lOMoARcPSD|7393617

Maternal-Newborn Outline finished

Cncpts Maternal Child Hlth Nur (University of Alabama at Birmingham)

StuDocu is not sponsored or endorsed by any college or university

Downloaded by Vin Campbell (afuture500@aol.com)
 lOMoARcPSD|7393617

Maternal-Newborn
Chapter 1: Contraception- strategies/devices to reduce the risk of implantation/fertilization
Natural Family Planning:
1. Abstinence: most effective
2. Coitus interruptus
3. Calendar Method: ovulation happens 14 days before onset of next cycle; fertile period calculated by subtracting
18 from number of days in shortest cycle and 11 from number of days in longest cycle
4. Basal body temp: slightly drops during ovulation: check each morning
5. Cervical mucous: Spinnbarkeit sign mucous stretchy and thin during ovulation; begin checking after last day of
cycle
Barrier Methods:
1. Male condom: only water soluble lube w/ latex condoms
2. Female condom
3. Diaphragm and spermicide: fitted by physician every 2 years; leave in 6 hr after intercourse
4. Cervical cap and spermicide: leave in 6 hr after intercourse; replace q 2 years
5. Contraceptive sponge: leave in 6 hr after intercourse; placed over cervix
Hormonal Methods:
1. Combined oral pills: suppress ovulation, thicken cervical mucus, and alter uterine decidua; decrease
effectiveness anticonvulsants/antibiotics; protects against endometrial/ovarian cancer and cysts; risk
clots/strokes/HTN
2. Progestin-only pills: Safe while breastfeeding; CX: lupus, breast cancer, cirrhosis
3. Emergency Oral Contraceptive: Take w/in 72 hr; test for preg if cycle doesn’t start w/in 21 days
4. Transdermal: less effective women over 198 lbs; wear 3 weeks no application fourth week
5. Injectable progestin: Injection q 11-13 weeks
6. Vaginal ring: replace ring w/in 7 days; can be removed up to 3 hr w/o compromising effect
7. Implantable progestin: effective for 3 years
8. Intrauterine device: Safe breastfeeding; inserted by provider
Transcervical Sterilization: Form scar tissue in tubes to prevent contraception; use alternative birth control for 3 months
Surgical Methods:
1. Female sterilization: permanent; can be done w/in 48 hr after birth
2. Male sterilization: Use condoms until had about 20 ejaculations

Chapter 2: Infertility- inability to conceive after engaging in unprotected for at least 12 months (6 months over 35)

Assessment:
Male/Female: Sexual history Medical history Substance Abuse Occupational Hazards
Female: Age (over 35) Gyno/Obstetric History Weight

Always test male first because less expensive and less invasive

Treatment/Interventions:
Nonmedical: Diet changes, exercise, stress reduction
Medical: Ovarian stimulation meds ex. Letrozole, Clomiphene citrate OR Metformin
Assisted Repro Tech:
1. Intrauterine insemination place sperm in uterus
2. In vitro fertilization fertilize egg outside body then place in uterus
3. Gamete intrafallopian transfer Place egg/sperm in catheter to inject into tubes
4. Donor oocyte: Same as IVF bt w/ donor eggs
5. Donor embryo: donor embryo placed in uterus
6. Gestational carrier: IVF w/ surrogate carrier
7. Surrogate: inseminated w/ semen and carries baby
8. Donor insemination: sperm bank

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Genetic counseling: Recommended family history of birth defects/diseases or older then 35

Complications:
1. Ectopic Pregnancy
2. Multiple Gestation

Chapter 3: Expected Physiological Changes During Pregnancy

Signs of Pregnancy
Presumptive- changes that makes a Probable- changes make provider Positive- s/s can only be explained by
woman think she’s preg think a woman is preg pregnancy
Amenorrhea Abdominal Enlargement Fetal heart sounds
Nausea/Vomiting Hegar’s sign- softening of lower Visualization of fetus via ultrasound
uterus
Fatigue Chadwick’s sign- violet/blue color of Fetal movement (palpated)
cervix
Urinary Frequency Goodell’s sign- softening cervix
Breast Changes Ballottement- rebound of unengaged
fetus
Quickening- flutter movement Braxton Hicks
Uterine enlargement Fetal Outline
Positive Pregnancy Test

W/ serum/urine tests, looking at presence of HCG too high can indicate multigestation, hydatidiform mole, or genetic
abnormality too low can indicate miscarriage

Determining Delivery Dates, Etc.

1. Nagele’s rule: take first day of last cycle, subtract 3 months, add 7 days, then add a year
2. Fundal Height: Should correspond w/ gestational age
3. Viability: viable around 22-25 weeks
4. GTPAL G is gravidity(# of preg) T is term births(38 weekers) P is preterm birth (from viability to 37
weeks) A is abortion (20 weeks or less) L is living kids

Physical Changes w/ Pregnancy

Repro: uterus changes in size, shape, and position
CV: Cardiac output increases
Resp: Oxygen need increases
Musculoskeletal: pelvic joints relax
GI: N/V. Constipation.
Renal: Increases frequency
Endocrine: Large amount hcg, progesterone, estrogen, prostaglandin, and lactogens
Skin: chloasma (pigment on face), linea nigra, stretch marks
Vitals: BP around the same. Pulse increases around 32 weeks. RR can slightly increase.
Fetus: HR should be in 110-160s

Chapter 4: Prenatal Care

Most birth defects occur between 2 and 8 weeks of gestation
Prenatal Assessments:
In normal pregnancy, scheduled monthly until 28 weeks, then q 2 weeks until 36 weeks, then q week until birth
1. Initial Visits: within 12 weeks; determine due date; physical assessment and labs
2. Ongoing Visits: Assess FHR and development; start fundal height in second trimester; check fetal movement
around 16 weeks; self-care education

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Client Education:
Health Promotion: 30 min of moderate exercise is beneficial; avoid hot tubs or saunas; flu immunization; avoid exposure
to hazardous materials
First Trimester: Lifestyle changes. Exercise. Expected labs.
Second Trimester: Fetal movement. Develop birthing plan. Potential complications(preterm labor, gestational HTN,
PROM)
Third Trimester: Pain management during labor. Postpartum care. Breathing techniques. Record fetal movement daily
by counting fetal activity 2-3 times a day for 2 hr after meals or bedtime and report fetal movement of less than 3/hr or
movement that ceases for 12 hr.
Common Preg Discomforts:
1. Nausea/Vomiting: 1st trimester. eat crackers/dry toast 30 min-1 hr before rising in the morning. Avoid having an
empty stomach. Drink fluids between meals.
2. Breast tenderness: 1st trimester. supportive bra
3. Urinary frequency: 1st and 3rd trimester. Perform Kegel exercises to reduce incontinence
4. UTIs: Urinate as soon as feel urge to go. Pee before and after intercourse. Fluids.
5. Fatigue: 1st and 3rd trimester. Frequent rest periods.
6. Heartburn: 2nd and 3rd trimester. Small frequent meals. Sit up 30 min after eating.
7. Constipation: 2nd and 3rd trimester. Fiber. Fluids. Exercise.
8. Hemorrhoids: 2nd and 3rd. Warm sitz baths. Witch hazel pads.
9. Backaches: 2nd and 3rd trimester. Pelvic tilt exercises (arch and straighten back). Side lying positions.
10. SOB: Sleep w/ extra pillows.
11. Leg cramps: Extend the affected leg, keep the knee straight and dorsiflex the foot.
12. Varicose veins/lower edema: Elevate legs.
13. Gingivitis/nasal stuffiness/epistaxis
14. Braxton Hicks: Change position or walk.
15. Supine hypotension
Danger Signs During Pregnancy:
First Trimester: Burning w/ urination; Severe vomiting; Diarrhea(infection); Fever/chills; Abdominal cramping or vaginal
bleeding
Second/Third Trimester: Gush of fluid from vagina; Vagina bleeding; Abdominal pain; Changes in fetal activity; Persistent
vomiting; Severe headaches; Elevated temperature; Dysuria; Blurred vision; Edema of face, hands, and sacrum;
Epigastric pain; S/S of hypo/hyperglycemia

Chapter 5: Nutrition During Pregnancy

Recommended weight gain: 25-35 lb (11.3-15.9 kg)
1-2 kg (2.2-4.4 lb) during first trimester and 0.4 kg (1 lb) per week for last two trimesters
Client Education:
1. Increase calories: increase 340 kcal/day 2nd trimester. Increase 462 kcal/day 3rd trimester. If breastfeeding,
increase 450-500 kcal/day.
2. Increase protein: 600 mcg folic acid if preg and 400 mcg if preparing to become preg
3. Iron: Take between meals w/ orange juice. May need stool softeners
4. Calcium: 1,000 mg/day if preg
5. Fluids: 8-10 glasses a day
6. Limit caffeine: no more than 200 mg a day
Dietary Complications:
1. Nausea/Constipation

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

2. Maternal phenylketonuria: PKU diet throughout pregnancy by avoiding food high in protein and dairy products;
can cause harm to fetus
3. Diabetes mellitus:

Chapter 6: Assessment of Fetal Well-Being

Ultrasound:
1. External abdominal: more useful after first trimester; have a full bladder
2. Transvaginal: esp useful obese clients and first trimester to assess abnormalities
3. Doppler: useful intrauterine growth restriction and poor placental perfusion; can be 2, 3, or 4D
Nursing Actions: Drink 1 quart of water b/f ultrasound; Supine position w/ wedge under right hip; lithotomy position for
transvaginal
Biophysical Profile: Combo of FHR monitoring and ultrasound
Measured five variables (score of 0(abnormal) or 2(normal) in each category):
1. FHR
2. Fetal breathing movements
3. Gross body movements
4. Fetal tone
5. Qualitative amniotic fluid volume
Normal:8-10; low risk fetal asphyxia
Abnormal: 4-6; suspect fetal asphyxia
Very abnormal: less than 4; strongly suspect fetal asphyxia
Nonstress Test: third trimester; compares FHR w/ fetal movement by mom pressing button every time fetus moves
In patients w/ diabetes mellitus, use twice a week from 28-32 weeks
Results:
1. Reactive: accelerates 15/min for at least 15 sec; occurs twice w/in 20 min
2. Nonreactive: further assessment via CST or BPP
Contraction Stress Test(CST):
1. Nipple-stimulated: brush pal across nipple for 2 min to stimulate contraction; watch FHR response; stop
stimulation once contraction begins w/ 5 min rest periods; want 3 contractions w/in 10 min
2. Oxytocin-stimulated: same as nipple except use oxytocin to stimulate contractions
Results: 1. Negative(normal): no late decels
2.Positive(abnormal): persistent decels
Complications: Preterm labor
Amniocentesis: performed after 14 weeks
Nursing Care:
-Have client empty bladder b/f procedure
-Assist client in supine position w/ wedge under right hip
-Have the client rest for 30 min after procedure
-Give RhoD if client Rh-negative
Results: 1. High levels: can indicate neural tube defects or can be normal if multiples
2.Low levels: can indicate chromosome disorders
3. Can detect fetal lung maturity; L/S ratio 2:1 indicates maturity; absence PG associated w/ resp distress
High Risk Preg: Percutaneous Umbilical Blood Sample
Results: Check for fetal hemolytic anemia and assess need for fetal blood transfusion
Complications: Cord laceration, Preterm labor, Amnionitis; Hematoma; Fetomaternal hemorrhage
High Risk Preg: Chorionic Villus Sampling: assessing placenta; 1st trimester alternative to amniocentesis

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Performed 10-13 weeks

Complications: spontaneous abortion; risk fetal limb loss; miscarriage; ROM
High Risk Preg: Quad marker screening: determines likelihood of birth defects
Preferred 16-18 weeks
Assesses Hcg, AFP, estriol, inhibin A
High Risk Preg: Maternal Serum Alpha-Fetoprotein(MSAFP): detects neural tube defects around 16-18 weeks
Results: High levels indicate neural tube defect or ab defect
Low levels indicate down syndrome

Chapter 7: Bleeding During Pregnancy

Spontaneous Abortion: terminated b/f 20 weeks or fetal weight less than 500 g
Five types: 1. Threatened 2. Inevitable 3. Incomplete 4. Compete 5. Missed
S/S: Ab tenderness; Backache; ROM; Cervix dilation; Fever; Signs of hemorrhage
Procedures:
1. Dilation& Curettage: scrape uterine lining
2. Dilation& Evacuation: evacuate uterine contents after 16 weeks
3. Prostaglandins/ Oxytocin: induce labor to expulse products of conception
Client Education: Contact HCP for heavy, bright red bleeding, increased temp, or foul smelling discharge; Small amount
discharge normal 1-2 weeks; No tub baths/things in vagina 2 weeks; don’t attempt pregnancy for 2 months
Ectopic Pregnancy: implantation of ovum outside uterus
S/S: Unilateral stabbing pain in lower ab; referred shoulder pain; s/s of shock or hemorrhage; delayed irregular menses
Diagnosed by ultrasound w/ empty uterus
Treatment: 1. Medical management
2.Methotrexate: dissolves pregnancy; avoid sun exposure, alcohol, and folic acid
3. Salpingostomy
4. Laproscopic Salpingectomy: removal of tube
Gestational Trophoblastic Disease: fluid-filled cysts
1. Complete
2. Partial: less likely to progress to choriocarcinoma, rapidly metastasizing malignancy
S/S: hyperemesis gravidarum; rapid uterine growth; signs of preeclampsia; hcg remains elevated after 10-12 weeks
Treatment: Suction curettage; hcg levels evaluated weekly for 3 weeks, then monthly for 6 months-1 year
Placenta Previa: placenta abnormally implants in lower uterus or over cervix instead of attaching to fundus
1. Complete: cervical os completely covered
2. Incomplete: cervical os is partially covered
3. Marginal/low-lying: placenta attached to lower uterine
S/S: painless bright red bleeding during third trimester; fundal height greater than expected; decreased urine output;
feus in abnormal position; reassuring FHR
Nursing Actions: Leopold maneuvers; no vaginal exams; bed rest for patient
Abruptio Placentae: premature separation of placenta from uterus
S/S: sudden onset uterine pain w/ dark red blood; hypertonic contractions; fetal distress; hypovolemic shock
Tx: Immediate birth. Oxygen via face mask. Fluids/blood.
Vasa Previa: Fetal umbilical vessels implant in fetus membrane instead of placenta
Nursing Action: Closely monitor patient during labor for excessive bleeding

Chapter 8: Infection
HIV/AIDS:

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

 Can be transmitted through placenta and breastmilk

 Avoid the following procedures: 1. Amniocentesis 2. Episiotomy 3. Internal fetal monitors 4. Vaccum extraction
5. Forceps 6. Newborn injections b/f bath
 If viral load more than 1,000, mom will have scheduled C-Section at 38 weeks
Nursing Actions/Education:
 Admin Retrovir at 14 weeks, during preg, and at labor. Admin to newborn at delivery and at 6 weeks.
 Instruct client not to breastfeed
TORCH: toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes; teratogenic
Toxoplasmosis: from consuming raw meat or cat feces(litter); s/s fever, tender lymph nodes
Cytomegalovirus: like herpes; droplet
Client Education: Hand hygiene. Cook food thoroughly. Have someone else change cat litter. Safe sex practices
Group B Strep: bacterial infection that passes to fetus during labor
S/S: PROM; Preterm labor; Chrioamnionitis; UTI; Maternal sepsis
 Vaginal/rectal cultures at 35-37 weeks
 Prophylaxis antibiotics(penicillin/ampicillin) to the following 1. Positive culture in current preg 2. Unknown
status and delivering at less than 37 weeks 3. Maternal fever of 100.4 F 4. ROM for 18 hr or more
Chlamydia:
 S/S: dysuria, bleeding, cervical discharge change
 Admin Azithromycin/amoxicillin to mom
 Admin erythromycin to all babies after delivery
Gonorrhea:
 S/S: dysuria, yellow-green discharge
 Admin Ceftriaxone IM and azithromycin PO to mom
 Admin erythromycin to all babies after delivery
Syphilis:
Three stages: 1. Primary: chancre
2.Secondary: skin rashes on hands and feet
3.Tertiary: damage to internal organs
HPV:
Testing Recommendations: Women 21-29 Pap test q 3 years
Women 30-65 Pap test q 5 years
Women older than 65 don’t have to be screened unless precancer is noticed
HPV vaccine recommended at 9-26 years old
Trich:
Pregnant women more likely to deliver preterm and low birth weight babies
S/S: Dyspareunia; frothy yellow-green discharge
Tx: Metronidazole/ Tinidazole
Bacterial Vaginosis:
S/S: Thin White/gray discharge w/ fishy odor
Medication: Metronidazole
Candidiasis:
S/S: thick cottage cheese like discharge; white patches on vaginal walls
Medication: Fluconazole; OTC meds
Teaching: Avoid tight clothing; Cotton panties; Limit wearing damp clothing; increase intake yogurt w/ active cultures

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Chapter 9: Medical Conditions

Cervical Insufficiency (Premature Cervical Dilation): expulsion of products of concepts occurs
S/S: increase in pelvic pressure; urge to push; pink stained discharge or bleeding; uterine contractions; short cervix;
effacement or funneling of cervix
Tx: 1. Prophylactic cervical cerclage- done at 12-14 weeks and removed at 37 weeks; reinforcement of cervix
2.Tocoytics
Client Education: Bed rest. Adequate hydration to promote uterus relaxation. No tampons/intercourse/douching.
Hyperemesis Gravidarum: excessive N/V prolonged past 12 weeks causing weight loss, electrolytes imbalance,
acetonuria, and ketosis
Complications: IUGR and Preterm labor
S/S: Excessive N/V; dehydration; increased pulse; decreased blood pressure; poor skin turgor
Tx: IV Lactated Ringers. Vitamin B6. Antiemetics. Steroids. Advance diet as tolerated.
Iron-deficiency Anemia:
S/S: Weakness; Pica; Palpitations; SOB; Pallor
Recommendation: Preg women take 27 mg/day of iron
Educate patient on iron supplements ( fiber, orange juice, etc)
Gestational Diabetes Mellitus:
Complications: Spontaneous abortion; Infection; Hydramnios; Ketoacidosis; Hypoglycemia; Hyperglycemia
Diagnostics: 1 hr glucose @ 24-28 weeks, if glucose 130-140 then 3 hr glucose test
Client Ed: Daily kick counts; Diabetic diet(carb restriction); Exercise; Admin of insulin
Gestational Hypertension: begins after 20 weeks
1. Mild Preeclampsia: GH w/ proteinuria and possible edema
2. Severe Preeclampsia: BP greater than 160/110; proteinuria; vision disturbances; edema; epigastric pain
3. Eclampsia: Preeclampsia w/ onset of seizure or coma
4. HELLP: hemolysis, elevated liver enzymes, and low platelets
Nursing Care: NST and daily kick counts. Urine samples. Lateral positioning.
Medications: Low dose ASA. Antihypertensive Meds. Mag Sulfate(s/s toxicity no DTR, bradypnea, dysrhythmias)
Client Ed: Side-lying positions and bed rest. Avoid foods high in Na. Dark quiet environment. Take meds.

Chapter 10: Early Onset of Labor

Preterm Labor: uterine contractions and cervical changes between 20 and 37 weeks
S/S: uterine contractions; persistent low backache; vaginal discharge; cervical dilation
 Vaginal secretion swab for fetal fibronectin is used to determine preterm labor
Nursing Care:
1. Activity Restriction: rest in lateral left position; avoid intercourse; modified bed rest
2. Ensure Hydration
3. Identify and treat infection
4. Monitor FHR and contraction patterns
5. Admin Medications
A. Nifedipinesuppresses contractions don’t give w/ Mag Sulfate
B. Mag Sulfate relaxes uterus CX active bleeding cervix more than 6 cm dilated greater than 34 weeks
C. Indomethacin suppresses labor don’t use more than 48 hr and if greater than 32 weeks
D. Betamethasone 2 IM injections 24 hr apart to increase fetal lung maturity
Premature ROM/Preterm PROM:
1. PROM: signifies onset of true labor; spontaneous rupture of membrane 1 hr bf labor
2. PPROM: membrane ruptures after 20 weeks and before 37 weeks

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Nursing Care:
1. Prepare for birth depending on gestational age
2. Perform cultures for infection
3. Assess vital sign q 2 hr
4. Medications
A. Ampicillin
B. Betamethasone
Client Ed: Discharged home if cervix less than 3 cm dilated, no evidence of infection, no contraction; Daily kick counts;
Nothing inserted vaginally; Hydrate

Chapter 11: Labor and Delivery Process

True Labor False Labor
Become stronger, more frequent, and last longer Decrease in frequency, duration, and intensity w/
position change/walkingP
Progressive dilation and effacement of cervix No significant cervical changes
Continues despite comfort measures Painless, irregular and intermittent
Presenting part in pelvis Presenting part not engaged in pelvis

Stages of Labor:
1. First Stage
A. Latent Phase: 0-3 cm dilated
B. Active Phase 4-7 cm dilated
C. Transition: 8-10 cm dilated; irritable, urge to push, may have N/V
2. Second Stage: delivery of baby
3. Third Stage: Delivery of placenta
4. Fourth Stage: Maternal stabilization
Physiological Changes Preceding Labor:
1. Backache
2. Weight Loss: 1-3.5 lb
3. Lightening: easier breathing but more pressure on bladder
4. Contraction
5. Increased vaginal discharge or bloody show
6. Energy burst
7. GI changes
8. Cervical Discharge
9. Rupture of membranes
10. Assessment of amniotic fluid: should be watery, clear, pale to straw yellow
Five P’s
1. Passenger: fetus and placenta
A. Fetal Presentation: part of the head that leads through the birth canal; can be occiput(head), mentum (chin),
scapula(shoulder), sacrum/feet(breech)
B. Fetal Lie: relationship of maternal spine to fetal spine; can be transverse or parallel
C. Fetal Attitude: flexion or extension
D. Fetopelvic or fetal position: labeled w/ three letters; right(R) or left(L); occiput(O), sacrum(S), mentum(M),
scapula(Sc); anterior(A),posterior(P), or transverse(T)
E. Station: fetal descent w/ 0 being at level of ischial spine; (+) means closer to coming out
2. Passageway: cervix must dilate and efface

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

3. Powers: uterine contraction

4. Position: Frequent position changes during labor
5. Psychological Response
Nursing Care Pre-Labor:
 Leopold Maneuvers: ab palpation of fetal presenting part, lie, attitude, descent and location
 External monitoring: Measures contractions
 External fetal monitoring
Nursing Care During Labor:
 Assess maternal vitals: temp q 1-2 hr if membranes ruptured
 Assess FHR
 Assess contraction characteristics: frequency, duration, intensity, and resting tone
 Intrauterine pressure catheter: membranes must be ruptured and cervix dilated
 Vaginal exams: check dilation, descent of fetus, fetal position, and membranes intact/ruptured
 Mechanism of labor in vertex presentation: process should be in the following order 1. Engagement 2. Descent 3.
Flexion 4. Internal rotation 5. Extension 6. External rotation 7. Birth by expulsion
Nursing Care Post-Labor
 Assess vitals, fundus, lochia, perineum, urinary output, and bonding activities
 Assess BP and pulse q 15 min for 1st 2 hr and temp q 4 hr for 1st 8 hr
 Assess fundus and lochia q 15 min for 1st hour
 Massage the uterine fundus and admin oxytocin if needed to prevent hemorrhage

Chapter 12: Pain Management

Appropriate Pain Relief During Labor
First Second Vaginal C-Section
Stage Stage Birth
Opioid Agonist Analgesics X
Opioid Agonist-Antagonist X
Analgesic
Epidural Analgesia X X X
Epidural Anesthesia X X
Combined Spinal-epidural X X
Analgesia
Nitrous Oxide X X X
Local infiltration Anesthesia X X
Nerve block X
analgesia/anesthesia
Pudendal Block X X
Spinal Block Anesthesia X X X
General Anesthesia X
Sources of Pain During Labor:
1. First Stage: internal visceral pain in back and legs from cervix changes, contractions, and distention of uterus
2. Second Stage: somatic pain w/ fetal descent and expulsion from stretching of lower structures
3. Third Stage: pain from expulsion of placenta similar to first stage from contractions and pelvic pressure

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

4. Fourth Stage: pain from distention of vagina and perineum that occurred in prior
NonPharm Pain Management:
1. Cognitive Strategies: Education, Breathing, and Relaxation; watch for hyperventilation
2. Sensory Stimulation: Aromatherapy; Imagery; Breathing; Music; Subdued Lighting
3. Cutaneous Stimulation: Touch/massage; Walking; Heat/cold; Hydrotherapy; Position Changes
Pharm Pain Management:
Analgesics: verify labor is well established b/f admin; alleviates or raises threshold for pain
1. Sedatives (barbs): Can be used during early latent stage; Don’t give if birth expected w/in 12-24 hr
2. Opioid Analgesics: early part of active labor; Confirm at least 4 cm dilated b/f giving; Monitor FHR
3. Ondansetron/Metoclopramide: adjunct w/ opioids
4. Epidural/Spinal Analgesia: Monitor FHR and fall precautions
Anesthesia: eliminates pain
1. Regional Blocks
A. Pudendal: given transvaginally during second/third stage and for repair of lacerations
B. Epidural: given 4/5 vertebrae to eliminate sensation from umbilicus to thighs; given in active labor and 4 cm
dilated; give bolus IV fluids prevent hypoTN; patient in sitting or side-lying Sime for admin; encourage client
to stay side-lying; can be used in all stages/types of birth/laceration repair
C. Spinal: admin in subarachnoid; eliminates sensation from nipple to feet; usually given for C-Sections; Assess
maternal VS q 10 min; IV bolus of fluids
General Anesthesia: only used when CX to nerve block anesthesia/analgesia
Nursing Actions: Monitor VS/FHR; Client NPO; Place wedge under client’s hip to displace uterus; Premed w/ oral antacid/
metoclopramide/ranitidine

Chapter 13: Fetal Assessment During Labor

Leopold Maneuvers: external palpation of uterus to determine 1. Number of fetuses 2. Presenting part
3.fetal lie 4. Fetal attitude 5. Degree of presenting part 6. Location of fetus back to assess FHR (if baby breached assess
above umbilicus, if vertex assess below umbilicus)
Nursing Actions:
 Have client empty bladder, lay supine w/ knees slightly flexed and place a towel under one hip
 Asses FHR after procedure

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Intermittent Ausculation/Uterine Contraction Palpation: use Doppler, stethoscope, and fetoscope to assess FHR while
palpating contractions at fundus; used in low risk mom to allow mom to move freely
 Perform q 30-60 min during latent phase, q 15-30 min during active, and q 5-15 min during second stage
 Count FHR for 30-60 sec between contraction to determine baseline; tachy is FHR greater than 160 for 1 min;
brady is FHR less than 110 for 1 min
Continuous Electric Fetal Monitoring: Two transducer, one abdomen/one fundus, to monitor FHR/contractions
Advantage: noninvasive; cervix doesn’t have to be dilated; don’t need ROM; nurse can perform
Disadvantage: can’t measure contraction intensity; frequent repositioning needed
Three Tier System for Fetal Monitoring:
1. Cat 1: Trace baseline HR, baseline variability(mod), accels, early decal, late decels
2. Cat 2: Abnormals in rate, variability, decels, and accels
3. Cat 3: any changes in baseline and uterine contraction
FHR Patterns: VEAL, CHOP, MINE
 NFHR associated w/ hypoxia: brady, tachy, absence variability, late decal, variable decels
 Acceleration: increase above baseline; reassuring; no intervention
 Fetal Bradycardia: less than 110 for 10 min; can be caused by uteroplacental insufficiency, cord prolapse,
prolonged cord compression, etc; place client side-lying; admin oxygen via nonrebreather; admin fluids; stop
oxytocin; notify HCP
 Fetal Tachycardia: greater than 160 for 10 min; can be caused from infection, dehydration, use of drugs; give
oxygen via nonrebreather; admin fluid bolus; admin antipyretic if needed
 Decrease/loss Variability: stimulate fetal scalp, assist HCP w/ scalp electrode; left-lateral position
 Early Decels: slowed FHR w/ start of contraction w. return to baseline after; caused by head compression; no
intervention
 Late Decels: slowed FHR continues after contraction over; side-lying position change; fluids; oxygen via
nonrebreather; elevate legs; notify HCP

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

 Variable Decels: abrupt slowing of FHR that varies in relation to uterine contraction; position client on side or
knee-chest; oxygen via nonbreather; vaginal exam; possible amnioinfusion
Continuous Internal Fetal Monitoring: attach scalp electrode to presenting part
Advantages: early detection abnormal FHR; accurate assessment FHR; greater movement freedome
Disadvantages: need ROM; need cervix dilated 2/3 cm; provider must perform
Complications: infection, fetal trauma

Chapter 14: Nursing Care During Stage of Labor

First Stage: onset of contraction to full dilation
 Leopold Maneuvers
 Assess for ROMwhen suspected, assess FHR first
 Encourage voiding q 2 hr
 Temp checks q 4 hr
 Discourage pushing efforts until cervix fully dilated
Second Stage: cervical fully dilated to birth of fetus
 BP, pulse, RR q 5-30 min and FHR q 15 min
 Prepare neonate care: warmer, oxygen, stethoscope/bulb syring, suction resuscitation equip
 Promote rest between contractions
Third Stage: birth of fetus to placenta delivery
 BP, pulse, and RR q 15 min
 1 and 5 min APGAR
 Check full expulsion of placenta
Fourth Stage: delivery of placenta to 2 hr after birth
 Assess BP, pulse, fundus, and lochia q 15 min (2 hr for BP, pulse/1 hr for lochia/fundus)
 Massage fundus
 Encourage voiding
 Provide opportunity for rest after baby bonding

Chapter 15: Therapeutic Procedures to Assist w/ Labor and Delivery

External Cephalic Version: externally manipulate fetus into cephalic lie around 36 weeks
Complications: Placental Abruption, Cord Compression, Emergency C-Section
CX: Uterine anomalies, Previous C Section, Cephalopelvic disproportion, Placenta Previa, Multiple, Oligohydraminos
Nursing Actions: Ensure Rho(D) was given at 28 week if mom Rh(-); Admin tocolytics prior; Kleihauer-Betke test in Rh(-)
moms; Montior FHR, bleeding, fetal activity
Bishop Score: determines maternal readiness for labor by rating dilation, effacement, cervix consistency cervix position,
and station of presenting part; given score of 0-3
At 39 weeks, should be greater than 8 for multiparous mom and greater than 10 for nulliparous mom
Cervical Ripening: promotes successful induction of labor
Admin low dose infusion oxytocin
Can be mechanical (Dilators/balloon catheters) or chemical(Misoprostol/Diniprostone)
Complications: Hyperstimulation give SQ terbutaline
Fetal Distress oxygen, left side position, fluids
Induction of Labor: Initiation of contraction via mechanical/chemicals, IV oxytocin, or nipple stimulation; must be 39
weeks and have suitable Bishop Score
Indications: Postterm Preg, Dystocia, Prolonged ROM, Fetal demise, Choriomionitis, Maternal Issues
Nursing Actions:

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

-Piggyback Oxytocin
-B/f admin oxytocin, ensure fetus is engaged and at minimum of 0 station
-D/C Oxytocin for uterine hyperstimulation: contraction more than q 2 min, longer than 90 sec, no uterine relaxation
between contractions
Complications:
NFHR: side lying position; increase maintenance fluid rate; admin oxygen; admin tocolytic SQ; prepare emergency C-
Section
Augmentation of Labor: stimulation of hypotonic contractions;Usually aggressive use of Oxytocin or ROM
Amniotomy: artificial ROM; increased risk for cord prolapse or infection; labor starts w/in 12 hr of ROM; enurse
presenting part is engaged prior; temp q 2 hr
Amnioinfusion: NS or LR given into amniotic cavity via transcervical catheter
Indications: Oligohydraminos. Fetal cord compression from postmature fetus.
Nursing Actions: Assist w/ ROM if hasn’t happened; Warm fluid b/f admin. Monitor mom/baby.
Vacuum-Assisted Delivery: cuplike suction device used to help birth fetus if there is vertex presentation, ROM, and
cephalopelvic proportion
Complications: scalp lacerations; subdural hematoma of neonate; cephalohematoma; maternal tears
Forceps-Assisted Delivery: use forceps to get baby out esp if vacuum didn’t work
Complications: Laceration of cervix/vagina; injury to bladder; facial nerve palsy of baby, facial bruising of baby
Episiotomy: incision to enlarge vaginal opening
Encourage alternate labor positions to reduce pressure on perineum
C-Section:
Indications: Cephalopelvic disproportion; Placenta Previa; Abruptio placentae; Cord Prolapse; Multiples
Complications: Wound infection, hemorrhage, aspiration, fetal injuries
Vaginal birth after Cesarean(VBAC):
Indications: no other uterine issues; no more than two low transverse Cesareans; no Cesarean criteria

Chapter 16: Complications Related to Labor Process (emergent)

Prolapsed Umbilical Cord: umbilical cord is before presenting part or protruding through cervix
Risk Factors: SGA, Transverse lie; Unengaged presenting part; long cord
S/S: Palpation or visualization of cord, variable or prolonged decels; mom feels something
Nursing Actions: Call help. Use sterile gloved hand to use two fingers to elevate fetus off cord. Knee to chest,
Trendelenburg or side position. Oxygen. Prepare vaginal birth if dilated or Cesarean. Watch FHR.
Meconium-Stained Amniotic Fluid:
Increased risk after 38 weeks
S/S: amniotic fluid that varies in colors(green, black)
Nursing Actions: Have neonate resuscitation team present. Suction mouth/nose w. bulb syringe if HR,RR and muscle
tone good. Suction below vocal cords w/ trach if RR, muscle, and HR not good.
Fetal Distress: FHR below 110 or above 160. Decreased/absent variability. Increase/absent fetal activity.
Nursing Actions: Left side lying position w. legs elevated. Oxygen. D/C oxytocin. Increase fluids. Prepare possible
emergency Cesarean.
Dystocia: difficult labor related to five P’s (passenger, passageway, power, position, psych)
S/S: lack of progression, hypotonic or hypertonic contractions, ineffective pushing
Nursing Care: Admin oxytocin for hypotonic. Encourage voiding, position changes, and ambulation. Apply
counterpressure to sacrum. Prepare for assisted delivery. For hypertonic, maintain hydration, promote rest, oxygen, and
lateral position.
Precipitous Labor: labor lasts 3 hr or less from onset of contractions to delivery

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Risk Factors: Hypertonic uterine dysfunction. Oxytocin use. Multiparous mom.

Nursing Actions: Don’t leave client. Promote panting between contractions. Side lying position. Don’t stop delivery.
Apply light pressure to perineal area and fetal head.
Complications: Tearing. Trauma. Uterine Rupture. Amniotic fluid embolism. Hemorrhage. Fetal hypoxia
Uterine Rupture: life-threatening
S/S: report tearing sharp pain; uterine tenderness; NFHR; cessation of contractions; hypovolemic shock
Nursing Actions: Fluids. Oxygen. Prepare for emergency Cesarean.
Anaphylactoid Syndrome(Amniotic Fluid Embolism): infiltration of amniotic fluid in mom’s circulation
S/S: sudden chest pain/SOB; resp distress; coagulation failure(petechiae, uterine atony); circulatory collapse (hypoTN,
tachy)
Nursing Actions: Oxygen. Fluids. Side position w/ pelvis at 30 degrees. Emergency Cesarean. Possible intubation/CPR.

Chapter 17: Postpartum Physiological Adaptations

Assessment should include BUBBLE-VT: breats, uterus, bowel, bladder, lochia, episiotomy, vitals, teaching needs

Chapter 18: Baby Friendly Care

Phases of Maternal Role Attainment:
1. Dependent: taking in phase; first 48 hr
2. Dependent-independent: lasts up to several weeks; want to learn and practice
3. Interdependent: focus on family as unit; resume other roles
Impaired parented can include.. 1. Emotional detachment that can place infant at risk for neglect or FTT 2. Failure to
bond w/ infant increase risk physical/emotional abuse

Chapter 19: Client Education and Discharge Teaching

Perineal Care: do everything front to back
Cleanse w/ warm water after voiding and bowel movements
Breast Care:
Lactating: empty breast at each feeding; for engorgement cool compress after feeding and warm before; roll nipples
between fingers for flat/inverted nipples
Nonlactating: avoid nipple stimulation and running warm under breasts for long periods of time
Activity:
No heavy lifting and limit stair climbing for 3 weeks
Don’t drive 1st 2 weeks postpartum
Nutrition:
Nonlactating clients need 1800-2200 cals
Lactating clients increase cal 330 for 1st 6 months and 450 to prepreg diet
Postpartum Exercise:
Kegel exercises 10 times 8 times a day and pelvic tilt exercises
Sexual Intercourse:
Avoid until lochia has turned white
Contraception:
If lactating oral contraception should not be started until milk established(4 weeks)
Preg can occur while breastfeeding
Menses resumes around 4-10 weeks
Report the following to provider…1. Chills/fever 2. Change in discharge 3. Tears 4. Pain in ab/pelvic 5. Calves w/ redness/
tenderness 6. Urination w/ burning/frequency 7. Postpartum depression

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Follow- up 4-6 if vaginal delivery and 2 weeks of Cesarean

Chapter 20: Postpartum Disorders

DVT: Cesarean doubles the risk
S/S: Leg pain and tenderness; calf tenderness; unilateral swelling
Prevention: Compression socks. Elevate legs when sitting. Fluids. Early ambulation
Management: Bed rest and extremity elevation. Don’t massage. Intermittent warm compress. Admin Anticoags(Heparin/
Warfarin)
Client Education: Avoid ASA/ibuprofen. Electric razors. Soft toothbrush. Don’t sit long periods.
Pulmonary Embolism: embolism lands in pulmonary artery
S/S: chest pain; dyspnea; hemopytsis; heart murmurs; hypotension
Nursing Care: Place in Semi-Fowler’s. Oxygen via mask. Thrombolytic therapy (Alteplase, Streptokinase)
Coagulopathies: suspected when usual mechanism to stimulate uterine contraction fail to stop bleeding
1. Idiopathic Thrombocytopenia Purpura: autoimmune where lifespan pf platelet decreased due to antiplatelet
antibodies; severe hemorrhage or lacerations can cause
2. Disseminated Intravascular Coagulation: clotting and anticlotting mechanisms occur at the same time;
preeclampsia risk factor
S/S: spontaneous bleeding; petechiae; hematuria; Oliguria
Nursing Care: Fluids/platelets. Oxygen. Protection from injury. May get hysterectomy for DIC.
Postpartum Hemorrhage: more than 500 ml blood loss after vaginal birth and more than 1000 ml blood loss after
Cesarean
Complications: hypovolemic shock and anemia
S/S: uterine atony/boggy; increase lochia; clots larger than a quarter; pad soaked in 15 mn
Nursing Care: Massage fundus. Foley for bladder distention. Isotonic fluids. Oxygen NC. Elevate legs.
Meds:
1. Oxytocin: monitor water intoxication
2. Methylergonovine: CX: HTN
3. Misprostol
4. Carborpost Tromethamine: CX: asthma
Uterine Atony: inability of uterine muscle to contract after birth
S/S: increased vaginal bleeding; tachycardia; boggy or larger uterus
Nursing Care: Ensure bladder empty. Fundal massage until firm. Oxygen NC. Fluids. If persists, may need a hysterectomy.
Subinvolution: uterine remains enlarged w/ continuous discharge
S/S: prolong bleeding; uterus large and higher than normal
Nursing Care: Encourage breastfeeding, ambulation, and frequent voiding to promote involution. Ed mom may need
D&C to remove fragments. Admin Oxytocin, Methylergonovine, or antibiotics.
Inversion of uterus: uterus turns inside it; can be partial or complete; emergency
S/S: pain lower abdomen; palpated or protruding uterus; pallor; shock
Nursing Care: Fluids. Oxygen. Stop oxytocin. Anticipate surgery if intervention unsuccessful. Admin Terbutaline,
tocolytic. No aggressive fundal massage. Ed mom that will need Cesarean in the future.
Retained Placenta: fragments of placenta remain in uterus
S/S: uterine atony,subinvolution, or involution; excessive bleeding; return of lochia rubra; high temp
Nursing Care: Oxygen NC. Fluids Prepare for surgery, D&C or hysterectomy. Admin Oxytocin to expel fragments or
Terbutaline to relax uterus b/f D&C
Lacerations/Hematomas: tearing of perineum; collection of clotted blood that bulges
Complications: hemorrhage; infection

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

S/S Laceration: sensation oozing; vaginal bleeding w/ firm uterus

S/S Hematoma: pain, difficulty voiding; bulging mass
Nursing Care: Ice packs for small hematoma. Admin pain meds. Sitz baths. Frequent perineal care. Assist provider w/
repair.

Chapter 21: Postpartum Infection

Endometritis: infection of uterine lining
S/S: pelvic pain, loss of appetite; uterine tenderness/enlargement; dark profuse lochia; elevated temp
Nursing Care: IV antibiotics; Analgesics; Hand hygiene. Consider breastfeeding w/ meds.
Wound Infections:
S/S: signs of infection; seropurulent drainage; elevated temp
Nursing Care: Wound care. IV antibiotics. Sitz bath. Warm/cold compress. Frequent peri care.
Mastitis: infection of breasts
S/S: enlarged axillary lymph nodes; redness; swollen; warmth
Nursing Care/Client Ed: Wash hands b/f feeding. Allow nipples air dry. Proper latching and complete empyting. Admin
antibiotics.
UTI: epidural anesthesia and Cesarean are risk factors
S/S: urgency, frequency dysuria, discomfort pelvic area, elevated temp
Nursing Care: Antibiotics. Tylenol. Proper peri care. Increase fluids. Cranberry/prune juice prevent future UTIS.

Chapter 22: Postpartum Depression

Baby Blues Postpartum Depression Postpartum Psychosis
Feeling sad Feelings of guilt and inadequacy Pronounced sadness
Crying easily for no apparent Irritability/ Flat affect Disorientation
reason
Headache Intense mood swings Hallucinations/Paranoia
Restlessness Weight loss Thoughts self-harm or harming
infant
Anxiety, anger, sadness Rejection of infant
Nursing Care: Encourage bonding. Encourage communication of feelings. Advise taking time for self.
Antidepressants/mood stabilizers.
Chapter 23: Newborn Assessment
Apgar Score: done at 1 and 5 min of life. Score of 7-10 is good.
Apgar Score 0 1 2
Heart Rate Absent Less than 100 Greater
than 100
Respiration Absent Weak cry Good cry
Muscle Tone Flaccid Some flexion Well-flexed
Reflex Irritability None Grimace Cry
Color Blue,pale Acrocyanosis Pink all over

Equipment for Assessment: bulb syringe. Thermometer. Scale. BP cuff. Tape measure
Initial Assessment: Quick look at all system including weight, length, head/chest circumference.
-Weight: 5.5 -8.8 lb -Length: 18-22 in -Head Circum: 12.6-15 in -Chest Circum: 12-13 in
Gestational Age: use New Ballard Scale
- AGA: 10th -90th -SGA: less than 10th -LGA:greater than 90th -LBW: 2500 g or less

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

- Term: 37 weeks-42 weeks -Preterm: b/f 37 weeks -Postterm: after 42 weeks

Vitals:
RR: 30-60 HR: 110-160 BP: 60-80/40-50 Temp: 97.7-99.5
Head to Toe Assessment:
Skin Normal Deviations:
Vernix- cheesy covering in creases
Lanugo-fine downy hair
Milia- small raised white spots on nose, chin, and forehead
Mongolian spot- bluish purple pigments usually on back side
Telangiectatic nevi- flat marks that easily blanch
-Nevus flammeus- capillary angioma usually on face
-Erythema toxicum- pink rash suddenly appears on body during 1 st 3 weeks
Head: check fontanels
-Caput Succedaneum: swelling of soft tissue that crosses suture line; self resolves
-Cephalohematoma: collection of blood that doesn’t cross suture line from birth trauma; self resolves
Eyes: blue or gray following birth
Ears: aligned w/ outer canthus
Nose: obligate nose breathers
Mouth: check palate
-Epsteins pear, small white cysts, normal
Neck: absence of head control can indicate Down’s
Chest: barrel-shaped; check clavicles
Abdomen: bowel sounds present 1-2 hr after birth
Anoogenital: meconium w/in 48 hr; urine w/in 24 hr
Extremities: Should be flexed
Reflexes:
 Sucking/Rooting: disappear 3-4 months
 Palmar grasp: lessens 3-4 months
 Plantar grasp: toes curl down; birth to 8 months
 Moro/Startle: birth to 6 months
 Tonic neck Reflex: turn head and baby extend opposite arm and flex leg; birth to 4 months
 Babinski Reflex: toes fan up and out; birth to 1 year old
 Steeping: birth to 1 months
Senses:
Vision: can focus on objects 8-12 in away; prefer bright colors and patterns
Hearing: can hear once amniotic fluid drains
Touch: should respond tactile pain/touch; mouth most sensitive
Smell: prefer sweet smells and can recognize mom’s smell
Complications:
1. Airway Obstruction From Mucus: suction w/ bulb syringe. Monitor axillary tempp
2. Inadequate Oxygen Supply: Check temp. Clear airway. Admin Oxygen. Prepare Resuscitation.

Chapter 24: Nursing Care of Newborns

Physical/Labs:
Vitals q 30 minX2, q 1hrX2, then q 8 hr
Genetic Screening via heel stick at 24 hr

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Hearing Screening
Resp Complications:
Bulb syringe if unsuccessful, Mechanical suction if unsuccessfuk, Backblow/chest thrusts
Bulb Syringe compress b/f insertion; avoid center of mouth; mouth b/f nose
Elimination:
-Void once w/in 24 hr
-Meconium w/in 24-48 hr
Umbilical Cord Care:
Cord clamps in place for 48 hr. Fold diaper underneath cord. No baths until cord fallen(10-14 days)
Medications:
1. Erythromycin: mandatory eye drops; protective against gonnorhea/chlamydia
2. Vitamin K: admin vastus lateralis w/in 1 hr after birth
3. Hep B Immunization: get a birth, 1 month, then 6 months
Complications:
1. Cold Stress: warm infant over 2-4 hr; check for hypoxia and hypoglycemia
2. Hypoglycemia: mom breastfeed instantly or donor milk/formula
3. Hemorrhage: from improper cord care; check clamp for tightness

Chapter 25: Newborn Nutrition

Nutritional Needs:
 Infant loses 5-10% of birth weight and regains 1120-200 g/week for 1 st 3 months
Breastfeeding:
 Recommended exclusively for first 6 months w/ feedings q 2-3 hr
 To promote successful breastfeeding: skin-to-skin right after birth; feed 15-20 min per breast; place on back
after feedings
Formula:
 Prepared formula can be refrigerated for 48 hr; burp multiple times; place on back after
Complications:
 If baby sleepy, unwrap, change diaper, hold upright, massage back, and apply cool cloth to face
 If baby fussy, swaddle, hold closely, reduce stimuli, and skin-to-skin
 Failure to thrive falls below 5th percentile assess latch if breastfeeding massage breats during feeding
assess how often feeding

Chapter 26: Discharge Teaching

 Wellness checkup 72 hr after birth
 Circumcision Care: clean w/ warm water w/ each diaper change; apply petroleum for 24 hr after; no tub bath
until healed; don’t wash off yellow exudate
 Report the following immediately 1. Temp greater than 100.4 or less than 97.9 2. Poor feeding 3. Forceful
vomiting 4. Decreased urination 5. Diarrhea/severe constipation 6. Labored breathing 7. Jaundice 8. Cyanosis 9.
Lethargy 10. Inconsolable crying 11. Difficulty waking 12. Bleeding/pus from cord/circumcision 13. Drainage
form eye

Chapter 27: Newborn Complications

Neonatal Substance Withdrawal:
S/S: high pitched cry; tremors; poor feeding; SGA

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Nursing Care: Swaddle w/ legs flexed. Offer non-nutrition sucking. Reduce stimuli. Admin Morphine for opioid or
Phenobarbital as anticonvulsant. W/ cocaine withdrawal, avoid eye contact and rock vertical.
Hypoglycemia: blood glucose less than 4o
S/S: tremors; hypothermia; weak cry; irregular repsirations
Nursing Care: If asymptomatic, offer oral feedings to get glucose above 45. If symptomatic, give IV dextrose. Frequent
feedings. Maintain skin-to-skin.
Resp Distress/Asphyxia/Meconium Aspiration:
S/S: tachypnea; nasal flaring; retractions; grunting; labored breathing
Nursing Care: Suction mouth/nose. Mouth and skin care. Thermoregulation. Na bicarb for acidosis. Decrease stimuli.
Admin artificial surfactants (-actant). Don’t suction 1 hr after admin.
Preterm Newborn:
Complications: Resp distress syndrome; Bronchopulmonary dysplasia; Aspiration; Apnea of prematurity; Intraventricular
hemorrhage; Retinopathy; Patent ductus arteriosus; Necrotizing enterocolitis
Nursing Care: Thermoregulation. Resp support. Minimize stimulation. Position in neutral flexion in prone or side-lying
position. Infection prevention. Nutrition via feedings, parental, or enteral.
SGA:
Complications: perinatal asphyxia, meconium aspiration, hypoglycemia, polycythemia, body temp issue
Nursing Care: Resp support. Neutral thermal environment. Early feedings. Hydration.
LGA:
 Risk for birth injuries
 B/f delivery: Place mom in McRoberts(lithotomy w/ legs flexed to chest); Apply suprapubic pressure. Prepare for
assisted birth or C-Section
 Post delivery: Early and frequent heel sticks; Early feedings to maintain glucose; Treat birth injuries
Postmature infant:
Complications: meconium aspiration; polycythemia; resp issues; hypoglycemia; temp issues
Nursing Care: Moisturize skin w/ petroleum based ointment. Oxygen. Thermoregulation. Early feedings.
Newborn Infection:
S/s: temp instability poor feeding decreased oxygen irritability
Nursing Care: IV therapy of fluids/medications. Maintain temp. Clean equipment b/f use
Client Ed: Clean bottles/nipples. Discard unused formula. Hand hygiene.
Birth Trauma/Injury
S/S: irritability; seizures w/in 72 hr; weak cry; facial flateening
Nursing Care: frequent assessment; promote parent-newborn interaction
Hyperbilirubinemia: elevation of bilirubin
1. Physiologic: benign; occurs 72 hr after birth
2. Pathologic jaundice: appears 24 hr after age
3. Acute bilirubin encephalopathy: bilirubin goes in brain
4. Kernicterus: irreversible s/s of bilirubin toxicity; cognitive impairments; severe quadriplegia
Nursing Care: Monitor levels q 4 hr until level returns to normal
Phototherapy remove q 4 hr and unmask; no lotions/ointments; turn off b/f drawing lab levels; check temp q 4 hr

Downloaded by Vin Campbell (afuture500@aol.com)

 lOMoARcPSD|7393617

Downloaded by Vin Campbell (afuture500@aol.com)