of the uterus. (Hatfield 55)
paired glands that empty an alkaline, fructose-rich Fallopian tubes: The paired fallopian tubes (also known as oviducts)
fluid into the ejaculatory ducts during ejaculation. are tiny, muscular corridors that arise from the superior surface of the
Prostate: muscular gland that surrounds the first part of the uterus near the fundus and extend laterally on either side toward the
urethra as it exits the urinary bladder. The alkaline fluids ovaries. The fallopian tubes have three sections
secreted by these glands are nutrient plasmas with several ❖ Isthmus
key functions, including the following: ❖ Ampulla
❖ Enhancement of sperm motility (i.e., ability to ❖ infundibulum
move) Uterus: uterus, or womb, is a hollow, pear-shaped, muscular
❖ Nourishment of sperm (i.e., provides a ready structure located within the pelvic cavity between the bladder and
source of energy with the simple sugar fructose) the rectum.
❖ Protection of sperm (i.e., sperm are maintained in The uterus is divided into four sections.
an alkaline environment to protect them from the ❖ cervix
acidic environment of the vagina) (Hatfield 51) ❖ uterine isthmus
❖ corpus
❖ fundus (Hatfield 53)

Menstrual cycle
Two main components : Ovarian cycle and Uterine cycle
Ovarian cycle : Cyclical changes in the ovaries occur in
response to two anterior pituitary hormones:
follicle-stimulating hormone (FSH) and luteinizing hormone
(LH). There are two phases of the ovarian cycle, each
named for the hormone that has the most control over that
particular phase. The follicular phase, controlled by FSH,
encompasses days 1 to 14 of a 28-day cycle. LH controls
the luteal phase, which includes days 15 to 28
❖ Follicular phase
❖
Luteal phase
Cellular development
Soma cells:
❖ Makeup organs and bodily tissue of the human body.
❖ Gametes: germ cells/ sex cells found only in the reproductive
glands
❖ Nucleus: contains 23 pairs of chromosomes
❖ Each parent donates 1 par of chromosomes ( 46 Chromosomes
equals little Mikey)
❖ Each parent donates 22 pairs of autosomes: genetic traits such
as eye color, hair color, ear wax consistency.
❖ One pair of sex chromosomes
Fetal development

Uterine cycle: changes that occur in the inner lining of the

uterus. These changes happen in response to the ovarian Pre-embryonic stage : 3-4 weeks
hormones estrogen and progesterone. gestation
There are four phases to this cycle: Embryonic: 5-10 weeks gestation
❖ Menstrual Fetal: 11-40 weeks gestation
❖ Proliferative
❖ Secretory
❖ ischemic.

Signs of pregnancy
❖ Presumptive: subjective data the
woman reports to the HCP for
example, “ My breasts hurt”
❖ Probable : objective data such as
cervical changes
❖ Positive : diagnostic confirmation
such as, fetal heartbeat & ultrasound
 FETAL HEART TONES
CONDITION CAUSE GRADE

Fetal Tachycardia ❖ Infection ❖ Mild : > 5 BPM from baseline

❖ Dehydration ❖ Moderate: 6-25 BPM from baseline
❖ Fever ❖ Severe: < 25 BPM from baseline
❖ Fetal hypoxemia ❖ Absent : No fluctuation in fetal heart rate
❖ Anemia
❖ Prematurity
❖ Terbutaline
❖ Caffeine
❖ Epinephrine
❖ Theophylline
❖ illicit drugs

Fetal bradycardia ❖ Maternal hypotension ❖ Mild : > 5 BPM from baseline

❖ Supine hypotensive syndrome ❖ Moderate: 6-25 BPM from baseline
❖ Fetal decompression ❖ Severe: < 25 BPM from baseline
❖ Late fetal hypoxia ❖ Absent : No fluctuation in fetal heart rate
❖ Cord compression
❖ Abruptio placenta
❖ Vagal stimulation

Accelerations & Decelerations

Variability Accelerations: must be 15 BPM above the FHR baseline for 15
seconds 15x15 window
FHR drops from baseline then recovers, usually jagged and Decelerations : A decrease in FHR during uterine contraction ”
erratically shaped. Can happen at anytime during contraction mirrors contractions usually a U shape
Periodic changes : variations that occur during a contraction.
Nursing interventions : Left Side. IV bolus of fluids, O2 6l mask, ❖ Reassuring periodic changes : must be 15 BPM
Notify HCP above the FHR baseline for 15 seconds ( 15x15 window)
❖ Benign periodic changes: Early decelerations
A great way to remember this is L.I.O.N
Decreased or absent variability: Non reassuring, acute treatment Episodic changes: occur in association with medication
and monitoring are indicated. administration or analgesia
Decreased or absent variability: medications, narcotics, mag
Wandering baselines with no variability could indicate
sulfate ( preeclampsia, preterm), terbutaline, fetal sleep (
❖ Congenital defects normally 20 minute cycles), prematurity, fetal hypoxemia.
❖ Metabolic acidosis

Fetal decelerations
The nurse should administer 02 and the baby needs to be
delivered as quickly as possible.

Memory trick
V: variable deceleration
E:early deceleration
A: acceleration
Late deceleration
Early decelerations : A decrease in FHR during uterine contraction mirrors
uterine contractions . caused by uterine squeeze
❖ FHR slows as the contraction begins
C: cord compression ❖ Lowest point coincides with the highest point ACME of the
H: head compression contraction
O: ok ❖ Deceleration ends with the contraction
Placental insufficiency Late deceleration: occurs after the peak of contraction due to uteroplacental
insufficiency, pitocin, HTN, diabetes, placental abruption.
❖ Too many decelerations will indicate a need for C-section
❖ Prepare for fetal resuscitation
Variable decelerations: may indicate cord compression. Occur at different
times during a contraction, resulting in fetal HTN that causes the aortic arch
to slow the FHR. usually abrupt and sudden.
Measures to clarify NONreassuring FHR patterns
❖ Fetal stimulation
❖ Fetal scalp sampling
❖ Fetal scalp oximetry
 Hematologic Changes
❖ Blood volume increases by
45-50%
❖ Red blood cell count
increases up to 30%
❖ Plasma increases up tp 50%
❖ Hemoglobin decreases
❖ Hematocrit decreases
❖ for example, “ My breasts hurt”
Cardiac changes
❖ Blood pressure slightly
decreases
❖ Heart rate increases by
10-15 BPM
❖ Cardiac output increases
Integumentary changes
❖ Chloasma : “ pregnancy mask”
brown blotchy areas on the skin of
the face, cheeks, nose and
forehead.
❖ Linea nigra: a dark line down the
middle of the skin on the abdomen
❖ Striae: develop in response to
increased glucocorticoid levels.
Also known as stretch marks
Musculoskeletal changes
❖ Lordosis: Excessive inward
curvature of the spine
❖ Diastasis rectus abdominis:
tearing of the rectus abdominis
muscles
Respiratory changes
❖ Nasal mucosa edematous due to
vasocongestion
❖ Nasal congestion and voice
changes possible
❖ Accommodations to maintain lung
capacity
❖ May feel short of breath when
eupneic
❖ Third trimester diaphragm pressure
GI changes
❖ Intestines are displaced
upwards & to the side.
❖ Pressure changes in the
esophagus & stomach
which leads to heartburn.
❖ constipation
PREGNANCY ❖
Weight gain
A woman should increase her
caloric intake by 300 kcal/day
during 2nd & 3rd trimesters.
Signs of pregnancy
❖ Recommended weight gain
depends on pre pregnancy BMI.
❖ Presumptive: subjective data ❖ FIRST TRIMESTER : 3-4 lb total
the woman reports to the HCP ❖ REMAINDER OF PREGNANCY: 1
lb per week.
❖ Total weight gain: 25-35 lb for a
❖ Probable : objective data such
as cervical changes woman with a normal BMI
❖ Positive : diagnostic
confirmation such as, fetal
heartbeat & ultrasound
Nutrition
❖ When a woman isn't getting the proper nutrients this can cause
Amenorrhea which can inhibit the ability to become pregnant.
❖ Lack of folic acid can cause neural tube defects( spina bifida) and cause
damage to the growing fetus.
❖ Deficits in Vit C have been shown to also cause birth defects and
cancer.
❖ Pica:
❖ persistent ingestion of nonfood substances such as clay, laundry
starch, freezer frost, or dirt.It results from a craving for these
substances that some women develop during pregnancy.
❖ These cravings disappear when the woman is no longer pregnant.
❖ Pica is associated with iron-deficiency anemia, but it is unknown
whether iron deficiency is the cause or the result
Nutritional requirements
❖ Proteins: Growth and repair of fetal tissue, placenta, uterus,
breasts, and maternal blood volume
❖ Minerals: Prevent deficiencies in the growing fetus and maternal
stores
❖ Iron : Formation of hemoglobin; essential to the oxygen-carrying
capacity of the blood
❖ Calcium: Nerve cell transmission, muscle contraction, bone
building, and blood clotting
❖ Phosphorus: Promotes strong bone growth
❖ Zinc: Fetal growth and maternal milk production
❖ Iodine : Promotes normal thyroid activity, preventing specific birth
defects
Vitamin requirements
Folic acid (Vitamin B9)
❖ Necessary for formation of the nervous system
❖ Prevents up to 70% neural tube defects
❖ Diet should include at least 400 mcg of folic acid per day
Vitamin A
❖ Recommended intake via beta-carotene
❖ Too much can be toxic to the fetus
❖ Too little can stunt fetal growth and cause impaired dark adaptation
and night blindness
Vitamin C
❖ Essential in the formation of collagen, a necessary ingredient to
wound healing
Vitamin B6
❖ Necessary for the healthy development of the
fetus’s nervous system
Vitamin B12
❖ Needed to maintain healthy nerve cells, RBCs, form DNA
 Assessment
Admission
❖ Birth imminence Components of assessment
❖ Fetal status Obstetric History
❖ Maternal status ❖ Number and outcomes of previous pregnancies in
❖ Risk assessment GTPAL (gravida, term, preterm, abortions, living)
format (see Chapter 7 for a detailed explanation of
these terms)
❖ Estimated delivery date
❖ History of prenatal care for current pregnancy

Assessment of reproductive history

❖ Complications during pregnancy
❖ Dates and results of fetal surveillance studies, such
as ultrasound or nonstress test (NST)
Gravida: Number of pregnancies the woman has had regardless
❖ Childbirth preparation classes
of outcome
❖ Previous labor and birth experiences
Nulligravida: never been pregnant
Current Labor Status
Multigravida: more than one pregnancy
❖ Time of contraction onset
Parity: the client communicates outcome of previous pregnancies
❖ Contraction pattern including frequency, duration,
GTPAL :
and intensity
G: Gravida – the total number of pregnancies regardless of
❖ Status of membranes
outcome
❖ Description of bloody show or bleeding
T: Term – the number of pregnancies that ended at term (at or
❖ Fetal movements during the past 24 hours
beyond 38 weeks’ gestation)
Medical–Surgical History
P: Preterm – the number of pregnancies that ended after 20
❖ Chronic illnesses
weeks and before the end of 37 weeks’ gestation either
❖ Current medications
A : Abortions – the number of pregnancies that ended before 20
❖ Prescribed
weeks’ gestation either spontaneous or induced
❖ Over-the-counter
L: Living – the number of children delivered who are alive when
❖ Herbal remedies
the history is taken
Social History
❖ Marital status
❖ Support system
❖ Domestic violence screen
❖ Cultural/religious considerations that affect care

Prenatal visits
Ist visit :
❖ Family History, Medical Surgical History,
Social History, Teaching, Avoiding
teratogenic, substance ingestion, Alcohol,
tobacco, illegal drugs, etc., Diet, nutrition, and
exercise, Infection control
❖ Medication use
❖ Determining due dates
❖ Naegele's rule
❖ Add seven days to the date of the first day of
the LMP, then subtract three months (and
add a year)
❖ Pelvic examination
❖ Practitioner sizes the uterus to estimate term
❖ Obstetric sonogram: High frequency sound
waves reflect off fetal and maternal pelvic
structures, allowing structure measurement
❖ Amount of smoking during pregnancy
❖ Drug and alcohol use during pregnancy
Desires/Plans for Labor and Birth
❖ Presence of a partner, coach, and/or doula (see
Chapter 7 for discussion of doulas)
❖ Pain management preferences
❖ Other personal preferences affecting intrapartum
nursing care
❖ Presence of a birth plan
❖ Desires/Plans for Newborn
❖ Plans for feeding—breast or formula
❖ Choice of pediatrician
❖ Circumcision preference, if the infant is male
❖ Rooming-in preference (Hatfield 208)
Tips
If a woman presents with ℅
bleeding ask her how man
sanitary napkins she has
saturated in an hour.
 Labor positions
Anticipatory signs of labor
The Four P’s of Labor
❖ Lightening or sense that the baby has
❖ “dropped”
❖ Increased frequency, intensity of
❖ Passageway: Pelvic shape
Braxton Hicks contractions
❖ Passenger: fetus
❖ Gastrointestinal disturbances
❖ Powers: contractions
❖ Expelling the mucus plug
❖ Psyche
❖ Feeling a burst of energy

Clinical signs
❖ Ripening (softening)
❖ effacement (thinning) of the cervix

Fetal lie
❖ Longitudinal lie: Long axis of the fetus is parallel to
maternal long axis
❖ Oblique lie: Between longitudinal and transverse lie
❖ Transverse lie: Long axis of fetus is perpendicular to
Maternal adaptation to maternal long axis

labor
❖ Maternal physiologic adaptation
Fetal presentation
❖ Increased demand for oxygen Foremost part of the fetus that enters the pelvic inlet
during the first stage of labor Three main presentations
❖ Increased heart rate ❖ Head: Cephalic presentation
❖ Increased cardiac output ❖ Feet or buttocks: Breech presentation
❖ Increased respiratory rate ❖ Shoulder: Shoulder presentation
❖ Gastrointestinal and urinary
systems are affected Fetal attitude
❖ Laboratory values impact Relationship of fetal parts to one another
❖ Flexion (ovoid shape):Most favorable for

Fetal adaptation to labor ❖

vaginal delivery
Military (no flexion or extension)
❖ Increase in intracranial pressure
❖ Brow or frontum (partial extension)
❖ Placental blood flow temporarily interrupted at peak of
uterine contractions ❖ Face (full extension)
❖ Stresses cardiovascular system; results in slowly
decreasing pH throughout labor
❖ Passing through the birth canal is beneficial in two ways
❖ Stimulates surfactant production; helps clear respiratory
passageways
❖ Ecchymosis :a discoloration of the skin resulting from
bleeding underneath, typically caused by bruising.(GOOGLE)
❖ Edema: swelling
❖ Caput succedaneum:serosanguinous, subcutaneous,
extraperiosteal fluid collection with poorly defined margins
caused by the pressure of the presenting part of the scalp
against the dilating cervix (tourniquet effect of the cervix)
during delivery.(GOOGLE)
❖ Cephalohematoma: is a traumatic subperiosteal
haematoma that occurs underneath the skin, in the
periosteum of the infant's skull bone. Cephalohematoma
does not pose any risk to the brain cells, but it causes
unnecessary pooling of the blood from damaged blood
vessels between the skull and inner layers of the skin.
 Stages of labor
First stage: Begins with the onset of true labor and
Second Stage of Labor: Expulsion of the Fetus
ends with full dilation of the cervix at 10 cm.
Assessment
1. Early labor
❖ Monitor the blood pressure, pulse, and respirations every 15
2. Active labor
to 30 minutes
3. Transition
❖ Assess the contraction pattern every 15 minutes
Latent Phase (Early Labor): Contractions during
❖ Assess fetal status
early labor are typically five to 10 minutes apart, last
❖ Assess the woman’s report of an uncontrollable urge to
30 to 45 seconds, and are of mild intensity. The
push
cervix is dilated from 1 to 3 cm, and effacement has
❖ Check the FHR every 15 minutes for the low-risk woman,
begun. Possible spontaneous rupture of membranes
every five minutes for woman at risk for labor complications
Assessment
❖ Assess FHR and contractions at least once
every hour
❖ Assess maternal status
❖ Assess status of fetal membranes
❖ Assess the woman’s psychosocial state
Goals, expected outcomes
❖ Goal: The woman and fetus remain free
from injury
❖ Goal: The woman’s anxiety is reduced
❖ Goal: The woman’s pain is manageable
Third Stage of Labor: Delivery of Placenta
❖ Goal: The woman and partner have
adequate knowledge of labor process Assessment
Active Labor: contractions occur every two to five ❖ Assess the woman’s psychosocial
minutes, last 45 to 60 seconds, and are of moderate state after she gives birth
to strong intensity. The cervix should dilate ❖ Monitor for signs of placental
progressively from 4 to 8 cm.contractions are regular separation
moderate and strong. Rapid effacement. Fetal
Selected nursing diagnoses
descent begins.
Assessment ❖ Risk for deficient fluid volume related
to blood loss in the intrapartum period
❖ Assess woman’s psychosocial
❖ Risk for trauma: Hemorrhage, amniotic
state
fluid embolism, retained placenta, or
❖ Assess labor progress
uterine inversion related to delivery of
❖ Assess fetal status
the placenta
❖ Assess maternal status

Transition Phase of Labor: contractions should

occur every two to three minutes, last 60 to 90
seconds, and be of strong intensity. The uterus
should relax completely between uterine
contractions. Cervical examination during transition
reveals dilation between 8 and 10 cm.
The client may be nauseous, vomiting or reporting
the need to have a bowel movement. Urge to push
and bloody show.
Assessment
❖ Assess for signs that woman has reached
transition phase
Fourth Stage of Labor: Recovery
Assessment
❖ Continue to assess for hemorrhage
❖ Assess the lochia: Color, quantity
❖ Monitor for signs of infection
❖ Monitor for suprapubic distention
❖ Assess comfort level
❖ Assess mother’s psychosocial state during the
fourth stage
❖ Assess initial bonding behaviors of the new

❖ Assess woman’s ability to cope
❖ Assess maternal status
❖ Assess fetal status
❖ She will often express irritability,
restlessness, and will feel out of control.
She may tremble, vomit, or cry. It is
important to assess for hyperventilation
during this phase.
Pushing
family
❖ Vigorous pushing: take a deep breath, hold the breath, and push while
counting to 10. She is encouraged to complete three “good” pushes in
this manner with each contraction.
❖ open-glottis pushing: method of expelling the fetus that is
characterized by pushing with contractions using an open glottis so that
air is released during the pushing effort.
❖ urge-to-push method, in which the woman bearsdown only when she
feels the urge to do so using any technique that feels right for her
 Pain management during labor
Pain General concepts of pain
❖ Individual &
❖ Pain threshold: Level of pain

Factors influencing pain

subjective
necessary for an individual to perceive
❖ Sensory experience
pain
❖ Physiologic ❖ Pain tolerance: Ability of an individual
❖ Psychological to withstand pain, once recognized
❖ Emotional
❖ Environmental

Non Pharmacological pain

❖ Sociocultural

interventions
Principles of pain relief ❖ Continuous labor support

during labor ❖ Comfort measures

❖ Women are more satisfied when Relaxation techniques

they have control over the pain ❖ Patterned breathing
experience ❖ Attention focusing/concentration
❖ Caregivers commonly underrate ❖ Movement and positioning
the severity of pain ❖ Touch and massage
❖ Women who are prepared for ❖ Water therapy;
labor usually report a more hypnosis,Intradermal water
satisfying experience than do injections
women who are not prepared ❖ Acupressure and acupuncture

Opioids
Medications with opium-like properties (also
known as narcotic analgesics); the most
frequently administered medications to provide
analgesia during labor. (ex.:Demerol IV, IM)
Advantages
❖ Increased ability for a woman to cope
with labor
❖ Medications may be
nurse-administered
Disadvantages
❖ Frequent occurrence of uncomfortable
side effects
❖ Nausea and vomiting; pruritus;
drowsiness; neonatal depression
❖ Pain not completely eliminated
❖ Possible overdose
Anesthesia
❖ Local: Used to numb the perineum just before birth,
allowing for episiotomy and repair
❖ Regional: Blocks a group of sensory nerves, supplying
a particular organ or body area
❖ General :Not frequently used in OB due to risks
involved
Complications of anesthesia
❖ Hypotension
❖ Total spinal blockade (rare)
❖ Inadvertent injection into the bloodstream
❖ Spinal headache
❖ Pruritus
❖ Respiratory distress
❖
Fatal complications of anesthesia
❖ Failed intubation
❖ Aspiration
❖ Malignant hyperthermia: is a disease that causes a
fast rise in body temperature and severe muscle
contractions when someone with the disease gets
general anesthesia. It is passed down through families(
google)
 DELIVERY
Getting ready for the newborn Birthing the placenta
❖ If the urinary bladder is full, the birth
attendant may request that you perform a ❖ nursing care focuses on monitoring for
straight cath placental separation and providing
❖ bed is “broken”—the lower part of the bed
physical and psychological care to the
is removed to allow room for the birth
attendant to control the delivery. woman.
❖ place the woman’s feet on foot pedals or ❖ the fundus rises in the abdomen, the
stirrups uterus takes on a globular shape,
❖ clean the woman’s perineum with an blood begins to trickle steadily from
antiseptic solution
the vagina, and the umbilical cord
❖ Position the instrument table close to the
birthing bed and uncover it. lengthens as the placenta separates
❖ Eye shields, gowns, and gloves may be from the uterine wall.
necessary for protection from contact with
bodily fluids.

Recovery
❖ The new mother is at highest risk for hemorrhage during the
first two to four hours of the postpartum period.
❖ Monitor the woman’s vital signs, and palpate the fundus for
position and firmness.
❖ The fundus should be well contracted, at the midline, and
approximately one fingerbreadth below the umbilicus
immediately after delivery.
❖ Assess the lochia (vaginal discharge after birth) for color and
quantity. The lochia should be dark red and of a small to
moderate amount. If she saturates more than one perineal pad
in an hour, palpate and massage the fundus,
❖ Monitor for signs of infection. The temperature may be
elevated slightly, as high as 100.4°F, because of mild
dehydration and the stress of delivery.
❖ The woman should void within six hours after delivery.
❖ Assess cramping from uterine contractions (referred to as
“afterbirth pains”) and perineal pain from edema or episiotomy
repair
❖ ibuprofen to be given every six to eight hours
❖ ice pack to the perineum.
 The newborn
Neonatal resuscitation
❖ Neonatal Resuscitation Program (NRP)
❖ Must be able to initiate resuscitation and
assist throughout process
❖ First 6 to 12 hours after birth are a critical
transition period for the newborn
❖ Must be alert to early signs of distress:
Bluish color of the skin and mucous
membranes (cyanosis),Brief stop in
breathing (apnea), Decreased urine output.
Nasal flaring. Rapid breathing.,Shallow
breathing.Shortness of breath and grunting
sounds while breathing.
❖ Must be ready to intervene quickly to
Assessment
prevent complications and poor outcomes
❖ Heart and respiratory rates at least every 30
minutes during the first two hours of transition.
❖ Monitor the axillary temperature every 30
minutes until it stabilizes in the expected range
between 97.7°F and 99.5°F
❖ Be alert for signs of hypoglycemia.
❖ A full physical assessment including gestational
age assessment is completed within the first few
hours of life.
Birth
❖ If the newborn cries vigorously: Palpate the
base of the umbilical cord and count the pulse
for six seconds and multiply x 10
❖ Pulse above 100 bpm and a vigorous cry are
reassuring signs
❖ Give constant attention to the airway.
❖ Newborns often have abundant secretions.
❖ A bulb syringe is used to suction the mouth
❖
first and then the nose.
Keep the bulb syringe with the newborn, and
teach the parents how and when to suction
the baby.
Complications
❖ If the newborn doesn't cry immediately: Transport him or
her to a preheated radiant warmer for prompt resuscitation
❖ Dry him or her quickly to prevent heat loss
❖ Bag and mask connected to 100% oxygen are used to
provide respiratory support
❖ Most newborns do not require resuscitation, and the ones
who do generally respond well to a short period of positive
pressure ventilation with a bag and mask.
❖ However, a very small number of infants require chest
compressions, intubation, and medications
❖ Give constant attention to the airway
❖ Position newborn on side; bulb syringe is used to suction
mouth first, then nose
Thermoregulation
❖ Critical to protecting the newborn from chilling
❖ Cold stress increases amount of oxygen and glucose
needed
❖ Can quickly deplete body’s glucose and develop
hypoglycemia( < 40 mg/ dl )
❖ Easily develop respiratory distress and metabolic
acidosis if exposed to prolonged chilling ( PH < 7.20 )
❖ Dry the newborn while on the mother’s abdomen
❖ Swaddle him snugly, and apply a cap to prevent heat
loss
❖ Kangaroo care
Hypoglycemia
❖ Ideal glucose range 40-60 mg/dL
❖ Perform a heel stick Glucose level of less than 50 mg/dL
requires confirmation (see hospital protocol)Immediately initiate
treatment ( 20-30 mg/dl start a line, 30-40 mg/dl give sugar
bottle)
❖ If the mother is breast-feeding, encourage early and frequent
feedings.
❖ If the newborn is to be bottle-fed, initiate early feedings.
INFECTION CONTROL OF THE NEONATE
❖ UMBILICAL CORD STUMP: Use strict aseptic technique
when caring for the cord
❖ Triple dye, bacitracin ointment, or povidone-iodine used
initially to paint the cord to help prevent the development
of infection.
❖ PREVENT OPHTHALMIA NEONATORUM: a severe eye
infection contracted in the birth canal of a woman with
gonorrhea or chlamydia.
❖ 0.5% erythromycin
 Principles
Newborn nutrition
Feeding types
❖ At birth, the passive intake of nutrition
ends and the newborn must actively Two main types of nourishment suitable for the healthy
consume and digest food term newborn:
❖ Newborn has unique nutritional needs
❖ Breast milk
❖ Healthy term newborn requires ❖ Commercial formula
❖ 80 to 100 mL/kg/day of water to maintain
fluid balance and growth Two delivery methods:
❖ 100 to 115 kcal/kg/day to meet energy
needs for growth and development ❖ Breast
❖ Bottle

Breastfeeding
Feeding method choices:

❖ Breastfeed exclusively
● Recommended method for feeding newborns
❖ Breastfeed and supplement with expressed breast
● Breast milk is nutritionally superior to commercial formulas
milk in a bottle
❖ Breastfeed and supplement with formula
● The American Academy of Pediatrics (AAP) recommends
❖ Formula-feed exclusively
● Exclusive breast-feeding until 6 months of age
● Continuation of breast-feeding until at least 12 months of
age
● Healthy People 2020 goals
● Increase proportion of women who breastfeed their babies

Maternal advantages Factors that affect feeding

❖ More rapid uterine involution, less bleeding in the
postpartum period
❖ Stress levels decrease; may enhance immune function
❖ More sleep at night; weight loss is faster on average
❖ Long-term advantages
❖ Decreased incidence of ovarian and premenopausal breast
cancers
❖ Potential osteoporosis protection
❖ Additional research needed
Newborn advantages
❖ Breast milk contains substances that facilitate critical
periods of growth and development, particularly in the
brain, immune system, and gastrointestinal tract
❖ Breast milk provides immunologic properties
❖ Lower incidences of otitis media, diarrhea, and lower
respiratory tract infections
❖ No physiologic disadvantages to either the woman or the
newborn
Disadvantages
Maternal conditions or situations in which breast-feeding is
contraindicated
❖ Illegal drug use
❖ Active untreated tuberculosis
❖ Human immunodeficiency virus (HIV) infection
❖ Chemotherapy treatment
❖ Herpetic lesions on the breast
❖ Newborn contraindications
❖ Galactosemia
❖ Phenylketonuria
❖ Other medical conditions
❖ Mother producing insufficient breast milk
Culture
❖ Acceptability of breast-feeding in public
❖ Amount and quality of family and community
support for breast-feeding
❖ When a woman initiates breast-feeding
❖ How many times per day a woman breast-feeds
❖ Whether or not a woman supplements
❖ When a woman stops breast-feeding
❖ –In the United States
❖ –83% (highest): Asian or Pacific Islander descent
❖ –59% (lowest): Non-Hispanic African American
women
❖ –Hispanic or Latino: Higher initiation rates (81%)
than white women at 77%
❖ –Hispanic women are more likely to breastfeed if
they are of Mexican descent and have not
completely acculturated
Sociodemographic
❖ Breast-feeding rates differ by age, amount of
education, and socioeconomic status
❖ Past experiences of a woman and her support
system
❖ The feeding experiences and attitudes of the
individuals who compose a woman’s support
system strongly influence a woman’s choice of
feeding method
❖ Intent to return to work or school
❖ Plays an important role in a woman’s feeding
choice
❖ Nursing considerations
❖ Provide education
❖ Support the woman
 Breastfeeding
Physical control of breastfeeding
Newborn features that facilitate ❖ When the breast is emptied, it responds by
breast-feeding ❖
replenishing the milk supply
If emptied incompletely, it will decrease milk supply
❖ Hormonal control of lactation
❖ Newborn facial anatomy ❖ Pituitary gland releases prolactin and oxytocin
❖ Designed uniquely for breast-feeding ❖ Lactogen

Nose breathers

❖ Rooting and sucking reflex

❖ Present at birth

What is breast Milk

The breast and lactation

Unique organ designed to provide newborn nourishment

via lactation ❖ Unique substance that commercial formulas cannot
duplicate, especially immunologic factors
Consists of 15 to 20 lobes containing milk-producing
alveoli ❖ Colostrum
❖ Higher in antibodies; lower in fat; higher in protein
❖ Makes milk in response to several different stimuli ❖ Milk appears approximately three to five days after birth
❖ Physical emptying of breast
❖ Hormonal stimulation Breast milk supplies 20 calories per ounce
❖ Sensory stimulation
Nutrition requirements for ❖ Foremilk: the breast milk your baby gets at the

breastfeeding beginning of each feeding when your breasts are full.

Foremilk is high in lactose (milk sugar) and low in fat and
calories. It's thin, watery, and it looks white or bluish.
❖ Approximately 500 kcal/day above her prepregnant
❖ Hindmilk: the high-fat, high-calorie breast milk that your
needs
baby gets toward the end of a feeding. It's richer,
❖ Plenty of fluids
thicker, and creamier than foremilk, the breast milk that
❖ Rest
your baby gets when he first starts to breastfeed. The
❖ Eat a balanced diet
color of hindmilk is creamy white.
❖ Multivitamin each day

Positioning for breastfeeding

❖ Assessing breast-feeding readiness
❖ Flat or inverted nipples
❖ History of breast surgery
❖ Attitudes toward breast-feeding ❖ Cradle hold
❖ Quality of support for breast-feeding ❖ football hold
❖ Refer to lactation consultant if special needs exist ❖ side-lying position

Education
Relieving common maternal breast-feeding problems
WHEN THE BABY ISN'T FEEDING WELL
❖ Sore nipples
❖ Engorgement ❖ Dry mouth
❖ Plugged milk ducts
❖ Mastitis ❖ Not enough wet diapers per day
❖ Breastfeeding amenorrhea ❖ Difficulty rousing the newborn for feeding
❖ Return of woman’s menstrual cycle occurs between ❖ Not enough feedings per day
six and 10 weeks post delivery
❖ Ovulation can occur in absence of a menstrual ❖ Difficulty with latching on or sucking
period, and she can become pregnant
❖ By end of third day of life at least six wet diapers and
about three bowel movements per day
❖ Monitor the newborn’s weight daily during the
hospital stay
 Cesarean section delivery
Indication
❖ History of previous cesarean
birth or other uterine incision
❖ Labor dystocia (failure to
progress in labor)
❖ Nonreassuring fetal status
❖ Fetal malpresentation
❖ Active herpes, prolapsed cord(
emergency)
❖ ruptured uterus(emergency)
❖ placenta previa
❖ abruptio placenta.
the rise of C-sections
❖ Change in perception of risk by physicians
and patients
❖ Increase in the percentage of pregnant
women who are carrying their first child
❖ Rise in the number of older pregnant women
❖ ❖
More labor inductions for nonmedical
reasons
❖ Almost universal use of continuous electronic
fetal monitoring, which carries with it high
false-positive indications of fetal compromise
❖ Return to the adage “once a cesarean,
always a cesarean”
❖ A decrease in VBAC attempts
Increasing concerns regarding malpractice
litigation
❖ Increased prevalence of multiple gestations
❖ Increased prevalence of maternal obesity
❖ New phenomenon of cesarean by demand
(women asking for planned cesarean without
medical indications)
indications for induced labor
❖ Postdate pregnancy: pregnancy that has gone
past the due date
❖ Premature rupture of membranes (PROM)
❖ Chorioamnionitis: infection of the fetal
membranes
❖ Gestational hypertension
❖ Preeclampsia
❖ Severe intrauterine fetal growth restriction
❖ Maternal medical conditions
Cesarean Birth
Maternal risks
❖ Major surgery risks and risks of birth itself
❖ Increases maternal risk of death
❖ Thrombophlebitis, laceration of uterine artery,
bladder, ureter, bowel
❖ Hemorrhage, infection, pneumonia, etc.
Fetal risks
❖ Inadvertent delivery of premature fetus
(miscalculation of dates)
❖ Increases incidence of neonatal respiratory
distress
❖ Scalpel cutting through the uterine wall can nick
the baby.
❖ The fetus can become wedged in
❖ the pelvis after a prolonged second stage with
the woman pushing, which can make for a
difficult extraction leading to bruising and
possibly other injuries.
National goal to decrease the cesarean delivery
Cesarean delivery procedures
rate
perioperative period
❖ Preoperative phase: Team approach, 2 MD or
1 MD and 1 first assist R.N and one
pediatrician.
❖ LVN cannot care for this client until they have
fully recovered from Anesthesia.
❖ informed consent must be obtained by the MD
and the anesthesiologist prior to the
procedure.
Contraindications for induced
labor
Maternal contraindications for induced labor
❖ Complete placenta previa: placenta covers the
cervix
❖ History of vertical uterine incision: This mom will
never have a vaginal birth due to risks of uterine
rupture and risk of hernia. this incision carries an
increased risk of dehiscence
❖ Structural abnormalities of the pelvis
❖ Invasive cervical cancer
❖ Medical conditions (e.g., active genital herpes): A
herpes outbreak can cause the baby to go blind
and/ or cause sores of the mouth
Fetal contraindications for induced labor
❖ Certain anomalies, such as hydrocephalus
❖ Certain fetal malpresentations
❖ Fetal compromise
 Labor Readiness
RIPENING OF THE CERVIX
A “Ripe” cervix: Prerequisite for successful
induced labor. Bishop score is most often
used to determine readiness for labor
❖ Five factors evaluated, each factor
scored 0 to 3
❖ Score ≥8: Associated with
successful oxytocin-induced labor
❖ Score ≤5: “Unripe” cervix or
unfavorable
Never schedule an induction without
asking the bishop score.
Methods of Cervical Ripening
Mechanical methods
❖ Membrane stripping
❖ Inserting a catheter into the cervix and
inflating the balloon holds 30-80cc of fluid
❖ Laminaria: Cervical dilators “seaweed”
Pharmacologic methods
❖ Prostaglandin E2 (dinoprostone)
❖ Cervidil (string)( tampon like)
❖ Prepidil (gel)
❖ Prostaglandin E1 (misoprostol) ( can cause
rough labor)
❖ Cytotec
Assisted Delivery
Episiotomy: Perineal surgical incision to enlarge the vaginal
opening immediately pre birth
Forceps: Instruments with curved, blunted blades are placed
around the head of fetus to facilitate rapid delivery
❖ Low, outlet forceps are more common than mid
forceps
❖ Maternal indications: Fatigue; certain chronic
conditions; prolonged second stage of labor
❖ Nonreassuring fetal strip
❖ monitor for skull fracture, bruising, and hypoxia
Vacuum-assisted delivery: RN assisted: Suction cup
connected to fetal head; suction is applied, used to guide
delivery
❖ Can be hazardous to infant, causing
❖ Scalp trauma, stop vacuum after 3 pop offs
❖ Subgaleal and intracranial hemorrhage
❖ Death
Potential complications of operative vaginal delivery
❖ Neonatal cephalohematoma; retinal, subdural, and subgaleal hemorrhage occur more
frequently with vacuum extraction than with forceps
❖ Facial bruising, facial nerve injury, skull fractures, and seizures: More common with forceps
❖ Potential maternal complications
❖ Extension of episiotomy into anal sphincter
❖ Uterine rupture, perineal pain, lacerations, hematomas, urinary retention, anemia, and
rehospitalization
Fetal readiness labor indicators
The Fetus should be mature. There are several ways to assess
maturity:
❖ ≥38 weeks’ gestation
❖ Fetal lung maturity is major point of consideration
❖ Measuring the lecithin/sphingomyelin (L/S) ratio via
amniocentesis assesses lung maturity. An L/S ratio greater
than 2 indicates fetal lung maturity.
Induction of Labor
Artificial rupture of membranes (AROM) – amniotomy
❖ Causes release of prostaglandins, which enhance
labor
Nursing interventions
❖ Observing, documenting amniotic fluid color
❖ Monitoring fetal heart rate
Oxytocin induction of labor
❖ IV oxytocin (Pitocin) is the most common agent
used
❖ IV line initiated: Infusion pump required
❖ Baseline fetal heart assessment before induction .
The RN can titrate the PIT until fetal distress
occurs, however they must call the HCP to obtain
an order to decrease the PIT
Potential complications of
oxytocin induction IV Pitocin
Potential risk for C-section doubles
❖ Primigravidas versus multi gravidas
❖ Hyperstimulation of uterus leading to one
contraction after another without substantial rest
periods in between : can blow the uterus. Give 02
10-12L via mask. IV bolus
Water retention may cause
❖ Hyponatremia
❖ Confusion; convulsions
❖ Coma
❖ Congestive heart failure; death
Nursing actions
❖ monitoring mother and baby during
pharmacologic induction interventions
❖ Assist with pelvic examination in mechanical
ripening of cervix or ROM
❖ Document fetal heart rate before and after ROM
❖ Communicate changes as needed

What is it?
A serious but rare complication
of childbirth. Characterized by
tearing of a previous uterine scar
from cesarean section. The
myometrial wall becomes
breached causing hemorrhage
into the peritoneum.
Causes
❖ Pressure of baby moving
through the birth canal against
a previous uterine scar.
❖
❖
abnormal presentation
prolonged labor
❖ multiple gestation
❖ improper use of oxytocin
❖ traumatic effects of forceps use
or traction.
Uterine rupture
Assessment
❖ Dramatic onset of fetal bradycardia
❖
or deep variable decelerations
Reports by the woman of a Types
“popping” sensation in her ❖ Incomplete: rupture only goes
abdomen through the endometrium and
❖ Excessive maternal (possibly
referred) pain the myometrium only, with the
❖ Unrelenting uterine contraction peritoneum still intact.
followed by a disorganized uterine ❖ Complete: rupture goes
pattern through the endometrium,
❖ Increased fetal station felt upon myometrium, and peritoneum,
vaginal examination and then the contractions
❖ Vaginal bleeding or increased
bloody show would immediately stop.
❖ Easily palpable fetal parts through
the abdominal wall
❖ Signs of maternal shock
Nursing interventions
❖ The nurse should prepare IV fluid
replacement.
❖ IV oxytocin administration .
❖ Laparotomy to control the
bleeding and repair the rupture.
❖ Cesarean hysterectomy or tubal
ligation
 Postpartum care
Maternal Adaptation During
Postpartum Period Weight loss
Physiologic adaptation
Reproductive system ❖ Immediate 12 to 14 lb = baby, placenta, and
❖ Uterine contraction leads to amniotic fluid
involution(shrinking of the uterus ❖ 5 to 15 lb (early postpartum) = fluid loss from
❖ Measured by assessing fundal height diaphoresis, urinary excretion
❖ Factors promote, inhibit involution ❖ Return to prepregnancy weight six months after
❖ Afterpains childbirth (if within recommended weight gain
range)

assessment/ education ❖ In general, the breastfeeding woman tends to

lose weight faster than the woman who does not
Assess fundal height: Assess the location, breastfeed because of increased caloric
consistency, and height of the fundus through palpation. demands.
❖ If the uterus is not firm upon palpation,
massage it gently. Placing the infant on the
mother’s breast also aids in stimulating
Nursing interventions for
contractions.
postpartum care after cesarean birth
Assessment
Lochia: blood, mucus, tissue, WBC compose uterine Primary causes of maternal mortality post cesarean
discharge ❖ Anesthesia complications
❖ Rubra: first 3-4 days, small-mod amount, ❖ Postpartum infection
mostly blood and dark red with fleshy odor ❖ Hemorrhage
❖ Serosa: days 4-10, decreases to small amount, ❖ Thromboembolism
brownish/pink color Monitor
❖ Alba: after day 10, white-pale yellow, mostly ❖ Lungs; signs of respiratory depression
❖ IV for Sources of pain
WBCs ❖ PCA
Ovaries ❖ discomfort
❖ Ovulation can occur as soon as three weeks ❖ Incision; bowel sounds; urinary output
❖ Signs of thrombus formation
post-delivery
Cervix
❖ Vagina, perineum
❖ Never fully return to pregravid state; Kegel

❖
exercises
Lactation can lead to vaginal dryness, Nursing management & Discharge
Breasts
dyspareunia (painful intercourse)
planning
❖ Colostrum; prolactin ❖ Preventing injury from Rh-negative blood type or non immunity
Cardiovascular system to rubella
❖ High plasma fibrinogen levels and other ❖ Is the woman a candidate for Rho(D) immune globulin
coagulation factors mark postpartum period (RhoGAM) I'M within 24 hours of delivery. Given and checked
Vital signs as if you were administering a blood product.
❖ Temperature may be slightly elevated first 24 ❖ Providing patient teaching
❖ Breast care; fundal massage
hours
❖ Perineum and vaginal care
❖ Slow pulse a first, then WNL first week post
❖ Pain management
delivery ❖ Nutrition; constipation
❖ Blood pressure should not be elevated ❖ Proper rest
For every 250 mL of blood loss, the hemoglobin and ❖ Stress importance of prioritizing self-care
hematocrit (H&H) fall by one and two points, ❖ MMR (subq) right before DC if needed
respectively. So, if the woman’s H&H were 12 and 34, ❖ Evaluation: Goals and expected outcomes
then fall to 10 and 30, the approximate blood loss is
500 mL.
❖ Musculoskeletal system: Abdomen is soft,
sagging immediately postpartum
❖ Gastrointestinal system: Very hungry;
constipation
❖ Urinary system: Transient glycosuria,
proteinuria, and ketonuria are normal
immediately postpartum
❖ Voiding issues
❖ Integumentary system: Copious diaphoresis
common
❖ Striae (stretch marks) on abdomen and breasts
 Newborn adaptation
Respiratory system
The Birth process:
❖ Helps expel fetal lung fluid
❖
Thermoregulatory adaptation
Stimulates lung inflation
❖ Stimulates surfactant
production
❖ Surfactant keeps alveoli from ❖ Thermoregulation is the physiologic process
collapsing after expansion of balancing heat production with heat loss
to maintain adequate body temperature
Circulation through the heart ❖ Newborn thermoregulation difficulties
❖ Fetal circulation ❖ Prone to heat loss due to lower proportion of
❖ High pressure in the lungs heat-producing tissue
causes pressure in right atrium ❖ Not readily able to produce heat
> left atrium ❖ Vulnerable to cold stress
Pressure differences help route
blood:
❖ Through the foramen ovale, Newborn loses heat in four ways:
❖ Conduction—body heat transfers to cold
ductus arteriosus object, infant placed in cold scale
❖ Away from non functioning ❖ Convection—air currents blow over infant’s
lungs body, infant susceptible to draft
❖ Back into general circulation ❖ Evaporation—wet skin dries and
❖ Ductus venosus shunts fetal evaporates
❖ Radiation—cold object close but not
blood away from the liver touching, infant close to cold windowpane
causing body heat to radiate to window

Newborn Metabolic adaptation

Newborn compensation
❖ Flexed posture conserves heat
❖ Burning brown fat produces heat
Neonatal hypoglycemia: Blood glucose falls to ≤50
mg/dL
(Differs at facilities)
Early signs of hypoglycemia Late signs of hypoglycemia
❖
Newborn Hepatic adaptation
❖ jitteriness Respiratory distress
❖ poor feeding ❖ Apnea
❖ listlessness ❖ Seizures
❖ Coma Liver immature at birth
❖ irritability Bilirubin
❖ low temperature Conjugated
❖ weak or high-pitched cry ❖ Water-soluble
❖ hypotonia ❖ Excreted in feces
❖ Unconjugated
Apgar score ❖
❖
Fat-soluble
Enters cells causing jaundice
Five parameters Hyperbilirubinemia
❖ Heart rate ❖ High levels of unconjugated
❖ Respiratory effort ❖ bilirubin in the bloodstream
❖ Muscle tone
❖ Reflex irritability ❖ serum levels ≥4 to 6 mg/dL
❖ Color Physiologic jaundice
Scored 0 to 2 points each ❖ Jaundice that occurs after first 24 hours of life
❖ Assessed @ 1 & 5 min of life (usually on days 2 or 3 after birth)
❖ Scores 7 to 10 at five minutes: Doing ❖ Bilirubin levels that peak between days 3 and 5
well ❖ Bilirubin levels that do not rise rapidly (no
❖ Scores 4 to 6 at five minutes: Needs greater than 5 mg/dL per day)
close observation ❖ First appears on head
❖ Score 0 to 3 at five minutes: In The liver manufactures clotting factors necessary for
severe distress normal blood coagulation. Several of the factors require
vitamin K in their production.
❖ Bacteria that produce vitamin K are normally
present in the gastrointestinal tract. However,
the newborn’s gut is sterile because normal
flora have not yet been introduced and colonized
in the infant’s gastrointestinal tract.
❖ Newborns receive vitamin K (AquaMEPHYTON)
intramuscularly shortly after birth
******Prevent hemorrhage *******
If parents refuse, additional paperwork must be
signed by parents.
 Complications:Miscarriage
What is it?
Can be elective or spontaneous
❖ Elective: The choice to terminate the
pregnancy.
❖ Spontaneous: spontaneous abortion
and pregnancy loss, is the natural death
of an embryo or fetus before it is able to
survive independently. Some use the
cutoff of 20 weeks of gestation, after
which fetal death is known as a stillbirth.
Causes
Chromosomal abnormalities might lead to:
❖ Blighted ovum. Blighted ovum occurs when no
embryo forms.
❖ Intrauterine fetal demise. In this situation, an
embryo forms but stops developing and dies
before any symptoms of pregnancy loss occur.
❖ Molar pregnancy and partial molar pregnancy.
With a molar pregnancy, both sets of
chromosomes come from the father. A molar
pregnancy is associated with abnormal growth of
the placenta; there is usually no fetal
development.
❖ Uncontrolled diabetes
❖ Infections
❖ Hormonal problems
❖ Uterus or cervix problems
❖ Thyroid disease
Prevention
❖ Seek regular prenatal care.
❖ Avoid known miscarriage risk factors
— such as smoking, drinking alcohol
and illicit drug use.
❖ Take a daily multivitamin.
❖ Limit your caffeine intake. A recent
study found that drinking more than
two caffeinated beverages a day
appeared to be associated with a
higher risk of miscarriage.
Assessment
❖ Cardinal signs are
❖ Spotting and cramping together
❖ Tissue expulsion from the vagina
Risks
❖ Age. Women older than age 35 have a higher risk of
miscarriage than do younger women. At age 35, you
have about a 20 percent risk. At age 40, the risk is
about 40 percent. And at age 45, it's about 80
percent.
❖ Previous miscarriages. Women who have had two
or more consecutive miscarriages are at higher risk of
miscarriage.
❖ Chronic conditions. Women who have a chronic
condition, such as uncontrolled diabetes, have a
higher risk of miscarriage.
❖ Uterine or cervical problems. Certain uterine
abnormalities or weak cervical tissues (incompetent
cervix) might increase the risk of miscarriage.
❖ Smoking, alcohol and illicit drugs. Women who
smoke during pregnancy have a greater risk of
miscarriage than do nonsmokers. Heavy alcohol use
and illicit drug use also increase the risk of
miscarriage.
❖ Weight. Being underweight or being overweight has
been linked with an increased risk of miscarriage.
❖ Invasive prenatal tests. Some invasive prenatal
genetic tests, such as chorionic villus sampling and
amniocentesis, carry a slight risk of miscarriage.
❖
Treatment
❖ Monitor HcG Levels, a decrease is
indicative of miscarriage.
❖ Pelvic rest
❖ Bed rest
❖ If it is sure that a miscarriage is
happening : prepare to start an IV,
administer blood & D&C
 Complications: Ectopic pregnancy
What Am I ? ASSESSMENT Diagnostics
❖ Pain ❖ H&H: Low if rupture occurs.
Fetal growth somewhere
❖ Referred shoulder pain ❖ Diagnosable with ultrasound.
outside of the uterus, usually
❖ Spotting ❖ Human chorionic gonadotropin
within the fallopian tubes.
❖ Bleeding into the peritoneum level (serum) (hCG) is abnormally
❖ Bleeding from vagina if rupture low; when the test is repeated in
occurs 48 hours, the level remains lower
Causes ❖ Normal signs/ symptoms of
pregnancy
than usual for a normal
(intrauterine) pregnancy.
❖ Congenital defects in reproductive tract ❖ Progesterone level (plasma) is
❖ Diverticula lower than expected for an
❖ Ectopic endometrial implants in the tubal
intrauterine pregnancy.
mucosa

Risk Factors
❖ Endosalpingitis
❖ History of multiple elective abortions
❖ Intrauterine device
❖ Previous surgery, such as tubal ligation ❖ History of tubal surgery
or resection ❖ Previous ectopic pregnancy
❖ Sexually transmitted tubal infection ❖ History of pelvic inflammatory disease
❖ Transmigration of the ovum ❖ Pelvic adhesions
❖ Tumor pressing against the tube ❖ Use of intrauterine device
❖ Hormonal imbalance ❖ History of endometritis
❖ Progesterone-only contraceptive use
❖ Use of assisted reproductive technologies
❖
Complications
Diethylstilbestrol exposure in utero
❖ Cigarette smoking
❖ Age between 35 and 44
❖ Rupture of fallopian tube ❖ Multiple sexual partners
❖ Hemorrhage ❖ Vaginal douching
❖ Shock ❖ Young age at first sexual intercourse
❖ Peritonitis
❖ Infertility

Interventions
❖ Disseminated intravascular
coagulation
❖ Death
❖ Vital signs

Treatments
❖ Vaginal bleeding
❖ Pain level and effectiveness of
❖ Transfusion with whole blood or packed red blood interventions
cells to treat hypovolemic shock if the tube has ❖ Fluid balance status
ruptured. ❖ Intake and output
❖ IV fluid replacement ❖ Signs and symptoms of hypovolemia and
❖ Supplemental iron if anemia occurs from blood loss impending shock
❖ Methotrexate sodium (Trexall) as primary treatment ❖ Surgical site (postoperatively)
for unruptured ectopic pregnancy (single I.M. dose
or multidose treatment via I.M. or IV route)
❖ Leucovorin I.N. between doses of multi dose
methotrexate therapy
❖ Rho(D) immune globulin, human, if the patient is
Rh-negative
 Complications : Placenta Previa
Assessment complications
What am i? ❖ Cord being the presenting part, possible
❖ Three types: Marginal, partial,
❖ Painless bleeding cord prolapse
and total
❖ Soft, nontender uterus ❖ Fetal hypoxia or blood loss
❖ Common cause of bleeding during
❖ Fetal malpresentation ❖ Preterm delivery
the second half of pregnancy
❖ Minimal descent of fetal ❖ Dystocia
❖ Good maternal prognosis if
presenting part ❖ Anemia
hemorrhage can be controlled
❖ Good fetal heart tones ❖ Hemorrhage
❖ Usually necessitates pregnancy
❖ Possible contractions ❖ Abruptio placentae
termination if bleeding is heavy
❖ Disseminated intravascular coagulation
❖ Fetal prognosis dependent on
❖ Shock
gestational age and amount of
❖ Placenta accreta, increta, percreta
blood lost; risk of death greatly
❖ Intrauterine growth restriction
reduced by frequent monitoring
❖ Abnormal fetal presentation
and prompt management
❖ Kidney damage
❖ Cerebral ischemia
❖ Maternal or fetal death

Patho
Improper implantation of the placenta
in the lower uterine segment has Medications
caused partial or total coverage of the
cervical os.With development of the ❖ I.V. fluids, such as lactated Ringer solution
lower uterine segment and gradual or normal saline solution, using a large-bore
changes in the cervix during the third catheter
trimester, shearing forces at the ❖ Oxygen
attachment site lead to partial
❖ Fresh frozen plasma and platelets, as
detachment and bleeding.
necessary, for coagulation problems
❖ Tocolytics, such as terbutaline sulfate,

Risk Factors
calcium channel blockers, or magnesium
sulfate short-term to halt preterm labor and
to allow time for doses of betamethasone
❖ Advanced maternal age (over age 35) dipropionate (Diprolene)
❖ Defective vascularization of the decidua ❖ Betamethasone dipropionate to enhance
❖ Endometriosis fetal lung maturity if less than 34 weeks'
❖ Multiparity Interventions
gestation
❖ Infertility treatments ❖ Pad counts, the patient should not saturate
❖ Multiple pregnancy more than one pad an hour.
❖ Previous uterine surgery or cesarean birth ❖ Monitor blood counts
❖ Monitor fetal heart tones
❖ Smoking
❖ Monitor contractions
❖ Male fetus ❖ Prepare for c-section
❖ Cocaine use ❖ Do not perform cervical exams
❖ History of placenta previa
❖ High altitudes
❖ Uterine abnormalities inhibiting normal
embryonic implantation (such as prior
curettage or the presence of uterine
fibroids)
 Complications: Abruptio Placenta
What Am I? Assessment
❖ Premature separation of the ❖
❖
Rigid board-like abdomen
Abdominal pain
Priorities
placenta from the uterine wall ❖ Keep baby safe,
❖ Difficulty palpating baby.
❖ Usually occurs after 20 weeks' ❖ Signs of fetal distress: prolonged continuous monitoring
gestation, most commonly during fetal bradycardia, repetitive late ❖ Manage maternal shock
the third trimester, and peaks at decelerations, and decreased
24 to 26 weeks' gestation short-term variability; absent fetal
heart tones
Complications
❖ Common cause of bleeding
❖ Uterine hypertonicity
during the second half of ❖ Abdominal tenderness
pregnancy
❖ Cesarean delivery
PATHo ❖ Hemorrhage/coagulopathy
Improperly implanted placenta ❖ Retroperitoneal
separates before the pregnancy bleed/bleeding into the
reches term. If the abruption is abdomen
classified as concealed it is bleeding ❖ Shock
into the uterus.
Can be classified on scale of 0-3, 3
❖ Acute kidney injury

Causes
being the worst prognosis. ❖ Disseminated intravascular
coagulation (DIC)
❖ Car accidents ❖ Adult respiratory distress
❖ Domestic or IPV
syndrome
❖ Previous C-section
❖ Rupture of membranes ❖ Multisystem organ failure
❖ Cocaine use ❖ Maternal death
❖ Smoking ❖ Fetal hypoxia or asphyxia
❖ Pregnancy induced ❖ Precipitous labor and
hypertension
delivery
❖ Prematurity
❖ Fetal death
❖ Sepsis
Interventions
❖ Insert an indwelling urinary : monitor urine Labs
output.
❖ Obtain blood specimens for Hb level and ❖ Serum hemoglobin level test and
hematocrit, coagulation studies, and typing and platelet count are decreased.
crossmatching. ❖ Fibrin degradation products test
❖ Evaluate the extent and amount of bleeding; shows progression of abruptio
perform a pad count, placentae and indicates the
❖ Provide continuous external electronic fetal presence of DIC.
monitoring if the fetus is viable. ❖ Hypofibrinogenemia suggests
severe abruption (fibrinogen
❖ Give I.V. fluids and blood products. Maintain
levels less than or equal to 200
one to two large-bore I.V. lines; inspect I.V.
mg/dL).
insertion sites frequently for signs and
❖ Kleihauer-Betke test is positive if
symptoms of inflammation or infiltration.
fetal-maternal transfusion has
Provide I.V. site care according to your facility's occurred.
policy. ❖ Rho(D) antibody screening is
❖ Position the patient on her left side to enhance positive if isoimmunization has
uteroplacental perfusion. occurred.
❖ Administer oxygen, as ordered, on the basis of
pulse oximetry levels and respiratory status.
❖ Prepare the patient for emergency delivery, as
appropriate.
 What is it?
Hyperemesis gravidarum
Excessive vomiting that
leads to dehydration,
starvation, and even Assessment Interventions
death among pregnant ❖ Hypotension ❖ 48 hours of NPO status
populations ❖ Elevated H&H ❖ IV fluids
Related to increased ❖ Decreased urine ❖ Antiemetics as ordered
estrogen levels output ❖ Vitamins
❖ Hypokalemia ❖ Decrease environmental
❖ Weight loss stimuli
❖ Ketonuria ❖ Clear liquids and small dry
feedings as tolerated.
❖ Give either cold or hot food,
nothing room temp.

Critical labs
❖ Potassium
❖ Have the patient on tele
❖ Monitor for symptoms of
shock and fluid volume
deficit.

Complications
❖ Dehydration
❖ Wernicke's encephalopathy from
vitamin B1 deficiency
❖ Mallory-Weiss tears (esophageal
tears and bleeding)
❖ Esophageal bleeding
❖ Pneumothorax
❖ Acute tubular necrosis
❖ Electrolyte and acid‑base
imbalances

Diagnostic studies
❖ Potassium, sodium, chloride, and protein levels
are decreased due to losses from vomiting.
❖ Blood urea nitrogen, non protein nitrogen, and
uric acid levels are increased due to renal
compromise and hemoconcentration.
Hemoglobin (Hb) level and hematocrit (HCT) are
increased due to hemoconcentration.
❖ Urinalysis reveals ketones and, possibly, protein;
urine specific gravity increases.
❖ Vitamin B1 and B6 levels are decreased due to
impaired intake.
❖ Thyroid-stimulating hormone, thyroxine, and
triiodothyronine levels may be mildly increased.
 What is it?
Extreme elevation in
blood pressure during
pregnancy with the
presence of protein in the
urine after 20 weeks of
gestation.
Magnesium sulfate
❖ Vasodilator & sedative
❖ Monitor for pulmonary
edema
❖ Monitor for signs of mag
toxicity: decreased
DTRS, BP, respiration,
decreased LOC.
❖ Labor will halt: have
oxytocin ready if
indicated.
Care
❖ Decrease environmental
stimuli. This decreases the
risk of seizures.
❖ Initiate seizure precautions
❖ Monitor mom and baby
Nclex tip!
Blood pressure that exceeds
140/90 millimeters of mercury
(mm Hg) or
greater,documented on two
occasions, at least four hours
apart , is abnormal.
preeclampsia
Assessment Types
❖ Sudden weight gain ❖ Mild : 30/15 mmhg off of baseline
❖ Swelling of the face and six hours apart. Increase the
hands amount of protein in the diet
❖ Headache
because they are spilling it into the
❖ Blurry vision
❖ Hyperreflexia urine. Glomerular damage is
❖ Clonus ( seizures) present.
❖ Severe: 160/110 mmHg 6 hours
apart. May have an episode of
seizure activity. Have mag sulfate
ready.
Interventions
❖ Magnesium sulfate : have
calcium gluconate at
bedside.
❖ Monitor for sedation and
hyporeflexia.
❖ Seizure precautions
❖ Safety checks
Risk factors
❖ History of preeclampsia.
❖ Chronic hypertension.
❖ First pregnancy.
❖ New paternity
❖ Age. The risk of preeclampsia is higher for very
young pregnant women as well as pregnant
women older than 40.
❖ Obesity.
❖ Multiple pregnancy. Preeclampsia is more
common in women who are carrying twins,
triplets or other multiples.
❖ Interval between pregnancies. Having babies
less than two years or more than 10 years apart
leads to a higher risk of preeclampsia.
❖ In vitro fertilization. Your risk of preeclampsia is
increased if your baby was conceived with in
vitro fertilization.
 PRETERM LABOR
What is it?
Onset of labor anywhere
between 20-37 weeks
gestation.
Risk factors
❖ Previous preterm labor or premature birth,
particularly in the most recent pregnancy or
in more than one previous pregnancy
❖ Pregnancy with twins, triplets or other
multiples
❖ Problems with the uterus, cervix or placenta
❖ Smoking cigarettes or using illicit drugs
❖ Certain infections, particularly of the
amniotic fluid and lower genital tract
❖ Some chronic conditions, such as high
blood pressure and diabetes
❖ Stressful life events, such as the death of a
loved one
❖ Too much amniotic fluid (polyhydramnios)
❖ Vaginal bleeding during pregnancy
❖ Presence of a fetal birth defect
❖ An interval of less than six months between
pregnancies
❖ Infection of tissues that surround and
support your teeth (periodontal disease)
Assessment
❖ Regular or frequent sensations of
abdominal tightening (contractions)
❖ Constant low, dull backache
❖ A sensation of pelvic or lower abdominal
pressure
❖ Mild abdominal cramps
❖ Vaginal spotting or light bleeding
❖ Preterm rupture of membranes — in a
gush or a continuous trickle of fluid after
the membrane around the baby breaks
or tears
❖ A change in type of vaginal discharge —
watery, mucus-like or bloody
Prevention
❖ Seek regular prenatal care.
❖ Eat a healthy diet
❖ Avoid risky substances.
❖ Consider pregnancy spacing.
❖ Be cautious when using assisted reproductive
technology (ART).
Treatment
❖ Terbutaline: Tocolytic
❖ Magnesium sulfate
❖ Betamethasone : to stimulate maturation of
babies lungs.
❖ Hydration
❖ Treatment of UTI
 Prolapsed cord
Diagnosis
What is it Umbilical cord prolapse should always be
Umbilical cord prolapse considered a possibility when there is a
occurs when the umbilical sudden decrease in fetal heart rate or
cord comes out of the uterus variable decelerations, particularly after the
with or before the presenting rupture of membranes. With overt
part of the fetus. It is a prolapses, the diagnosis can be confirmed
relatively rare condition and if the cord can be palpated on vaginal
occurs in fewer than 1% of examination. Without overt prolapse, the
pregnancies. Cord prolapse is diagnosis can only be confirmed after a
more common in women who cesarean section, though even then it will
have had rupture of their not always be evident at time of procedure
amniotic sac

Treatments
❖ Lift the baby's head off the cord.
❖ Trendelenburg or knee chest
position
❖
Causes
Hyperoxygenate mom
❖ Never push the cord back in
❖ Premature delivery of the baby
❖ Delivering more than one baby
per pregnancy (twins, triplets,
etc.)
❖ Excessive amniotic fluid
❖ Breech delivery (the baby comes

❖
through the birth canal feet first)
An umbilical cord that is longer
Management
than usual ❖ Monitor fetal heart tones
❖ manual elevation of the presenting fetal part
❖ repositioning of the mother to be head down
with feet elevated
❖ filling of the bladder with a foley catheter, or
tube through the urethra to elevate the
presenting fetal part

NCLEX Tip
❖ use of tocolytics (medications to suppress labor)
have been proposed, usually in addition to
If the cord stops pulsating fetal bladder filling rather than a standalone
death has occured.
intervention
 Assessment of Growth and Development of the Infant
Head Should measure 13.75 cm at birth
-Posterior fontanelle should close by 2nd month Well checkup schedule
-Anterior fontanelle should close in 12-18 months
❖ Second week of life
Height and weight ❖ 2, 4, 6, 9 months of age.
- In the first 6 months birth weight doubles and baby should grow 6 inches
- By 12 months birth weight should triple and baby should grow 10-12 in. Vitals
Skelton ❖ HR: 70 resting - 180 awake and crying
- Is made up of cartilage at 3 month gestation and continues to ossify and grow ( accurate HR is taken apically)
throughout life.
❖ RR: 30 but can range from
- Bone age, injury, abuse or nutritional deficits can be determined by X-Ray.
Circulation
20-50 with increase or
decrease of activity.
- Hemoglobin and RBCs decrease when respiratory system takes over until
3 months of age
❖ BP: 85/60 mmHg
❖
Neuro
Temp: 98.6
- Nerve cells grow and coordination begins in an orderly pattern.

Physical milestones Psychological milestones

❖ Jerky quivering arm movements, ❖ Focuses 8-12 in away
❖ Brings hands to mouth , makes fists ❖ Eyes wonder and cross
❖ Head flops back if unprepared ❖ Likes black and white/ high contrast patterns.
❖ Strong reflexes ❖ Prefers human face to other patterns
❖ 5-8 feedings per day - 3 meals 2 snacks ❖ Hearing is fully mature, may turn toward sound
❖ Progresses from sleeping 20 hours a day to 10-12 ❖ Likes sweet smells, dislikes sour
hours at night and two naps by 12 months,place ❖ Likes soft sensations
awake child in crib to sleep ❖ Likes to be handled gently

Social Milestones Emotional growth

❖ 0-1 month: extensive sleep, dependent, eye contact ❖ 0-1 mo: general tension
❖ 0-3 months: smiles and fixes on faces,solitary play ❖ 1 mo: happy and sad emotions
❖ 3-6 mo: enjoys peekaboo, smiles at familiar faces ❖ 6 mo: separation anxiety
❖ 6-12 mo: knows name, gives and takes objects, ❖ 6-12 mo: stranger anxiety, shows curiosity by
understands easy commands. 12 months .

Language Nutrition
❖ 0-3 mo: Cries, grunts and Rapid growth causes a need for the greatest amount of nutrients
Coo ❖ 4-6 mo- 12 mo: breast milk or commercial formula, introduction of solid foods.
❖ 0-6 mo: babbling, vowels, One food at a time starting with veggies.
❖ You may need to supplement Vit C/D iron, fluoride.
half consonants
❖ 6mo: iron rich foods are needed to supplement
❖ 12 mo: 1-2 words, imitation, ❖ 7-8 mos: self feeding begins by grasping and bringing food to mouth. Ends with
responding to simple use of utensils
commands ❖ WIC program helps children and women get proper nutrition when they qualify
❖

Age Theorist Stage Description Nursing care

Sigmund Freud Oral Pleasure center in Encourage self feeding.

Birth -18 mo Avoid putting objects in
mouth
mouth

Erik Erikson Trust vs Depends on parents Encourage bonding and

1st year to meet needs to family relationships
mistrust create trust

Jean Piaget Sensorimotor Coordinates sensory Plan tactile activities

Birth -2 yrs experiences with with use of colorful
stage physical action materials
 Assessment of Growth and Development of the Toddler 1-3
Physical growth Discipline
❖ slows
❖ Communication and mobility Safety Training and instructing to produce positive
skills increase ❖ Proper restraint in car
behavior patterns
❖ Stubbornness , explore, seat ❖ Self control is gradual
dependent ❖ Never leave the toddler ❖ 2yrs: begin accepting responsibility
❖ Begin to explore Autonomy alone in water even ❖ Consistency and timing are key
“ I DO MYSELF” buckets pose a drowning ❖ Calmly remove the child from the
❖ Bed rituals are important risk situation

Height and weight
- Gain 5 to 10 LBs per year
- Grow 3 inches per year
- Normal to go on food jags
Learns to stand alone and walk,
1 year Need 12-14 hours a day of sleep
3 years need 10-12 hours
❖ Put away poisons and ❖ Tell child the behavior is bad, not them
medications with locks
❖ Burns from hot Well visits
appliances and water are
❖ 15 mo for shots
common
❖ Annually after that
❖ Assess growth/ development, caregiver skill,and
relationship between toddler and parent

Physical milestones Psychological milestones

❖ Lordosis and pot belly, organs adapt moderately to ❖ Well established walking
stress ❖ Hand eye coordination
❖ Well established walking ❖ Progressive development of fine motor skills
❖ Growth is slowed and stable ❖ They begin to draw and write
❖ Bones and muscles still immature requires nutrition ❖ Bladder control is gained , with occasional
and exercise for adequate development relapses
❖ Brain is 90% developed by age 5

Social Milestones Emotional growth

❖ Moves to parallel play, mostly imitates role models ❖ Many emotions in one day
❖ Does Not share readily until later toddler years ❖ Increased use of emotion language and
❖ Separation anxiety is overcome easily understanding of emotion
❖ causes/ consequence understanding

Language Nutrition
❖ Vocabulary begins to increase names objects, ❖ Require about 1000-1400 calories a day
body parts, animals, and familiar locations ❖ Toddlers should be active 60 min a day
❖ Primary method of communication ❖ Fruites: 1-1.5 cups
❖ Continuous questioning “why” ❖ Veggies: 1-1.5 cups
❖ Toys that talk are preferred ❖ Grains : 3-5 oz
❖ Brief sentences ❖ Protein : 2-4 oz
❖ Dairy : 2-2.5 cups
❖ Allow children to eat when hungry instead of forcing
meals.

Age Theorist Stage Description Nursing care

Sigmund Freud Anal Pleasure center in Encourage the family to

18 mo- 3 teach good hygiene
the anus
years

Erik Erikson Autonomy vs Mastering Support bonding and

1- 3 years environment and family relationships
shame and building self esteem
doubt

Jean Piaget Pre operational Sensory / action Plan drawing and

2-7 coordination, writing, tactile
symbolic thinking. experiences. Use
Represent world and colorful materials to
words together stimulate senses.
Assessment of Growth and Development of the preschool child
Growth rate has slowed
❖ -Language and play change remarkable Well checkup schedule
❖ - soak up info “little sponges, let them choose their own clothes” ❖ Boosters and vaccines
❖ - 3yrs still chubby faced 4-6yrs
❖ - 5 yrs leaner and taller and better coordinated but can't distinguish fantasy from real life. ❖ Annual exams for
Height and weight growth and health
❖ Gains 3-5 lb a year and grows 2.5 in. a year
❖ By 12 months birth weight should triple and baby should grow 10-12 in.
Vision
Skelton ❖ Still immature
❖ Gross motor skills improve by age 5 they can climb, jump, catch and throw ❖ Distance judgement faulty
A ball and ride a bicycle.
❖ Screen for amblyopia
❖ 5 yrs, leaner taller and better coordinated, teach them to wash hands thoroughly
❖ Bathing and brushing teeth still need supervised, can't wash own hair. ❖ 20/20 vision by age 6
Dentition ❖ Depth perception occurs at
❖ The skull is 90% of adult size by age 6 8-10 yrs old.
❖ Early preschool insidious teeth have completely emerged ,you floss their teeth.
❖ End of preschool teeth have erupted w/ incisors being first.

Physical milestones Psychological milestones

❖ Aware of their sexuality ❖ Develop imagination
❖ May have an imaginary friend
❖ May be attracted to parent of the opposite sex
❖ Magical thinking
❖ Parents should teach accurate sexual info ❖ May be afraid of the dark or have nightmares
❖ Teach the difference between good and bad touch ❖ 4:Temper tantrums, pushing, hitting, and
❖ Calm matter of fact response to masturbation manipulating environment
❖ Teach safety and privacy regarding genitals ❖ Discipline: teach the child responsibility and self
control and consistency.
❖ Taking favorited away is more effective than hitting

Social Milestones Emotional growth

❖ Preschoolers use imitative play, all types of play are
❖ 0-1 mo: general tension
needed for development
❖ Dramatic play: act out situations and control it ❖ 1 mo: happy and sad emotions
❖ Cooperative play: organized groups ❖ 6 mo: separation anxiety
❖ Associative play: play together but unorganized and no ❖ 6-12 mo: stranger anxiety, shows curiosity by
leader 12 months .
❖ Solitary : playing alone away from groups

Language
❖ 3-4: non communicative w/
language
❖ 4: communicate with language
❖ 4-5: use naughty words
❖ Converse in a way they can
understand
❖ Delays can be caused by:
hearing impairment, lack of
stimulation,
Nutrition
❖ Do not need large quantities of food, keep portions small.
❖ Requires high amount of protein
❖ Erratic appetite, frequent small meals are better
❖ Guide them when choosing food
❖ Provide healthy snacks
❖ Rituals are important.

Age Theorist Stage Description Nursing care

Sigmund Freud Phallic Pleasure center in Explain to the family and

3-6 yrs teach hygiene
the genitals

Erik Erikson Initiative vs guilt Child develops a Monitor and protect from
3-5 yrs conscious and sense injury and poisoning.
of right and wrong Encourage them to ask
questions

Jean Piaget Pre operational The child sees the Plan drawing and writing
2-7 yrs world egocentrically activities.
phase
 Growth and Development of the school aged CHILD
Head Should measure 13.75 cm at birth
❖ School starts
❖ Thinking skills develop
Height and weight
❖ Growth is slow and steady gains 5-6 lb a year.
❖ Grows 2.5 in. a year until pre-teen.
❖ Spine straightens and abdomen flattens
❖ Long bone growth is noted
Dentition
❖ Starts to lose baby teeth at about 6
❖ Eruption of permanent teeth begins
Neuro
❖ -Refines motor and cognitive skills
❖ - Engages in meaningful tasks
Physical milestones
❖ Slowed growth, graceful on their feet
❖ Strength and abilities double
❖ Loss of baby teeth
❖ Structural bone changes
❖ Girls begin to experience secondary sex
characteristics
Social Milestones
❖ Develop confidence in family and explore
relationships outside of family
❖ Peers become important
❖ Motivated by accomplishment
❖ success/ failure have a strong impact
Language
❖ Language is refined vis
grammar education
❖ Ability to use words to express
knowledge
❖ Narrative skills improve
❖ Able to make inferences
❖ Able to evaluate speech and
messages
Age Theorist
Sigmund Freud
6-10 yrs
Erik Erikson
6-10 yrs
Jean Piaget
2-7 yrs
Well checkup schedule
❖ Annual physicals
❖ Booster tetanus and diphtheria
❖ Visit the dentist 2x a year
❖ Screening for scoliosis at 10-11
❖ Vision and hearing screen .
Substance abuse The birds and the bees
❖ Teach family values
❖ Teach right and wrong ❖ Help develop a positive attitude of
❖ Set rules and enforce sexuality
❖ Teach facts about ❖ Sexual roles
drugs and alcohol ❖ Satisfaction with being a boy or
❖ Actively listen girl
Psychological milestones
❖ Displays a sense of duty and accomplishment
❖ Applies energy from play to complete tasks
❖ Develops positive sense of self
❖ Magical thinking, sit still for short periods
❖ Understands taking turns , enjoys groups
❖ Enjoys real life activities
❖ Give consistent rules, positive attention, and
clear expectations, questions parents standards
Emotional growth
❖ Greater understanding of complex emotions
❖ Understands they can have more than one
emotion
❖ Greater ability to control emotion
❖ Uses strategies to redirect feelings
Nutrition
❖ Requires more food for increased energy demands
❖ Choose foods from all food groups
❖ Food jags and increased appetite are normal
❖ Limit fat intake, supervise snack habits
❖ Offer choices.
Stage Description Nursing care
Latency Preparing for adult Encourage sibling and
peer contact. Assess for
life but awaiting
maturity sexual activity in later
stage
Industry vs Developing sense of Provide activities based
self worth and talent on talents and abilities
Inferiority
Pre operational The child sees the Plan drawing and writing
world egocentrically activities.
phase
 Assessment of Growth and Development of the Adolescent
11-18yrs
Early adolescents
Well checkup schedule
❖ -puberty : reproductive maturity
❖ - starts at age 10 in girls and ends with menstruation
❖ - starts age 12 in boys and ends sperm production ❖ 2x during teens
❖ Immunizations, hearing, vision,
Growth scoliosis, thyroid and pelvic for
sexually active girls..
❖ Girls achieve 98% of height of 16 ❖ BP, height and weight
❖ Skeletal growth outpaces muscle growth
❖ Nonvoluntary with early menses, 13-15 ovulation begins
❖ Boys : grow rapidly from 13-20
❖ Muscle strength and coordination develop rapidly
❖ Larynx becomes enlarged
❖ Both sexs : body takes on contours
❖ Primary sex organs develop, hormonal activity increases
❖ Bone growth continues until 20s

Physical milestones Psychological milestones

❖ Anorexia and bulimia can happen due to body image issues

❖ Girls : 9-11: growth spurts last 18 months ❖ They wonder who they are
❖ Grows 3 in annually until menarche ❖ What will they become
❖ Begin to develop figure ❖ More mobile
❖ Boys: 11-13: slower and steadier than girls ❖ Seek out intimate relationships
❖ Changes in penis testes and scrotum ❖ Most are heterosexual, homosexuality can be
❖ Nocturnal emissions “ wet dreams” difficult emotionally
❖ Body image is closely related to self esteem
❖ Underdevelopment causes anxiety

Social Milestones Emotional growth

❖ Greater focus on peers develops a separate self ❖ Rebellious
from parents ❖ Emotional highs and lows
❖ Moral development ❖ Focus on appearance
❖ Less egocentric ❖ Sexually active teens may have impaired self image
❖ Focused on mixed gender friendships ❖ Privacy becomes important. .

Language Nutrition
● Able to communicate Rapid growth causes a need for the greatest amount of nutrients
complex thoughts ● Appetite increases and teens eat frequently
● Food choices not always wise
● May skip meals
● Can have nutritional deficits of vit A, D and B. folic acid, iron and zinc. Due to
menses girls need additional iron.

Age Theorist Stage Description Nursing care

Sigmund Freud Genital Pleasure center in Encourage safe sex,

Puberty educate on teen
the genitals
pregnancy and STI

Erik Erikson Identity vs role Integrating multiple Support self esteem, be

10-20yrs roles, self image and honest maximize
confusion peer pressure positive aspects of
image and minimize
defects

Jean Piaget Formal Reasons in more Discuss conditions

11- adulthood abstract idealistic openly with client. Allow
operational ways privacy to discuss
stage
 Pediatric Assessment
Circulation
Airway / Breathing ❖ Warmth of skin
❖ Respiratory rate
❖ Respiratory effort Heart rate

Air entry ❖ regularity/rhythm/rate

❖ Adequate Pulses
❖ adventitious breath sounds ❖ strength and regularity
❖ central vs. peripheral
Respiratory Distress
❖ Tachypnea Perfusion
Mechanics of breathing ❖ capillary refill
❖ skin color (e.g. pale, mottled)
❖ Retractions
❖ Tracheal Tug Cardiovascular Collapse
❖ Nasal flaring ❖ Tachycardia
❖ Head bobbing ❖ Altered perfusion
❖ Grunting on exhalation
❖ Prolonged expiratory phase Skin
❖ Diminished air entry ❖ Prolonged capillary refill > 2 sec
❖ Change in breath sounds ❖ Increased core to skin temperature gradient
❖ Stridor
❖ Wheezing
Brain

Late signs ❖ Altered level of consciousness/activity

❖ Skin color changes-dusky/cyanotic
❖ Inaudible air entry
❖ Apnea/irregular respiration
❖ Changes in level of consciousness/activity
❖ Bradycardia
❖ Decreased response, “worried” appearance
Kidneys
❖ Decreased urinary output <1ml/kg/hr
❖ Decrease in pulse quality

Neurological
❖ Level of consciousness Late signs
❖ Decreased response to pain
❖ Mental status,
❖ Flaccid tone
interaction
❖ Hypotension
❖ Activity, movement,
❖ Bradycardia
muscle tone
❖ Age appropriate
responses

Vital signs
GI/GU
❖ Bowel sounds
Newborn ❖ Appetite
❖ Resp: 30 - 50
❖ Bowel movement
❖ Heart: 120 - 160
/Emesis
Infant (1-12 months)
❖ Resp: 20 - 30 Hydration status
❖ heart: 80 - 140
Toddler (1-3 yrs.) ❖ Urine output
❖ Resp: 20 - 30 ❖ Moist oral mucosa
❖ Heart: 80 - 130 ❖ Skin Turgor
Preschooler (3-5 yrs.) ❖ Fontanelle
❖ Resp: 20 - 30
❖ Heart: 80 - 120
 LARYNGOTRACHEOBRONCHITIS
WHAT IS IT? Assessment Treatment
Also known as croup, a type of ❖ Steam
❖ "barking" cough,
respiratory infection that is usually ❖ Car Rides with
stridor
caused by a virus.The infection leads windows down at night
to swelling inside the trachea, which ❖ hoarseness,
❖ difficulty breathing ❖ Cool down the
interferes with normal breathing and environment to open
produces the classic symptoms of which usually
up the airway and
"barking" cough, stridor, and a worsens at night
blood vessels.
hoarse voice. Fever and runny nose
may also be present.[1] These
symptoms may be mild, moderate,
or severe. Often it starts or is worse
at night. It normally lasts one to two
days

Medical management
❖ Nebulized epinephrine
❖ Corticosteroids
 Respiratory syncytial virus: Bronchiolitis
What am I ? Assessment Diagnostics
Respiratory syncytial virus (RSV) ❖ Sneezing ❖ Secretions from the
is a very common virus that leads ❖ Rhinorrhea nose and throat are
to mild, cold-like symptoms in ❖ Low grade fever cultured.
adults and older healthy children. ❖ Coughing ❖ ELISA test
It can be more serious in young ❖ Wheezing ❖ IFA test
babies, especially those in certain ❖ Retractions
high-risk groups ❖ Nasal flaring
❖ Dyspnea
❖ Prolonged expiratory phase
❖ Intermittent cyanosis

Patho R: Rhinorrhea, retractions

The inflammatory process leads
U: Unable to expire Treatments
N: Nasal flaring ❖ Suction
to airway edema and
N: Not a high fever ❖ Possible mechanical
accumulation of mucus and
Y: Yes they may be blue ventilation
cellular debris. Obstruction of the
airway leads to overinflation of the ❖ Iv fluids
N: Not able to breathe ❖ High humidity and fluids
alveoli or atelectasis in some
O: Overloaded, crackles ❖ Rest
instances.
S: Some wheezing ❖ Mist therapy with oxygen
Expiratory phase is prolonged via hood or tent to
alleviate dyspnea and
hypoxia
Risk factors ❖ Ribavirin for severely ill:
aerosol mist
❖ Palivizumab
❖ Prematurity ❖ Albuterol
❖ Crowded places with people who ❖ Antipyretics
may be infected
❖ Exposure to other children (e.g., in
daycare) or to older siblings
attending school
❖ Infants younger than 6 months of
age Interventions
❖ Smoke ❖ Continuous respiratory
❖ Congenital disorders assessments
❖ Young children, especially those ❖ Hand washing
under 1 year of age, who were ❖ Place the client on
born prematurely or who have an isolation: Droplet
underlying condition, such as ❖ Do not care for other
congenital heart or lung disease high risks clients.
❖ Children with weakened immune ❖ Do not care for this
systems client if pregnant.
❖ Adults with asthma, congestive
heart failure, or chronic obstructive
pulmonary disease (COPD)
❖ People with immunodeficiency,
including those with certain
transplanted organs, leukemia, or
HIV/AIDS
 Pneumonia
What am I ? Assessment
Acute inflammation of the Diagnostics
pulmonary parenchyma ❖ Cough either productive or nonproductive ❖ Sputum culture
associated with alveolar ❖ Malaise ❖ Chest x ray
consolidation. Can be bacterial or ❖ Fever
viral. ❖ Anorexia
❖ Wheezing fine crackles, absent breath
sounds
❖ Headache
❖ Tachypnea
❖ Gi upset with abdominal distention

Patho
Infection that inflames the air
sacs in one or both lungs. The air Treatments
sacs may fill with fluid or pus
❖ Antibiotics for bacterial
CLASSIFICATIONS
(purulent material), causing cough
pneumonia after you
with phlegm or pus, fever, chills,
❖ Lobular: Large portion of collect the sputum
and difficulty breathing. A variety
lung involvement sample.
of organisms, including bacteria,
❖ Interstitial : Involves the ❖ Hydration
viruses and fungi, can cause
alveolar walls, ❖ Nebulizers
pneumonia.
peribronchial, and ❖ 02 therapy
interlobular tissue. ❖ Chest physiotherapy
❖ Bronchial: involves the
bronchi and lung fields

Risk factors
❖ Cigarette smoking
❖ Recent viral respiratory infection—a cold,
laryngitis, influenza, etc.
❖ Difficulty swallowing (due to stroke, dementia,
Parkinson's disease, or other neurological
conditions), which can lead to aspiration
(breathing in a foreign object)
❖ Chronic lung disease such as COPD,
bronchiectasis, or cystic fibrosis
❖ Cerebral palsy Interventions
❖ Other serious illnesses, such as heart ❖ Airway is the priority
disease, liver cirrhosis, or diabetes ❖ Oxygen therapy
❖ Living in a nursing facility ❖ Increase fluids to
❖ Impaired consciousness (loss of brain increase sputum
function due to dementia, stroke, or other production and thin
neurologic conditions) secretions
❖ Recent surgery or trauma ❖ Antibiotics for bacterial
❖ Having a weakened immune system due to pneumonia
illness, certain medications, and autoimmune ❖ Supportive care
disorders
 asthma
What am I ? Assessment
A respiratory condition marked
by spasms in the bronchi of the ❖ Expiratory wheezing
lungs, causing difficulty in ❖ Chronic cough Diagnostics
breathing. It usually results from ❖ Dyspnea ❖ Decreased peak
an allergic reaction or other forms ❖ Nonproductive cough expiratory flow rates
of hypersensitivity. ❖ Tachypnea ❖ Pulmonary function
❖ Irritability test
❖ Restlessness
❖ Use of accessory muscles to
breathe
❖ Orthopnea
Treatments
Patho W: Wheezing ❖ Corticosteroids
Characterized by chronic ❖ Cromolyn
E: Extra cranky
inflammation , ❖ Metered dose inhaler
E: EXtra fast breathing
bronchoconstriction, and ❖ Salmeterol
Z: Zones Of muscles ( accessory muscle
bronchial ❖ Methylxanthines
use)
hyperresponsiveness. Most ❖ Anticholinergics
Y: Yes they cough
common respiratory disorder ❖ Leukotriene modifiers
in childhood. Do not give beta blockers to an
asthmatic

Triggers
❖ air pollutants
❖
❖
strong odors
seasonal and perennial allergens
Interventions
❖ stress and emotional distress ❖ High-Fowler's
❖ medications (aspirin, NSAIDS, beta ❖ O2 therapy
blockers, cholinergics) ❖ Monitor cardiac rate and rhythm
❖ enzymes (laundry detergents) for changes during acute attack
❖ chemicals (cleaners) ❖ Initiate and maintain IV
❖ sinusitis with post nasal drip
❖ viral respiratory tract infection

STATUS Asthmaticus
life threatening episode of airway
obstruction that is often unresponsive
to common treatment
-extreme wheezing, labored
breathing, use of accessory muscles,
distended neck veins
-creates risk for cardiac and /or
respiratory arrest
 Acute epiglottitis
What am I ?
Acute infection of
Assessment
Treatments
supraglottic structures
resulting in edema and
Remember the 4 D’s ❖ Antipyretics
swelling cause the upper
❖ Drooling ❖ Antibiotics ( swelling of
airway to be obstructed
❖ Dysphasia epiglottis usually subsides,
A flap of cartilage at the
❖ Dysphonia 24 hrs after) c
root of the tongue, which is
❖ Distress ❖ Constant monitoring of
depressed during
swallowing to cover the respiratory status
Respiratory distress ❖ o2 humidification
opening of the windpipe.
❖ nasal flaring ❖ Intubation
❖ sternal/intercostal retraction ❖ let child sit in position they
❖ pale/blue find most comfortable
❖ tachycardia
Patho ❖
❖
increased restlessness
Tripod position with tongue
Epiglottitis is a potentially
protruding
life-threatening condition that
occurs when the epiglottis a
small cartilage "lid" that
covers your windpipe and
swells, blocking the flow of air
into your lungs.
.

Interventions
NEVER USE A TONGUE DEPRESSOR
Triggers TO ASSESS AIRWAY! THIS COULD
❖ Swallow a chemical that CAUSE SPASMS AND FURTHER
burns your throat BLOCK THE AIRWAY!
❖ Swallow a foreign object ❖ protect airway
❖ Smoke drugs, such as crack ❖ avoid throat culture or using
cocaine tongue blade
❖ Streptococcus infection ❖ prepare for intubation
❖ provide humidified oxygen
❖ monitor pulse ox
❖ Administer corticosteroids and IV
fluids
❖ Administer abx therapy starting
with IV then transition to oral to
Emergency management complete 10 day course
Respiratory arrest ❖ Droplet isolation precaution first
❖ Bag ventilation 24 hr after IV initiation
❖ Attempt to intubate ❖
❖ Preform needle or surgical
cricothyroidotomy
❖ Start IV- ceftriaxone or cefotaxime
❖ Racemic epi & steroids are
ineffective