OB Peds Women S Health Nurse S Clinical Pocket Guide Series PDF

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OB Peds
Women’s Health
Notes Nurse’s Clinical Pocket Guide
Brenda Holloway, CRNP, FNP, MSN
Cheryl Moredich RNC, MS, WHNP
Kathie Aduddell, Ed.D, MSN, RN-BC
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A Davis’s Notes Book
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GYN ANTE- INTRA- POST- PEDS PEDS MEDS/ TOOLS

BASICS PARTUM PARTUM PARTUM BASICS ASSESS ACUTE
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01Holloway (F)-01 12/28/05 12:24 PM Page 1
1
Nurses Impact the Health
of Women Through
■ Educating women about healthy lifestyle choices
■ Role modeling healthy behavior and promoting wellness
■ Describing the role of prevention and early detection
■ Informing women about disease treatment and progression
■ Being an advocate and resource for community referrals
Cervical/Gynecological Health
■ According to the guidelines of the American College of
Obstetrician and Gynecologists (ACOG) and the American
Cancer Society (ACS), initial cervical screen for cancer should
begin 3 years after first sexual intercourse or by age 21,
whichever comes first
■ However, ACOG recommends that a visit to an
obstetrician/gynecologist occur before that time for health
guidance, screening, and prevention
■ Follow-up cervical screen for low-risk women less than
30 years of age
ACOG Guidelines Annually

ACS Guidelines Annually with conventional Pap
smear
Every 2 years with liquid-based
cytology
■ Women 30 years of age and older, with three consecutive

negative cervical screens, are recommended to have repeat
exams every 2–3 years
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Sexually Transmitted Infections (STIs)
■ Abstinence from sexual activity (both oral and genital) is the

only 100% effective method of STI prevention
■ Consistent and proper use of condoms during sexual
intercourse will decrease the incidence of STIs
■ STIs transmitted via skin contact (human papillomavirus
[HPV], herpes simplex virus [HSV]) may still be transmitted
with use of latex condoms
■ Sexual partners should be tested and treated when an STI is
identified; sexual activity should be avoided until treatment
regimen completed
■ Patients diagnosed with a viral STIs should consult their
health-care provider for long-term management
■ Reportable STIs must be forwarded to the local health
department along with treatment rendered
■ Encourage immunization against hepatitis B
■ Visit CDC Web site www.cdc.gov for latest treatment
guidelines for STIs
(Continued text on following page)
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Page 3
Sexually Transmitted Infections (STIs) (Continued)

Infection Symptoms (May be asymptomatic) Detection
12:24 PM
Gonorrhea Yellow-green vaginal discharge Endocervical culture

Dyspareunia Urine test
Abdominal pain
Dysuria
Chlamydia Mucopurulent discharge Endocervical culture
Postcoital bleeding Urine test
12/28/05
Dyspareunia
Abdominal pain
Dysuria
3
Trichomoniasis Frothy malodorous vaginal discharge Saline wet mount of vaginal

Dyspareunia discharge viewed under
Vaginal itching/irritation microscopy
01Holloway (F)-01
Dysuria
Hepatitis Fatigue Serological testing
Dark urine
Clay-colored stool
Jaundice/abdominal pain
Human Papilloma Many subtypes exist, some associated Pap smear report
Virus (HPV) with cervical dysplasia Colposcopy/biopsy
Visible wartlike growths in genital area
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associated with subtypes 6, 11
Page 4
Sexually Transmitted Infections (STIs) (Continued)

Infection Symptoms (May be asymptomatic) Detection
12:24 PM
Syphilis Primary Serological testing

Chancre (painless raised ulcer) Nontreponemal (RPR, VDLR)
Secondary ■ Reported quantitatively
Skin rash, lymphadenopathy (titers)
Latent ■ Four-fold change in titers
Lacking clinical manifestations clinically significant
12/28/05
Tertiary ■ Effective treatment will result

Cardiac, ophthalmic, auditory in falling titers
involvement ■ False-positive possible; verify
with treponemal test
4
Treponemal (FTA-ABS)
Reported as positive or negative
HIV Fever Serological testing
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Malaise (Pretest and posttest counseling

Lymphadenopathy with informed consent
Skin rash required)
Positive screen must be
confirmed by more specific
test (Western blot)
Herpes Simplex Painful, recurrent vesicular lesions Viral culture with DNA probe
BASICS
Virus (HSV) Fever, malaise
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Enlarged lymph nodes
5
Breast Health
■ Monthly breast self-exam, starting at age 20, instructed to
woman as an optional tool for identifying and reporting
breast changes
■ Clinical breast exam at least every 3 years (age 20–40) during
a physical exam by a health professional; yearly after age 40
■ Annual mammogram starting at age 40
Instructions for Breast Self Exam (BSE)
Step 1: Inspection
1. Visually inspect the breasts, looking for dimpling, lumps, skin
irregularities, symmetry
2. Visually inspect in several positions; may accentuate an
abnormality
◆ Hands at the side ◆ Hands above the head
◆ Hands pressed onto hips ◆ Leaning over
BSE positions. (From Dillon PM. (2003) Nursing Health Assessment: A

Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p. 459.)
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Step 2: Palpation
1. Feel the breast tissue and lymph node chain for lumps or
thickening by using three finger pads while exerting light,
medium, and deep pressure in a systematic fashion
BSE palpation patterns. (From Dillon PM. (2003). Nursing Health

Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A.
Davis, p 461.)
6
7
2. Begin by lying down on a flat surface with arm raised and a
folded towel under the back of the breast being examined
3. After examining breast tissue, bring arm toward body and feel
the axilla and the skin above as well as below the collar bone
4. Repeat technique on the other side
5. Report lumps, thickening, nipple discharge or any suspicious
findings to health-care provider
Preconception Counseling
Preconception counseling should be included in health screen-
ings for all women of childbearing age and focus on factors that
impact organogenesis.
■ Discuss chromosomal abnormalities associated with
advanced maternal age
■ Incorporate 400 mcg of folic acid daily (for low-risk women)
■ Avoid alcohol, smoking, and drug use
■ Teach prevention of sexually transmitted infections
■ Update immunizations and investigate rubella titer
■ Review exposure to environmental risk factors
■ Control of chronic medical conditions
■ Review classification of prescribed medication
Family Planning Options

■ Educate women on available family planning methods,
discussing the risks, benefits, and efficacy of each method
■ Efficacy of each method influenced by correct and consis-
tent use, user preparedness, motivation, dexterity, and
comorbidities
■ Educate women on the process of menses
■ The menstrual cycle is a cyclic feedback system occurring
approximately every 28 days with the first day of menses
being day 1
■ Low levels of estrogen and progesterone stimulate the
hypothalamus to secrete gonadotropin-releasing hormone
(GnRH), which stimulates the anterior pituitary to release
GYN
BASICS
GYN
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follicle stimulating hormone (FSH), encouraging maturation

of the Graafian follicle
■ Estrogen, produced by the maturing follicle, causes the
endometrial lining to proliferate
■ The mid-cycle release of luteinizing hormone (LH) from the
anterior pituitary promotes release of the mature ovum
(ovulation)
■ Once ovulation occurs, the corpus luteum (remaining cells
of the follicle) produces estrogen and progesterone, which
stimulates endometrial thickening
■ If conception does not occur, the corpus luteum regres-
ses, causing a decrease in estrogen and progesterone,
and ischemic changes to the functional layer of the
endometrium
■ The menstrual cycle is divided into phases of the ovarian
and endometrial cycle:
Ovarian Cycle Endometrial Cycle

Menstrual Menstrual
Follicular Proliferative
Ovulatory Secretory
Luteal Ischemic
Sexual Abstinence
■ Refraining from sexual activity is the only 100% effective way

to prevent pregnancy
Fertility Awareness Methods
■ Teaches familiarity with body in order to recognize signs of

fertility
■ Useful to avoid or achieve pregnancy, as well as monitor
gynecological health
■ To prevent pregnancy, couples abstain during recognized
period of fertility
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9
Cervical Mucus
Amount and character of cervical mucus changes throughout the
menstrual cycle in response to hormones
■ Following menses, cervical mucus scant, thick, and cloudy
■ At ovulation, cervical mucus becomes more abundant,
slippery, clear, and stretchable in response to estrogen
(known as “spinnbarkeit”), promoting sperm motility;
increased likelihood of pregnancy with unprotected
intercourse
■ After ovulation, cervical mucus scant, thick, cloudy, and is no
longer stretchable
■ Cervical mucus should be evaluated and charted daily
Basal Body Temperature (BBT)
■ Monitor and graph BBT daily before rising
■ Prior to ovulation, BBT decreases slightly in response to
estrogen
■ After ovulation, a surge of progesterone increases BBT by
0.5–1.0F
■ BBT remains high with conception, but falls without
conception, prior to menses
■ Certain activities may alter BBT: smoking, use of electric
blanket or heated waterbed, restless sleep, illness
Calendar Method
■ Based on assumption that ovulation occurs 14 days before the
onset of menses
■ Record menstrual cycles for 6–8 months
■ Calculate fertile period
Subtract 18 from the shortest menstrual

cycle (28 18 10)
Subtract 11 from the longest menstrual

cycle (32 11 21)
Days 10–21 fertile time; abstain from intercourse
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Lactation Amenorrhea Method (LAM)
■ Prolactin suppresses follicle stimulating hormone (FSH), and

therefore suppresses ovulation
■ Postpartum woman who exclusively breastfeed during the
first 6 months after childbirth, including at least one night
feeding, may postpone ovulation
■ Instruct patients that ovulation and return of fertility may
occur before first menses with a risk of unintended pregnancy
Barrier Methods
Prevents conception by blocking entry of sperm into the cervix

Diaphragm
■ Dome-shaped rubber cup with a flexible ring that fits over the
cervix; regularly examine integrity of rubber
■ Inserted with spermicide applied to dome before intercourse
and left in place for at least 6 hours after intercourse
■ Should not be left in place more than 24 hours due to risk of
toxic shock syndrome
■ Additional spermicide may be added with diaphragm still in
place for repeated intercourse
■ Diaphragm is custom fitted and must be refitted with 20 pound
weight change and after a vaginal birth
■ Urinary tract infections (UTI) more common with diaphragm
use; teach to report symptoms of UTI
■ Wash with soap and water after each use; inspect integrity of
rubber by holding up to light to inspect for holes
Male Condom
■ Thin latex sheath that covers the erect penis during sexual
intercourse
■ Provides protection from STIs
■ Space should be left at the end of the condom for ejaculate
■ Hold condom at base of the penis upon withdrawal to prevent
spillage
■ Only water-soluble gel should be used for lubrication to pre-
vent degradation of the latex
10
11
■ New condom should be used with each act of intercourse
■ Store in unopened package in cool, dry place
Female Condom
■ Prelubricated polyurethane sheath with two flexible rings
■ Inner ring helps with insertion and covers the cervix
■ Outer ring rests on vulva
■ Water or oil-based lubricant and spermicide may be used
■ Can be stored at any temperature; 5-year shelf life
■ Remove prior to standing by twisting the outer ring to contain
semen and pull out
■ Material degradation could occur if both male and female
condoms used simultaneously
Hormonal Methods
Hormonal contraceptives
Hormonal contraceptives alter the normal menstrual cycle,
inhibiting ovulation, altering the endometrial lining, and
thickening cervical mucus.
■ Mechanism of Action
■ Effects of Estrogen
• Ovulation inhibited by suppression of follicle stimulating
hormone (FSH) and luteinizing hormone (LH)
• Endometrial lining altered making the endometrium less
receptive to implantation
■ Effects of Progestin
• Cervical mucus thickened, hampering sperm transport
• Suppression of midcycle LH peak prevents ovulation
• Decreases cilia movement within the fallopian tube
■ Advantages of hormonal contraceptives include decreased
dysmenorrhea, decreased menstrual blood loss, and reliability
■ Requires addition of condom for STI protection or as back-up
with user error
■ Side effects may include nausea, vomiting, breast tenderness,
breakthrough bleeding, headaches, mood changes, decreased
libido, or weight change
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BASICS
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■ May cause serious health issues; advise hormonal contra-

ceptive users not to smoke and teach reportable symptoms
of possible complications:
■ Abdominal pain (severe)
■ Chest pain
■ Headache (severe)
■ Eye problems (blurred, double vision)
■ Severe leg pain, redness, and swelling
■ Shortness of breath
■ Worsening depression
■ Jaundice
■ Contraindications to hormonal contraceptives
■ History of heart attack, stroke, blood clot; estrogen
promotes blood clotting
■ History of breast or female reproductive cancer; tumors
may be hormonally provoked
■ Diabetes with vascular involvement; estrogen promotes
blood clotting
■ Impaired liver function; OCs are metabolized through the
liver and use may adversely affect existing liver disease
■ Suspected or confirmed pregnancy
■ Uncontrolled hypertension; increased risk for
cardiovascular complications
■ Smoker over 35 years of age; increases the risk for cardio-
vascular complications
■ History of migraine headaches (with aura); increased risk
for stroke
■ Major surgery planned with immobilization; increased risk
for deep vein thrombosis
Combined Hormonal Methods

(Combination of estrogen and progestin)
Combination Oral Contraceptives (OC)

■ Most OCs are administered daily for 21 days, followed by
7 hormone-free days (either no pills taken or placebos taken
for 7 days)
■ Pill selection based on amount of estrogen, type of progestin,
adrenergic effect, or symptoms presented
12
13
■ Combined OCs may be monophasic (estrogen and progestin
remain constant) or multiphasic (hormone dosing changes
throughout the month)
■ Extended-cycle OCs are taken consistently for 12 weeks,
followed by 7 days of inert pills; withdrawal bleeding
occurring only four times per year
■ Combination hormonal contraceptives may decrease
production of breast milk and should be avoided while
breastfeeding
■ Effectiveness of OCs altered by certain medications; patients
should report use of contraceptive agents to all health-care
providers
Transdermal Patch
■ Patch applied to skin weekly for 3 weeks; fourth week is patch-
free to allow withdrawal bleeding
■ Acceptable application sites include abdomen, buttocks, upper
outer arm, and upper torso (but not the breasts); site should
vary weekly
■ Application involves cleansing skin, avoiding lotion, and
firmly applying patch making sure all corners adhere to skin
■ May engage is usual activities (bathing, swimming,
exercising)
■ Partial removal and skin reactions possible
■ Decreased effectiveness noted in women who weigh more
than 198 pounds
Vaginal Ring
■ Small, flexible hormone-impregnated ring inserted and left in
the vagina for 3 weeks; removed in fourth week to allow for
withdrawal bleeding
■ Ring should be kept inside unopened package before
insertion; protect from sunlight and high temperatures
■ Side effects include increase in vaginal discharge, vaginal
irritation, or infection
■ Expulsion may occur; if out for more than 3 hours, back-up
method of birth control needed for the next 7 days
GYN
BASICS
GYN
BASICS
Progestin Only Preparations
■ Progestin-only preparations are indicated for women who

cannot use estrogen
■ Alteration in menstrual cycle common with progestin-only
methods
■ May be used in lactation once breastfeeding is well
established
■ Side effects include weight gain, menstrual irregularities, and
depression
Oral Contraceptives “minipill”
■ Important to take at the same time each day
■ Back-up method of birth control needed with missed or late
pills
Injectable Progestin Contraception
Depo-medroxyprogesterone (DMPA)
■ Injected by health-care provider intramuscularly (IM) every 3
months
■ Return to fertility may be delayed
■ Bone loss may be of concern with continued use; should not
be used for greater than 2 years continuous use
Intrauterine system (IUS)/Intrauterine Device (IUD)
■ Inhibits fertilization by altering fallopian tube transport of

sperm and ova, as well as producing cellular changes to the
endometrial lining
■ Recommended for parous women in a mutually monogamous
relationship with no history of pelvic inflammatory disease
(PID)
■ Inserted in office by qualified practitioner
■ Increased incidence of pelvic inflammatory disease (PID)
■ Uterine perforation and expulsion of device possible
■ Attached to string that extends outside of the cervix; instruct
patient to check for presence of string monthly
■ Teach patient the following reportable warning signs
14
15
Signs of IUD complications:
Period late (pregnancy)
Abdominal pain (infection)
Infection
Not feeling well (infection)
String missing (IUD expelled)
Types
1. T-shaped hormone-releasing (levonorgestrel) device placed in
the uterus to prevent pregnancy for up to 5 years
2. Copper IUD contains no hormones; continuous use for up to
10 years if no complications
Emergency Contraception (EC)
Contraceptive agents used after unprotected intercourse

intended for the prevention of pregnancy
■ Available agents
■ Copper IUD inserted within 5 days of unprotected
intercourse
■ Oral contraceptives taken at higher doses; both combina-
tion and progestin-only preparations are available
• Initial dose within 72 hours of unprotected intercourse
• Follow-up dose within 12 hours of first dose
Permanent Methods
■ Prevent conception by mechanically blocking the fallopian

tubes, preventing passage of ovum
■ Low failure rate, however, if pregnancy occurs, may be
ectopic
Tubal Ligation (Incisional Method)
■ Performed in a hospital or outpatient surgical unit under
general anesthesia
■ Fallopian tubes cut, cauterized, and/or clipped
■ Complications may include bleeding, infection, incomplete
tube closure, injury to adjacent organs, or complications from
anesthesia
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Hysteroscopic Tubal Sterilization (Nonincisional method)

■ Microinserts placed into the opening of the fallopian tubes,
causing scar tissue to grow in approximately 3 months
■ Performed in physician’s office or outpatient procedure lab
with local anesthetic to cervix
■ Follow-up hysterosalpingogram performed at 3 months to
ensure both tubes have been blocked; alternate method of
birth control used until tube status verified
■ Complications may include incorrect placement requiring
second or operative procedure, ectopic pregnancy, infection,
perforation of the uterus
Health Promotion in Adult Women

Cardiovascular Health Promotion
■ Cholesterol screening every 5 years after age 20

■ Blood pressure screening at each medical visit
■ Incorporate fitness into daily lifestyle
■ Discourage smoking
Promotion of Weight Management and Fitness
■ Calculate body mass index and determine goal

■ Discuss exercise regimen for current fitness level
■ Provide nutrition guidance according to the guidelines set
forth by the U.S. Department of Agriculture (USDA)
Prevention and Treatment of Osteoporosis
■ Risk increases after menopause; estrogen reduction results in

increased bone resorption
■ Discuss adequate intake of calcium and vitamin D
■ Encourage weight-bearing exercise
■ Educate concerning bone density scans
■ Discuss medications to reduce bone loss with primary health-
care provider
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Early Detection of Colorectal Cancer
■ Screening starting at age 50 (ACOG, ACS)

■ Yearly fecal occult blood test plus
■ Flexible sigmoidoscopy every 5 years or
■ Colonoscopy every 10 years or
■ Double contrast barium enema every 5 years
Early Detection/Prevention of Skin Cancer
■ Use sunscreen with SPF of 15 or higher

■ Avoid sun exposure from 10 a.m. to 4 p.m. and tanning
beds
■ Perform self-evaluation of the skin; report suspicious
lesions
■ Thorough skin exam every 3 years age 20 to 39; annually
after age 40
Menopause
■ Cessation of menses with amenorrhea for 12 months

■ Symptoms
■ Vasomotor symptoms
• Hot flushes
• Night sweats
■ Urogenital symptoms
• Thin, friable vaginal mucosa
• Vaginal dryness and irritation
• Dyspareunia
■ Other Systemic Symptoms
• Sleep disturbance
• Mood swings
• Memory loss
• Skin changes
• Hair thinning
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Hormone Replacement Therapy (HRT)
■ The decision of whether of not to use hormone replacement

therapy should be made after careful medical evaluation and
discussion with the primary health-care provider concerning
the risk/benefit ratio for each woman
■ Current guidelines by the U.S. Food and Drug Administration
(FDA) recommend HRT use only for moderate to severe
menopausal symptoms at the lowest effective dose for the
shortest period of time, noting the risk/benefit ratio for each
woman
■ If HRT prescribed solely for vaginal/vulvar symptoms, local
hormone therapy should be considered
■ Alternatives to HRT should be considered if HRT used for sole
purpose of osteoporosis prevention
18
19
Establishing Pregnancy
■ Pregnancy may be assumed based on the presence of certain
signs and symptoms Presumptive signs are subjective and
recorded under the history of present illness
■ Probable and positive signs of pregnancy are objective and
recorded as physical assessment findings
Presumptive Probable Positive

Amenorrhea ■ Positive pregnancy test Fetal heart beat
Breast ■ Uterine enlargement auscultated
tenderness ■ Hegar’s sign (softening Fetal movement
Quickening of lower uterine palpated per
segment) practitioner
Nausea/
Vomiting ■ Goodell’s sign Ultrasound of
(softening of cervix) gestation
Urinary
frequency ■ Chadwick’s sign (bluish
hue to cervix/vagina)
■ Braxton Hicks
contractions
■ Urine pregnancy test

■ Reacts with human chorionic gonadotropin (hCG)
■ Performed on first voided urine sample of the day;
positive results possible before the first day of a missed
menstrual period
■ Serum pregnancy test
■ Useful in monitoring expected pattern of progression of
hCG; detects hCG as early as 9 days postconception
■ Ultrasound
■ Confirms presence of gestational sac, fetal pole, and fetal
cardiac activity
■ Validates location of pregnancy (intrauterine versus
ectopic)
ANTE-
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ANTE-
PARTUM
Estimated Date of Delivery
■ Establishing an accurate date of delivery is important to:

■ Determine timing of antenatal screening
■ Monitor growth of the fetus
■ Scrutinize timing of delivery
■ Common abbreviations denoting delivery date are:
■ EDD. …………………… estimated date of delivery
■ EDC. …………………… estimated date of confinement
■ EDB. …………………… estimated date of birth
Naegele’s Rule
■ Formula used to estimate date of delivery

■ Count back 3 months and add 7 days to the last normal
menstrual period (LNMP) reported by the patient
Example: The patient states that her LNMP was April 20th
April is the 4th month 20th day
3 months 7 days
1st month 27th day
The baby is estimated to be due on January 27th of the
following year
Trimesters of Pregnancy
Normally, pregnancy continues for 40 weeks or 280 days

1st trimester conception until 12 weeks’ gestation
2nd trimester 13 weeks until 27 weeks’ gestation
3rd trimester 28 weeks until 40 weeks’ gestation
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21
Schedule of Prenatal Visits (low-risk pregnancy)
■ Monthly until 28 weeks’ gestation

■ Biweekly from 28 weeks until 36 weeks
■ Weekly from 36 weeks until delivery
Prenatal Health History
Performing a thorough health history in the prenatal period

is essential to planning nursing care and identifying high-
risk women.
■ Medical history
■ Chronic illness
■ Current and recent medication
■ Recent acute illness
■ Childhood illnesses
■ Surgical history
■ Problems with anesthesia
■ Previous surgeries
■ Uterine/cervical surgeries
■ Obstetrical history
■ Type of deliveries: vaginal/cesarean
■ Complications with past pregnancies
■ Infertility
■ Documentation of obstetrical history
Descriptive Term Definition

Gravida (G) Number of pregnancies
Term (T) Number of deliveries after 37 weeks
Preterm (P) Number of deliveries after 20 weeks but
before 38 weeks
Abortion (A) Number of deliveries before 20 weeks,
either spontaneous or induced
Living (L) Number of living children
ANTE-
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ANTE-
PARTUM
Documentation Example 1: The prenatal client states having

three children at home. She reports that her son was born on
his due date, but her daughters were both born a month early.
She states that she lost a baby in her second month.
G: 5 (currently pregnant, 3 children at home, one abortion)
T: 1 (her son was born on his due date)
P: 2 (her daughters were each born a month early)
A: 1 (she lost a pregnancy at approximately 8 weeks)
L: 3 (reports three children at home)
Document as G5-1213
Documentation Example 2: The same prenatal client may also

be described as G5 (5 pregnancies) P3 (number of live births);
pregnancies ended before 20 weeks are not counted as “P” in
this method.
■ Sexual history
■ Number of sexual partners
■ Sexually transmitted infections
■ Sexual abuse
■ Methods of contraception
■ Condom use
■ Social history
■ Use of recreational drugs
■ Smoking
■ Domestic abuse
■ Educational level/ability to read
■ Economic status
■ Type of health insurance
■ Need for community referrals
• Transportation
• Nutrition
• Medications
22
23
Physiological Changes in Pregnancy
Heart Cardiac Blood Blood Systemic vascular

rate output volume pressure resistance
↑ ↑ ↑ * ↓
*slight↓ with return to baseline by 3rd trimester
Stroke Red White

volume blood cells Hemoglobin Hematocrit blood cells
↑ ↑ ↓ ↓ ↑
Glomerular Basal Respiratory

filtration rate Urine output metabolic rate rate
↑ ↑ ↑ ↔
↑ Increase ↓ Decrease ↔ No change
Hormonal Changes in Pregnancy
Hormone Functions
Estrogen ↑ Increase uterine muscle mass
Increase blood flow to uterus
Prepare breasts for lactation
Progesterone ↑ Relax venous walls
Inhibit uterine contractions
Human chorionic ↑ Stimulate estrogen/progesterone
gonadotropin (hCG) production
Relaxin ↑ Discourage uterine contraction
Remodeling of collagen
Prolactin ↑ Maturation of breast ducts/alveoli
Stimulate lactation
Human placental ↑ Insulin antagonist
lactogen Allow adequate glucose for fetal
demand
ANTE-
PARTUM
ANTE-
PARTUM
Nursing Care with First Prenatal Visit

■ Determine EDD based on LNMP
■ Document current gestational age (gestational wheel is a tool
for quick reference to current gestational age)
■ Document baseline vital signs
■ Document height, weight, and body mass index (BMI)
■ Obtain urine specimen and test for presence of:
Substance Expected Finding

Glucose Negative/Trace
Protein Negative/Trace
■ Auscultate fetal heart tones

■ Measure fundal height in centimeters from symphysis pubis
to the top of the fundus
■ Uterine size increases in pregnancy in a predictable pattern
and is measured to gauge fetal growth
■ Fundal height that is lagging or greater than expected
should be further investigated
Weeks’ Gestation Fundal Height

12 Just above symphysis pubis
16 Halfway between symphysis pubis and
the umbilicus
20 At the umbilicus
21–36 Fundal height generally matches weeks
gestation in centimeters
EXAMPLE: Fundal height at 28 weeks
should be approximately 28 cm.
24
25
Fundal height. (From Dillon PM. (2003). Nursing Health Assessment: A

Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p 736.)
■ Provide appropriate education for gestational age

■ Discuss procedure for lab testing
ANTE-
PARTUM
ANTE-
PARTUM
Common Expected Finding

Laboratory Tests in Pregnancy
HIV *Check state laws regarding Negative
HIV testing in pregnancy
Blood type A, B, AB, O
Rh factor Negative/Positive
Antibody screen Negative
Hemoglobin 11.5 mg/dL
Hematocrit 33%
Platelets 150,000–400,000 mm3
WBC 5,000–12,000 mm3
RPR Negative
Hepatitis B antigen Negative
Rubella titer 1:8 Immune
Hemoglobin electrophoresis AA, unaffected
Chlamydia culture Negative
Gonorrhea culture Negative
Pap smear Normal cytology
26
27
Diagnostic Testing in Early Pregnancy
Diagnostic Test Nursing Considerations

Ultrasound Performed Position to avoid supine
throughout pregnancy hypotension; folded towel
Clinical Applications: under right hip if supine
■ Confirm and date pregnancy
■ Verify pregnancy location
■ Detect fetal cardiac activity
■ Measure fetal growth
■ Detect fetal anomalies
■ Measure amniotic fluid index
■ Determine fetal position
■ Determine placental position
■ Measure cervical length
■ Adjunct to invasive procedures
Chorionic villi sampling (CVS) Review blood type, Rh and
Performed at 10–12 weeks antibody status
Clinical Application: Administer Rh (D) immune
■ Chromosomal analysis globulin if indicated
Amniocentesis Monitor patient for post-
Performed throughout pregnancy procedure cramping or
Clinical Applications: bleeding
■ Chromosomal analysis is Monitor fetal heartbeat
desired
■ Measure AFP
■ Measure bilirubin level
■ Determine lung maturity
■ Lecithin/Sphingomyelin
Ratio (L/S Ratio)
■ Phosphatidylglycerol (PG)
■ L/S Ratio of 2:1 and positive
PG indicative of fetal lung
maturity
Maternal Serum Triple Screen NOTE: This is a screening
(tests maternal serum for method only. A positive
AFP, hCG, and estriol) result suggests the need
for further testing
ANTE-
PARTUM
ANTE-
PARTUM
Diagnostic Test Nursing Considerations

Performed at 15–18 weeks Results adjusted according
Clinical Applications: to documented gestational
■ Serum screen for neural tube age, maternal age, race,
defects/ Down syndrome and weight, presence of
diabetes/multiple
Interpretation of Results
gestation; the nurse must
Defect AFP hCG Estriol accurately document these
Risk for open variables on the
neural tube ↑ WNL WNL laboratory requisition
Risk for Down
syndrome ↓ ↑ ↓
↑ elevated ↓ decreased
WNL within normal limits
Education in the Early Prenatal Period

■ Elevated estrogen and progesterone levels in early pregnancy
generate changes in the body, causing pregnancy associated
discomforts
■ Offer suggestions to lessen discomforts
■ Teach patient to report symptoms that may indicate a potential
complication (in red)
Discomfort Patient Education

Urinary Related to uterine position/weight
frequency Encourage frequent emptying of bladder
Discourage limiting oral fluids
Report burning or pain with urination
Nausea Related to elevated hormone levels
and vomiting Encourage small, frequent meals
Eat crackers before rising
Avoid pungent odors, spicy or greasy food
Discuss limited time frame for nausea
(subsides around 12 weeks’ gestation)
Report excessive vomiting
28
29
Education in the Early Prenatal Period (Cont’d)
Emotional Related to hormone changes
lability Discuss normalcy of emotional changes with
patient and partner
Ambivalence normal in first trimester
Report constant crying, inability to care for
self, suicidal thoughts
Leukorrhea Related to vasocongestion of mucous
membranes
Avoid tampon use and douching
Wear peri-pad to absorb discharge
Encourage cotton underwear
Report vaginal discharge with an odor or
color, vaginal bleeding, or leaking of
amniotic fluid
Breast Hormone-related breast development often
discomfort first presumptive sign of pregnancy
Wear a supportive bra
Colostrum may be expressed in pregnancy
Introduce the value of breastfeeding
Introduce/reinforce breast self-exam
Report any breast lump or unusual discharge
Fatigue Related to rapid hemodynamic and
metabolic changes in the first trimester
Encourage naps during the day
Encourage prenatal vitamins
Encourage healthy diet
Report syncope and vertigo
Nasal stuffiness/ Related to vasocongestion of mucous
epistaxis membranes
Increased humidity in home may help
Warm compresses to sinus area
Avoid over-the-counter (OTC) cold remedies
Report fever, green/yellow nasal discharge,
or frequent nosebleeds
ANTE-
PARTUM
ANTE-
PARTUM
Teratogen Exposure
Teratogens are substances that are harmful to the developing fetus;

advise patient to avoid exposure.
Teratogen Patient Education

Viruses Avoid contact with ill persons
Report fever, rash, illness to primary
health-care provider
Infections causing serious harm to fetus:
Toxoplasmosis
Other (hepatitis B)
Rubella
Cytomegalovirus
Herpes simplex virus (HSV)
Environmental Avoid exposure to:
Mercury
Radiation
Lead
Other environmental toxins
Drugs Recreational
Discourage alcohol use
Encourage patient to stop smoking
Refer to smoking cessation classes
Assess use of illicit drugs
Refer to addiction counselors
Discuss the role of drug screening
Discuss adverse effects to fetus
OTC/Herbal
Caution patient to discuss use of all OTC/herbal
medications with primary health-care provider
Prescription
List all medications prescribed since LNMP on
prenatal record
Investigate drug classification in drug
guide book
Inform primary health-care provider of drug list
Record drugs/dosages on prenatal record
30
31
Pregnancy Classification of Medications
Drug Class Pregnancy Safety

A No evidence of fetal risk
B No animal risk demonstrated; human fetal risk
not demonstrated
C Animal study demonstrates risk
No adequate study in humans
D Evidence of human risk
Weigh risk/benefit ratio of drug
X Definite fetal risk
Contraindicated
Source: U.S. Food and Drug Administration
Nutrition
■ Inquire about dietary practices

■ Gather 24-hour diet recall
■ Suggest an addition of 300 healthy calories per day
■ Encourage daily prenatal vitamin with 400 g folic acid
■ Suggest 6–8 glasses of water daily
■ Encourage to follow food pyramid in daily choices
ANTE-
PARTUM
Page 32
KEY
Fat (naturally occurring and added) Fats,oils and sweets
12:24 PM
Sugars (added) Use sparingly

These symbols show fats and
added sugars in foods
Dairy group Protein group
2-3 servings 2-3 servings
12/28/05
32
Vegetable group Fruit group
3-5 servings 3-5 servings
02Holloway (F)-02
Bread, cereal, pasta

and grain group
PARTUM
6-11 servings
ANTE-
Food Pyramid. (From U.S. Department of Agriculture and Department of Health and Human Services.)
33
Weight Gain in Pregnancy
■ Recommended weight gain depends on prepregnancy

weight/BMI
Prepregnant Weight Recommended Weight Gain

Normal 25–35 pounds
Overweight 15–25 pounds
Underweight 28–40 pounds
■ Assess and document the pattern of weight gain
Trimester Suggested Weight Gain

1st 1–4 pounds total
2nd & 3rd 0.5–1 pound per week
Exercise in Pregnancy
■ Physical activity in pregnancy is recommended unless

contraindicated by medical complications
■ Avoid sports with potential for abdominal trauma or falls
■ Avoid overheating and supine positioning
■ STOP exercise if experiencing
■ Vaginal bleeding
■ Cramping
■ Leaking of amniotic fluid
■ Decreased fetal movement
■ Dizziness
■ Headache
■ Chest pain
■ Calf pain
■ Dyspnea
ANTE-
PARTUM
ANTE-
PARTUM
Sexuality in Pregnancy
■ Sex not restricted in pregnancy unless risk factors exist for

bleeding or preterm labor
■ Discuss expected changes in sexuality
■ Change in libido
■ Body image changes
■ Braxton-Hicks contractions with orgasm
■ Comfortable positioning for intercourse
Warning Signs During Pregnancy
Patient should be instructed to notify primary health-care

provider if experiencing any of the following symptoms:
Warning Sign Possible Cause

Vaginal bleeding Abortion
Placenta previa
Abruptio placentae
Preterm labor
Leakage of vaginal Premature rupture of amniotic fluid
fluid Incontinence of urine
Dysuria Urinary tract infection
Headache Pregnancy-induced hypertension
(PIH)
Altered vision Pregnancy-induced hypertension
Blurred vision (PIH)
Flashes of light
Abdominal cramping Preterm labor
Severe epigastric pain Pregnancy-induced hypertension
(PIH)
Decreased fetal Fetal demise
movement
Elevated temperature Infection
Persistent vomiting Hyperemesis gravidarum
34
35
Nursing Care for Return Prenatal Visits
■ Measure pulse and blood pressure (BP)
■ Compare BP to initial reading (measured in the same position
at each visit)
■ Measure weight and compare to last reading
■ Note total weight gain
■ Note pattern of weight gain
■ Obtain urine specimen and test for protein and glucose
■ Measure fundal height
■ Determine fetal position
■ Perform Leopold’s Maneuver
• Palpate fetal body part in fundus (A)
• Palpate for fetal back (B)
• Palpate for presenting part (C)
• Palpate for attitude of presenting part (D)
Leopold’s Maneuver. (From Dillon PM. (2003). Nursing Health

Assessment: A Critical Thinking, Case Study Approach. Philadelphia:
F.A. Davis Company, p 739.)
ANTE-
PARTUM
ANTE-
PARTUM
■ Place Doppler on maternal abdomen over fetal back to

monitor fetal heart tones (FHT)
Placement of Doppler. (LSA = left sacral anterior; LOP = left occiput

posterior; LMA = left mentum anterior; LOA = left occiput anterior; RMA
= right mentum anterior; ROA = right occiput anterior; ROP = right
occiput posterior; RSA = right sacral anterior) (From Dillon PM. (2003).
Nursing Health Assessment: A Critical Thinking, Case Study Approach.
Philadelphia: F.A. Davis Company, p 737.)
■ Record presence of fetal movement

■ Assess for presence of edema/deep tendon reflexes
■ Record symptoms since last visit
■ Discuss procedure for diagnostic testing
■ Provide patient education appropriate for gestational age
36
37
Diagnostic Tests Nursing Considerations
1-hour glucose screen Administer 50 g glucose load
Performed at 24–28 weeks Patient should not eat, drink,
or smoke during the test
Serum sample drawn in
1 hour
Clinical Application EXPECTED RESULT
Detection of gestational 140 mg/dL
diabetes
Group B vaginal culture Explain test to patient

Performed between Collect vaginal/rectal
35–37 weeks specimen
Positive culture treated Negative
with antibiotics in labor
to prevent newborn
transmission
Fetal fibronectin (fFN) NO intercourse 24 hours

Performed between 22 prior to exam
and 35 weeks in women Cervical/posterior fornix
at high risk for preterm specimen
labor
Negative predictive value Negative
for preterm labor
Antibody screen Administer Rh (D antigen)

Performed at 28 weeks in immune globulin at 28
Rh negative women weeks to prevent antibody
formation if Rh negative
and antibody screen
negative
Detects presence of positive Negative
antibodies in serum of Rh
negative women
ANTE-
PARTUM
ANTE-
PARTUM
Education in the Second and Third Trimester

■ Teach patient to count fetal movement and report change in
fetal movement pattern to primary health-care provider
immediately (See bulleted information under “Teach patient
to count fetal movements” on page 50)
■ Discuss fetal growth and development
■ Demonstrate palpating for contractions
■ Discuss symptoms of preterm labor
■ Lower backache
■ Increased vaginal discharge
■ Bloody show
■ Leaking amniotic fluid
■ Contractions
■ Pelvic pressure
■ Differentiate between true and false labor
True Labor False Labor

Cervix dilates Cervix unchanged
Contractions increase Contractions irregular and
in intensity and decrease with change of
frequency position/activity
Leaking amniotic fluid, No evidence of change in
bloody show vaginal discharge
■ Encourage childbirth preparation class

■ Discuss options for pain control in labor
■ Cesarean preparation class, if indicated
■ Epidural anesthesia class, if indicated
■ Explore preparing for the newborn
■ Breastfeeding
■ Circumcision
■ Choosing a pediatrician
■ Car seat safety
■ Discuss the discomforts associated with late pregnancy and
teach reportable symptoms (in red)
38
39
Changes in Related to hormone changes in pregnancy;
pigmentation fade after pregnancy
Linea nigra Moisturizers decrease itching, but will not
(pigmented line prevent striae
from umbilicus Report body rashes
to pubic bone)
Chloasma (deeper
facial pigment)
Striae (stretch marks)
Round ligament Related to round ligament stretching as
pain (occasional, uterus grows
sharp lower Change positions slowly
abdominal pain) Encourage good body mechanics
Report abdominal cramping, constant pain,
or bleeding
Braxton-Hicks Instruct patient how to palpate contractions
contractions Labor should occur after 38 weeks gestation
(false labor Teach patient to differentiate between true
contractions) and false labor
Report signs of preterm labor
Ankle edema Related to decreased venous return due to
pressure of the gravid uterus
Rest in lateral recumbent position
Elevate legs when sitting
Continue with 6–8 glasses water daily
Report generalized edema
Varicose veins Caused by increased venous stasis related
to pressure from the gravid uterus
Wear pregnancy support hose
Avoid lengthy standing
Change positions frequently
Report pain, redness, localized heat to legs
Faintness Related to hemodynamic changes
Avoid sudden position change
Avoid long periods without eating
Avoid lying supine
Report loss of consciousness
ANTE-
PARTUM
ANTE-
PARTUM

Heartburn Related to increased pressure on
abdominal organs and sphincter
relaxation
Encourage small, frequent meals
Avoid spicy foods
Sit up after meals
Report persistent symptoms
Backache Related to shift in posture due to gravid
uterus
Encourage low-heeled shoes
Avoid standing for long periods
Teach pelvic tilt exercises
Report constant or rhythmic backache
Shortness of breath Related to upward diaphragmatic
pressure exerted by the gravid uterus
Allow more time for strenuous activities
Eat small, frequent meals
Lightening will lessen symptoms
Report dyspnea with rest
Insomnia Related to fetal movement, nocturia
Teach relaxation techniques
Encourage side-lying with pillow support
Warm milk/shower before sleep
Leg cramps Related to uterine pressure on the pelvic
nerves or calcium imbalance
Review daily calcium intake
Teach signs of deep vein thrombosis
Report pain, redness, localized heat
Constipation Related to decreased gastric motility; iron
Hemorrhoids supplement may worsen constipation
Increase dietary fiber and water intake
Encourage exercise
Discourage enemas and laxatives
Report painful or bleeding hemorrhoids
40
41
Pregnancy Complications
Vaginal Bleeding (before 20 weeks’ gestation)
May be related to spontaneous abortion, ectopic pregnancy, or

gestational trophoblastic disease
Spontaneous Abortion
Loss of pregnancy before viability
■ Clinical Findings
■ Vaginal spotting (may pass clots)
■ Abdominal cramping
■ Cervical changes
■ Fetal heartbeat may be present or absent
Ectopic Pregnancy
Products of conception implant outside the uterus
■ Vaginal spotting
■ hCG lower than expected for dates
■ Lower abdominal pain
■ Ultrasound findings: absence of intrauterine gestational sac
■ If rupture occurs:
• Positive Cullen’s sign
(periumbilical bluish hue)
• Shoulder pain
• Signs of shock
Gestational Trophoblastic Disease
Abnormal proliferation of trophoblastic cells without viable fetus
■ Vaginal spotting (dark brown)
■ Fundal height greater than expected for dates
■ hCG greater than expected for dates
■ Excessive nausea and vomiting
■ Absence of fetal heart tones
■ Ultrasound findings: Snowflake-like clusters,
absence of fetus
ANTE-
PARTUM
ANTE-
PARTUM
■ Nursing Care (vaginal bleeding/early pregnancy)

■ Monitor amount of bleeding
■ Assess vital signs
■ Observe for signs of shock
■ Auscultate for fetal heart tones (FHTs)
■ Collect passed tissue/clots
■ Monitor patient comfort
■ Check blood type and Rh factor
■ Administer Rh(D) immunoglobulin if indicated
■ Initiate IV fluids as ordered
■ Report lab/ultrasound findings
■ Attend to patient’s emotional needs
Vaginal Bleeding (after 20 weeks’ gestation)
May be related to placenta previa or abruptio placentae

Placenta Previa
Low-lying position of placenta in the uterus that partially or
completely covers the cervical os
■ Painless bright red vaginal bleeding
■ Bleeding may be reported after intercourse
■ Uterine tone soft upon palpation
■ Interventions dependent on amount of bleeding and
labor status
■ If partial placenta previa is noted in early gestation, repeat
ultrasound later in pregnancy (may demonstrate absence
of previa as uterus grows)
■ If labor active and os is covered, cesarean birth necessary
■ If bleeding controlled and labor absent, conservative
management
• Patient Teaching (Conservative Management)
– No tampon use
– No sexual intercourse
– Monitor and report bleeding
– Patient instructed to report placenta placement when
admitted to hospital
– Cesarean preparation class
– Count fetal movements
42
43
Internal os
Blood
External os A
Membranes
Internal os
Blood B
External os
Membranes
Internal os
Blood C
External os
Placenta previa.
ANTE-
PARTUM
ANTE-
PARTUM
Abrupto Placentae
■ Abdominal pain (sudden onset, intense and localized)
■ Fundus firm, boardlike, with little relaxation
■ Vaginal bleeding
■ Bleeding may be concealed within the uterine cavity
■ Fetal heart tones may be nonreassuring
■ Nursing Care (vaginal bleeding/late pregnancy)
■ Monitor amount of bleeding
■ Check vital signs
■ Observe for signs of shock
■ Evaluate fetal heart tones
■ Palpate uterine tone
■ Apply electronic fetal monitor (EFM)
■ REPORT alterations in fetal heart rate pattern
■ REPORT hypertonic contractions with poor resting tone
■ Do not attempt vaginal exam until placenta
placement verified
■ Initiate IV fluids
■ Report laboratory and ultrasound findings
■ Prepare staff for possible cesarean birth
■ Attend to patient’s emotional needs
Hyperemesis Gravidarum
Intractable vomiting in pregnancy with resultant weight loss and

dehydration
■ Nursing Care
■ Observe for signs of dehydration
■ Review electrolytes
■ Access IV site as ordered
■ Record fetal heart tones
■ Record intake and output
■ Record daily weight
■ Check urine for ketones
■ Administer antiemetics as ordered
44
Page 45
Abruptio Placentae
Premature separation of the placenta; may be partial or complete
12:24 PM
12/28/05
45
02Holloway (F)-02
PARTUM
ANTE-
Partial separation Partial separation Complete separation
(concealed hemorrhage) (apparent hemorrhage) (concealed hemorrhage)
Abruptio placentae.
ANTE-
PARTUM
Preterm Labor
Onset of regular labor before the 37th completed week of

gestation
■ Rhythmic lower abdominal cramping
■ Complaints of backache
■ Increased vaginal discharge
■ Downward pelvic pressure
■ Leaking of amniotic fluid
■ Vaginal spotting
■ Cervical effacement/dilation
■ Shortening cervical length
■ Nursing Care
■ Determine gestational age
■ Assess uterine tone
■ Auscultate fetal heart tones and apply EFM
■ Obtain vaginal/urine cultures
■ Assess for leaking amniotic fluid
• Ferning—Microscopically, amniotic fluid will resemble the
leaves of a fern plant
• Nitrazine paper—Due to the alkaline nature of amniotic
fluid, the nitrazine paper will change from yellow to blue
■ Perform vaginal exam to determine dilation and effacement
of the cervix
■ Position side-lying
■ Administer corticosteroid to mother
• Accelerates maturity of fetal lungs
• Most benefit 24 hours after administered
■ Initiate tocolytic therapy
46
47
Tocolytic Medication Nursing Precautions (Closely
monitor maternal and fetal
tolerance to medication)
Magnesium Sulfate ■ Monitor for respiratory
depression
■ Assess deep tendon reflexes
■ Watch level of consciousness
■ Monitor intake and output
■ Assess fetal heart tones
■ Monitor for contractions
ANTIDOTE: Calcium ■ Auscultate lungs
gluconate at bedside ■ Report magnesium sulfate levels
β-adrenergic agonist ■ Monitor for hypotension
terbutaline ■ Assess for tachycardia
ritodrine ■ Assess patient for tremors
■ Assess for pulmonary edema
■ Screen glucose/potassium
■ Assess for cardiac arrhythmias
and chest pain
■ Monitor fetal heart tones
■ Monitor contractions
Prostaglandin antagonist ■ May lead to premature closure
indomethacin of ductus arteriosus
Calcium channel blockers ■ Monitor for hypotension
nifedipine ■ Assess for tachycardia
Preeclampsia
Hypertensive disorder of pregnancy with multisystem involvement
■ Blurred or altered vision
■ Epigastric pain
■ Headache
■ Edema
■ Proteinuria
■ Hyperreflexia
■ Hypertension
ANTE-
PARTUM
ANTE-
PARTUM
■ Nursing Care
■ Closely monitor vital signs
■ Dipstick urine for protein
■ Record presence of edema
■ Palpate tone of fundus
■ Auscultate fetal heart rate and apply EFM
■ Monitor patient comfort
■ Collect 24-hour urine
■ Place patient in side-lying position
■ Keep environment quiet and dim
■ Institute seizure precautions
• Side rails up and padded
• Bed in low position
• Suction equipment available at bedside
• Oxygen available at bedside
■ Initiate medications as ordered
Drug Therapy Nursing Precautions

Magnesium sulfate See precautions listed under preterm
labor for magnesium sulfate
Anti-hypertensives Administer slowly
Closely monitor for hypotension
Eclampsia
■ Worsening of symptoms of preeclampsia
■ Seizure activity
HELLP Syndrome
■ Worsening symptoms of preeclampsia
■ Malaise
48
49
■ Epigastric pain
■ Nausea/vomiting
■ Laboratory findings:
Hemolysis
Elevated Liver enzymes
Low Platelets
Gestational Diabetes
Glucose intolerance that is first recognized in pregnancy

■ Polyuria
■ Polydipsia
■ Polyphagia
■ Fatigue
■ Blurred vision
■ Glucosuria
■ Recurrent yeast infections
■ Slow healing wounds
■ Abnormal glucose results
• 1-hour glucose 140 mg/dL
• Abnormal 3-hour glucose tolerance test: 2 out of 4 values
elevated
FBS 95mg/dL
1-hour 180mg/dL
2-hour 155mg/dL
3-hour 140mg/dL
■ Outpatient Management
■ Dietician consult for ADA diet instructions
■ Discuss pathophysiology of gestational diabetes
with patient
■ Demonstrate home glucose monitoring
■ Review range for glycemic control
■ Demonstrate logging of glucose results
■ Discuss role of exercise in glycemic control
■ Demonstrate urine ketone testing
ANTE-
PARTUM
ANTE-
PARTUM
■ Demonstrate insulin administration

■ Teach patient to count fetal movements
• Find comfortable position in quiet place and concentrate
on fetal movement
• Document time of first fetal movement and time required
for 10 movements (should not take more than 2 hours)
• If pattern of movement decreased, REPORT immediately
Fetal Surveillance in Pregnancy

Nonstress Test (NST)
■ Procedure used to monitor fetal response to movement; FHR

acceleration with fetal movement is reassuring and a sign of
fetal well being
■ Place patient in a Semi-Fowler’s or side-lying position
■ Record vital signs and apply electronic fetal monitor
■ Record baseline fetal heart rate and monitor FHR pattern for
20–30 minutes
■ Patient marks paper with each perceived fetal movement
■ NST may take longer with absence of accelerations; fetal
movement may be stimulated vibroacoustically
■ Report findings to primary health-care provider
EXPECTED FINDINGS: REACTIVE

Two accelerations of FHR within 20 minutes that are at least 15
BPM above the baseline rate and last for a minimum of 15
seconds each
Contraction Stress Test (CST)
Also called Oxytocin Challenge Test (OCT)

■ Procedure used to determine fetal tolerance to the stress of
uterine contractions
■ Calculate gestational age (should not be performed on
preterm patients; test stimulates contractions)
50
51
■ Place patient in side-lying position
■ Record vital signs
■ Apply EFM and record baseline fetal heart rate for 20 minutes
■ Stimulate uterine contractions until three contractions occur
within 10 minutes lasting 40 seconds each
■ Contractions can be stimulated with
■ Nipple stimulation or
■ IV Oxytocin per hospital protocol
■ Document FHR response to contractions
EXPECTED FINDING: NEGATIVE

Three contractions that last at least 40 seconds within 10
minutes without the presence of late or significant variable
decelerations
Biophysical Profile (BPP)
■ Ultrasound exam observing four specific fetal criteria

■ Nonstress test included as a fifth parameter
■ Scoring of Biophysical Profile (BPP)
Parameter Expected Findings

Measured (within 30 minutes) Score
Fetal tone Active flexion/extension 2
Fetal breathing One or more episodes lasting 2
30 seconds
Gross fetal movement Three or more discrete 2
movements
Amniotic fluid volume Single vertical pocket 2 cm 2
FHR reactivity per NST Reactive 2
EXPECTED FINDING: NEGATIVE

BPP Score of at least 6/8 if NST omitted
BPP Score of at least 8/10 if NST included
ANTE-
PARTUM
INTRA-
PARTUM
Intrapartum
■ Patients present to labor and delivery for medical procedures,
triage, and birth
■ Upon admission to labor and delivery, the nurse should:
■ Determine reason for admission
■ Gather patient history
■ Review prenatal health record
■ Perform a physical exam
Prenatal History
■ Estimated date of delivery
■ Current gestational age
■ Complications in pregnancy
■ Results of laboratory tests and ultrasounds
■ Medications used in pregnancy
■ Presence of vaginal discharge or bleeding
■ Amniotic fluid status
■ Presence of fetal movement
■ Onset and pattern of contractions
Obstetrical History
Type of births
■ Vaginal
■ Instrumentation
■ Episiotomy
■ Length of labor
■ Cesarean
■ Reason for cesarean
■ Document type of incision
• Low-transverse
• Classical
■ Complications of birth
■ Neonatal outcomes
Medical History
■ Chronic health problems
■ Current medications
■ Time and description of last oral intake
■ Allergies to food/medicine
52
53
Surgical History
■ Complications with anesthesia

■ Date/reason for surgery
Perform a Physical Exam

■ Assess maternal vital signs
■ Collect urine specimen for protein and glucose
■ Assess for presence of edema
■ Perform Leopold’s maneuver to determine fetal position
■ Assess fetal heart rate (FHR)
■ Measure fundal height
■ Determine the frequency, duration, and intensity of contractions
■ Determine the stage and phase of labor
■ Assess cervical changes
■ Dilation (0 to 10 cm)
■ Effacement (0–100%)
■ Station (Level of presenting fetal part in relation to the ischial
spines of the maternal pelvis)
Iliac Iliac
crest crest
–5
–4
–3
–2
–1
0
Ischial 1
2
3
Ischial
spine 4 spine
5
Ischial Perineum Ischial
tuberosity tuberosity
Station
INTRA-
PARTUM
INTRA-
PARTUM
■ Note presence, color, and amount of bloody show

■ Check status of amniotic membranes
■ Intact
■ Bulging
■ Ruptured (note color, amount, and odor)
Nursing Responsibility with Fetal Monitoring

■ Position patient to avoid supine hypotension
■ Assess FHR and interpret findings
■ Compare FHR to maternal pulse to ensure monitoring of fetal heart
and not maternal rate
■ Implement nursing interventions for nonreassuring patterns of FHR
■ Evaluate effectiveness of nursing interventions for nonreassuring
patterns
■ Update primary health-care provider with FHR status
■ Document findings and interventions
■ Assessment of the FHR may be intermittent or continuous
Intermittent Auscultation
■ Auscultate fetal heart tones (FHT) over fetal back with Doppler
or fetoscope
Fetoscope. (From Dillon PM.

(2003). Nursing Health
Assessment: A Critical
Thinking, Case Study
Approach. Philadelphia:
F.A. Davis, p. 737.)
■ Count FHR between, during, and immediately following a
contraction
■ Note both rate and rhythm of FHR
■ Frequency of auscultation based on:
■ Phase/stage of labor
■ Hospital protocol
54
55
■ Risk status
■ Labor interventions
■ Physician orders
Stage/Phase of Labor Frequency of FHR Monitoring

Stage 1: Latent phase Every 30–60 minutes
Stage 1: Active phase Every 15–30 minutes
Stage 1: Transition Every 5–15 minutes
Stage 2 Every 5–15 minutes
Continuous Fetal Monitoring
Monitored with external or internal fetal monitoring

External Fetal Monitoring (EFM)
■ Encourage patient to void before applying EFM
■ Test internal circuitry of EFM
■ Place ultrasound transducer over fetal back
■ Place toco transducer over uterine fundus
■ Monitor for 20–30 minutes on admission
Ultrasound
Toco transducer transducer
(uterine contractions) (FHR)
External fetal monitor
INTRA-
PARTUM
INTRA-
PARTUM
Internal Fetal Monitoring

■ Indicated when EFM not providing adequate FHR or contraction
tracing
■ May be implemented only after amniotic sac is ruptured
■ FHR measured by spiral electrode attached to presenting part
■ Uterine tone measured by intrauterine pressure catheter (IUPC)
■ Resting tone of uterus averages 5–15 mmHG
■ Contraction tone of uterus averages 50–85 mmHG
Scalp
electrode
Internal fetal monitor

Catheter
Evaluating the Baseline Fetal Heart Rate
■ Normal baseline FHR is 110–160 BPM

■ Evaluated between contractions over 10 minutes
■ Documented as a range
■ Does not include accelerations or decelerations
■ Influences on the fetal heart rate
■ Central nervous system
Fetal sleep ↓ variability of FHR
Fetal movement ↑ variability of FHR
■ Autonomic nervous system
Sympathetic branch (↑ FHR)
Parasympathtic branch (↓ FHR)
■ Baroreceptors respond to ↓ blood pressure with subsequent
↓ FHR
■ Chemorecptors sense ↓ oxygen and ↑ FHR
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12:25 PM
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57
PARTUM
03Holloway (F)-03
INTRA-
Normal fetal heart rate. (Top: fetal heart rate; bottom: contractions.)
INTRA-
PARTUM
Changes to Baseline Fetal Heart Rate

■ TACHYCARDIA
■ FHR greater than 160 BPM for 10 minutes
■ Possible cause:
• Infection/hyperthermia
• Fetal hypoxia
• Maternal medications (ex. terbutaline, albuterol)
■ BRADYCARDIA
■ FHR less than 110 BPM for 10 minutes
■ Possible cause:
• Vagal stimulation
• Hypoxia
• Anesthetic agents
■ VARIABILITY
■ Fluctuations in FHR over time
■ Important indicator of fetal well-being
■ Sensitive to hypoxia and changes in Ph
■ Short-term variability (STV)
• Beat-to-beat changes in FHR
• Documented as present or absent
• Most accurate with internal FHR monitoring
■ Long-term variability (LTV)
• Pattern of fluctuations in FHR baseline
(Expected pattern highlighted in blue)
Long-Term Variability Possible Cause

Absent (0–2 BPM) Maternal medication
Minimal (3–5 BPM) Fetal sleep
Fetal hypoxia
Average (6–10 BPM) Adequate fetal oxygenation
Moderate (11–25 BPM)
Marked (25 BPM) Early sign of mild fetal hypoxia
Fetal stimulation
58
59
Changes in Fetal Heart Rate
■ The nurse interprets changes to baseline FHR as reassuring
or nonreassuring
■ The nurse must act on nonreassuring FHR patterns
■ ACCELERATIONS
■ Sudden increase of fetal heart rate over baseline
■ Indication of fetal well-being
■ Reassuring pattern
■ Possible cause: Fetal movement/stimulation
Acceleration. (Top: fetal heart rate; bottom: contractions.)
■ DECELERATIONS (Early, Late, Variable)

■ EARLY DECELERATION
• Decrease in FHR occurring with contractions
• Onset occurs before the contraction peak
• Recovery to baseline rate occurs by contraction end
• Commonly seen in active phase of first stage of labor
• Mirrors the contraction
• Usually benign finding
• Continue to monitor FHR pattern for nonreassuring
patterns
• Possible cause: Fetal head compression
INTRA-
PARTUM
INTRA-
PARTUM
Early deceleration. (Top: fetal heart rate; bottom: contractions.)
■ LATE DECELERATIONS
• Decrease in FHR occurring with contractions
• Onset with or after the peak of contraction
• Recovery to baseline rate occurs after contraction ends
• Repetitive pattern
• Nonreassuring requiring intervention
Late deceleration. (Top: fetal heart rate; bottom: contractions.)
60
61
• Etiology: decreased uteroplacental blood flow/oxygen
delivery related to
– Maternal supine hypotension – Hypertension
– Hyperstimulation of uterus – Diabetes
– Preeclampsia – Anemia
– Chronic maternal disease
■ VARIABLE DECELERATIONS
• Decrease in FHR occurring without regard to contractions
• Can range from mild to severe
• May be persistent or occasional
• Shaped like a “V” or “W”
• Onset variable
• Nonreassuring variable decelerations
– Repetitive and/or deep decrease in FHR
– Associated with minimal variability
– Prolonged with slow return to baseline FHR
• Possible causes:
– Cord prolapse
– Umbilical cord compression
• Intervention: AMNIOINFUSION may be performed to try to
relieve cord compression
– Infusion of warmed normal saline into uterus via sterile
catheter
– Monitor FHR, contraction status, and maternal temperature
– Verify that fluid is exiting uterus
Variable deceleration. (Top: fetal heart rate; bottom: contractions.)
INTRA-
PARTUM
INTRA-
PARTUM
Nursing Interventions for Nonreassuring FHR Patterns
■ Turn patient to side-lying position

■ Shifts weight of gravid uterus off the inferior vena cava
■ Allows for improved uteroplacental blood flow
■ O2 per mask at 8–10 L/min
■ Improve oxygen delivery to fetus
■ Discontinue IV Oxytocin
■ Decreases uterine contractions, thus improving
uteroplacental blood flow
■ Hydrate patient as indicated
■ Corrects identified maternal hypotension
■ Notify primary health-care provider
■ Document findings
■ Document baseline FHR (baseline FHR should be between
110 and 160 BPM)
■ Describe variability
■ Note changes in FHR in relation to contractions
■ Document nursing interventions, effectiveness of
interventions and notification of primary health-care
provider
Monitoring Contractions
■ Frequency
■ Beginning of one contraction to the beginning of the next
contraction
■ Documented as range, for example, “every 2–5 minutes”
■ Duration
■ Beginning of the one contraction to the end of the same
contraction
■ Documented as a range, for example, “lasting 60–90
seconds”
■ Intensity
■ Palpate uterus both during and after contraction
■ Resting tone palpated between contractions
■ Document intensity of uterine contractions (findings
subjective unless monitored with IUPC)
62
63
Intensity Palpated by nurse
Mild Fundus easily indented
Moderate Requires more pressure to indent fundus
Strong Unable to indent fundus
During contraction
Before contraction
Beginning of contraction
Beginning of contraction
Acme
t Interval
n
Dec
eme
between
contractions
re m
I n cr
nt
e
Duration of Relaxation Contraction Relaxation

contraction
Frequency of contractions
Counting contractions.
Nursing Care of the Laboring Patient

First Stage of Labor: Dilation
Divided into Three Phases: Latent, Active, Transition
INTRA-
PARTUM
INTRA-
PARTUM
First Stage
Stage 1: Latent Phase

■ Power: Contractions palpate mild, every 5–10 minutes, lasting
30–45 seconds
■ Psyche: Patient is usually excited about the start of labor
■ Measuring progress in labor: Cervical dilation (0–3 cm)
■ Passageway: Encourage frequent position changes that optimize
fetal descent, rotation, and widen pelvic outlet
■ Ambulation (with intact amniotic sac)
■ Squatting
■ Hands and knees position
■ Rocking chair
■ Side-lying
■ Check bladder status and encourage patient to void every
2 hours
■ Nursing considerations
■ Monitor vital signs every 30–60 minutes
■ Fetal heart tones every 30–60 minutes
■ Hydration
• Oral fluids as ordered
• Monitor intake and output
■ Pain management
■ Pain medication usually avoided until in active labor
■ Techniques for pain management
• Hydrotherapy
– Shower
– Labor tub
• Massage
– Effluerage: light, circular stroking of gravid abdomen
– Counter-pressure to back
• Relaxation techniques
– Progressive relaxation
– Patterned breathing
– Soft music and lighting
– Distraction
Stage 1: Active Phase

■ Power: Contractions palpate moderate to strong, every
2–5 minutes lasting 40–60 seconds
64
65
■ Psyche: Patient may have greater difficulty coping with the pain
of contractions
■ Measuring progress in labor: Cervical dilation (4–7 cm)
■ Passageway
■ Encourage frequent position changes
■ Check bladder status and encourage patient to void every
2 hours
■ Monitor vital signs every 30 minutes
■ Pain management
■ Continue with effective techniques used in latent phase
■ Systemic medications to decrease pain perception
• Document and report maternal and fetal response to
systemic medications
• Neonatal side effects related to both dose and timing of
administered medication
Systemic Pain Medications in Labor
Medication Drug Nursing

Class Action Considerations
Opioid Reduce pain Side effect: nausea and
analgesics perception vomiting
Meperidine Long-acting active metabolite,
Butorphanol may cause respiratory
fentanyl depression (in the neonate)
Nalbuphine Caution with women who are
opiate dependent, may cause
withdrawal
IV push dosing should be at the
beginning of a contraction to
limit transfer to fetus
Adjunct drugs Reduce nausea No analgesic effect
Promethazine Reduce anxiety
Hydroxyzine
Sedatives Promotes rest May have prolonged
with prolonged depressant effect on neonate
latent phase
INTRA-
PARTUM
INTRA-
PARTUM
■ Epidurals in labor
• Oxygen, suction equipment, emergency medications
should be at bedside
• Document vital signs and monitor fetal heart rate prior to
procedure
• Encourage patient to void
• Administer IV bolus prior to epidural insertion (500 cc to
1000 cc of saline or lactated Ringer’s solution) to prevent
maternal hypotension
• Position and support patient during insertion of epidural
catheter
• Note maternal vital signs before and after test dose, then
every 5 minutes with administration; thereafter, monitor
vital signs and FHR per hospital protocol
• Evaluate bladder status every hour and encourage to
void; catheterize if unable to void or bladder overdi-
stended
• Assess for level of anesthesia
• Monitor for comfort with contractions
• Monitor progress of labor
• Assist with position changes
• Report adverse effects
Hypotension
Pruritis (itching)
Pyrexia (fever)
Respiratory depression
Stage 1: Transition
■ Power: Contractions palpate strong, every 1.5–3 minutes
lasting 45–90 seconds
■ Psyche: Patient may feel a loss of control; provide encourage-
ment to patient
■ Measuring progress in labor
Cervical dilation (8–10 cm)
Fetal descent (0/1 station)
■ Physical changes common with transition
■ Urge to push if presenting part is low
■ Nausea/vomiting
■ Trembling limbs
66
67
■ Beads of sweat on upper lip
■ Increased bloody show
■ Passageway: Activity more restricted, however, encourage
positions that promote fetal rotation and descent
■ Squatting
■ Hands and knees position
■ Side-lying
■ Encourage patient to void
■ Monitor vital signs and fetal heart tones every 5–15 minutes
■ Pain management
■ Continue with effective techniques used in active phase
■ If systemic medications are given, consider amount of time
estimated until birth and potential for newborn effects
(respiratory depression)
■ Have naloxone hydrochloride (Narcan) available to reverse
effects if needed
■ Document maternal and fetal response to medications
Second Stage of Labor: Expulsion
■ 10 cm dilated until the birth of the baby

■ Power: Contractions palpate strong, every 2–3 minutes lasting
60–90 seconds
■ Psyche: Patient may be eager or afraid to push
■ Measuring progress in labor
■ Descent of fetus: from 1 station to crowning
■ Cardinal movements of labor (changes in fetal position that
facilitate birth)
• Engagement/Descent/Flexion
• Internal rotation
• Extension
• External rotation
• Expulsion
■ Passageway
■ Promote effective pushing
• Wait for urge to bear down called the “Ferguson reflex”
• Discourage prolonged breath-holding
• Encourage open glottis pushing
INTRA-
PARTUM
INTRA-
PARTUM
■ Position for pushing

• Squatting
• Side-lying
• Modified Lithotomy
Encourage patient to void
Patient may pass stool with pushing
■ Monitor vital signs every 15–30 minutes
■ Pain management per primary health-care provider
■ Pudendal block: Local anesthetic that blocks pudendal
nerve to numb lower vagina and perineum for vaginal
birth; useful with forcep delivery
■ Local anesthesia to perineum: Numbs perineum for
episiotomy/laceration repair
■ Prepare for the birth of the baby
■ Cleanse the perineum
■ Check working order of suction equipment, oxygen, radiant
warmer
■ Neonatal resuscitation equipment should be readily avail-
able for every delivery
■ Prepare delivery instruments
■ Note precise time of birth
■ Provide immediate care of the newborn
■ Assess airway and suction as needed
• Remove excess fluid from infant’s nose and mouth
(infants are obligate nose breathers)
• If meconium is noted in nose or mouth, endotracheal
intubation and suctioning must be performed imme-
diately
■ Assess breathing effort (rate of at least 30 per minute)
• If respiratory effort is not observed, gently stimulate
infant by tapping sole of foot or stroking the back
• Positive pressure ventilate if tactile stimulation does not
result in respiratory effort
■ Assess circulation: heart rate 100 BPM
■ Temperature regulation
• Dry infant
68
69
• Place infant under prewarmed radiant warmer with
temperature probe applied
• Remove wet towels and lay infant on warm blankets
• Keep temperature of labor room warm
• Once infant is stabilized, encourage skin-to-skin contact
with mother
■ Assign Apgar Score at 1 and 5 minutes
• Score of 10 possible; Score of at least 8 desirable
Apgar Score
Score 0 1 2
Heart Rate Absent Less than 100 Greater than 100
Respiratory Absent Slow, irregular Good; crying
Effort
Muscle Limp Some flexion of Active motion
Tone extremities
Reflex No response Grimace Cough, sneeze or
irritability vigorous cry
Color Blue or pale Body pink; Completely pink
extremities
blue
■ Assess for abnormalities that may need immediate

attention (example: neural tube defects, open lesions, or
birth injuries)
■ Examine umbilical cord and count number of vessels: 2
arteries and 1 vein; place plastic clamp on cord
■ Identification
• Fingerprint mother and footprint newborn
• Apply identification bands to both mother and newborn
before leaving birthing room
■ Medications
• Administer eye prophylaxis; ophthalmic antibiotic
ointment (based on hospital protocol) to prevent
chlamydial or gonococcal eye infection
• Administer vitamin K, IM to boost production of clotting
factor (needed due to sterile gut at birth)
INTRA-
PARTUM
INTRA-
PARTUM
■ Weigh and measure infant (head, chest, and abdominal

circumference as well as length)
■ Assess skin for lacerations, bruising, or edema
■ Note passage of stool/urine
Third Stage: Delivery of Placenta
■ Power: Strong uterine contractions cause the placenta to

detach from the uterine wall
■ Psyche: Patient may be exhausted; encourage bonding with
baby
■ Signs of placental separation
■ Sudden gush or trickle of blood from vagina
■ Lengthening of visible umbilical cord at introitus
■ Contraction of the uterus
■ Instruct patient to push when appropriate
■ Note time of placenta delivery
■ After placenta expelled:
• Monitor amount of bleeding
• Monitor vital signs
• Assess fundus
– Height
– Location
– Tone
■ Administer oxytocic medication as ordered
• Stimulates uterus to contract
• Prevents hemorrhage
■ Cleanse and apply ice pack to the perineum
■ Provide clean linen under patient
■ Provide warm blanket: patients often tremble/shiver
immediately after the birth
■ Assess level of consciousness/comfort
■ Place newborn in arm of mother, encouraging skin-to-skin
contact
■ Assist with positioning for breastfeeding and bonding
70
71
Nursing Care with Intrapartum Procedures
Induction of Labor
■ Artificial stimulation of uterine contractions to facilitate vaginal

delivery
■ Commonly performed in postterm pregnancy
■ Prior to induction of labor the nurse should note
■ Indication for induction
■ Gestational age
■ Bishop’s score
■ Any contraindications for procedure
■ Bishop’s Score
■ Assigned by primary health-care provider prior to
induction of labor
■ Higher scores indicate increased likelihood of successful labor
induction
■ Parameters of Bishop’s score
• Degree of Dilation (1–3 points)
• Percent of Effacement (0–3 points)
• Station (0–2 points)
• Consistency of cervix (0–2 points)
• Cervical position (0–2 points)
■ Use of Oxytocin (Pitocin): Hormone that stimulates uterine
contractions to induce or augment contractions
■ Assess mother and fetus 20–30 minutes prior to oxytocin
administration
■ Prepare and clearly label solution
• 10 units of Pitocin into 500–1000 ml of isotonic IV solution
• Administer IV piggyback per electronic infusion pump
• Started at small dose and gradually increased until
contractions every 2–3 minutes (follow hospital protocol)
■ Monitor maternal-fetal tolerance to procedure
• Uterine resting tone
• Contraction frequency, duration, and intensity
• Intake and output
• Fetal heart tones (baseline, variability, changes)
• Cervical dilation and effacement
• Vital signs
• Patient comfort
INTRA-
PARTUM
INTRA-
PARTUM
■ Monitor for complications of oxytocin (may become evident

as dosage increases)
• Uterine hyperstimulation (excessive frequency/duration of
contractions without uterine relaxation)
• Nonreassuring fetal heart rate patterns
• If complications become apparent:
– Change position to lateral side-lying
– Discontinue IV oxytocin
– Provide oxygen per mask at 8–10L/min
– Increase rate of nonadditive IV solution
– Call primary health-care provider
■ Cervical Ripening
■ Facilitates cervical softening, effacement, and dilation
■ Indicated when there is a medical need for induction of labor
and cervix unfavorable
■ Methods:
• Laminaria tents (mechanical cervical dilator made from
seaweed)
• Prostaglandin E1-misoprostol (Cytotec)
• Prostaglandin E2-dinoprostone (Cervidil Insert, Prepidil Gel)
■ Nursing care
• Monitor fetal heart rate and contraction status for 20–30
minutes prior to procedure
• Encourage patient to void prior to insertion
• Position side-lying position after procedure
• Monitoring maternal vital signs, contractions, and fetal
status (per hospital protocol)
• Report adverse reactions to physician
– Hyperstimulation of uterus
– Nonreassuring fetal heart tones
– Nausea, vomiting, diarrhea
• Ensure proper waiting period between cervical ripening and
Oxytocin administration
■ Amniotomy
■ Artificial rupture of amniotic sac performed by the primary
health-care provider during a vaginal exam to augment
contraction frequency and intensity
■ Nursing care
• Pad bed to absorb amniotic fluid
• Document time of amniotomy
72
73
• Document fetal heart tones immediately following
amniotomy
• Note color and amount of amniotic fluid
• Document cervical dilation, effacement, station, and
fetal presentation
• If presenting part is not engaged, limit patient activity to
prevent cord prolapse
• Once amniotic sac is ruptured, there is potential for
infection
– Monitor maternal temperature every 1–2 hours
– Limit number of vaginal exams
Vaginal Birth After Cesarean (VBAC)
■ Women who have had a previous cesarean birth may be

candidates for vaginal birth
■ Previous cesarean uterine incision documented as low-
transverse
■ No contraindications noted to VBAC
■ Physician and surgical team readily available for emergent
cesarean birth
■ Patient and physician agree that VBAC is desirable
■ Risks of vaginal birth following cesarean must be explained,
including
■ Uterine rupture with possible loss of fetus or uterus
■ Unsuccessful trial of labor with subsequent cesarean
■ Location of previous uterine scar must be documented
Low Transverse Low Vertical Classic
Uterine scars.
INTRA-
PARTUM
INTRA-
PARTUM
■ Nursing care
■ Closely monitor uterine response to labor
■ Monitor fetal response to labor
■ Initiate IV access
■ Monitor for signs of uterine rupture
• Severe abdominal pain
• Nonreassuring fetal heart rate patterns
• Cessation of uterine contractions
• Ascending station of presenting part
• Vaginal bleeding
• Signs of shock
Complications in the Intrapartum Period

Prolapsed Umbilical Cord
■ Umbilical cord slips below/wedges next to presenting part

■ May lead to fetal hypoxia due to cord compression
■ Possible cause
■ Rupture of membranes without engaged presenting part
■ Non-cephalic fetal presentation
■ Symptoms
■ Prolonged variable deceleration
■ Pulsating cord palpated upon vaginal exam
■ Visible cord at introitus
■ Nursing actions
■ Stay with patient and call for assistance
■ Apply sterile glove and hold pressure of presenting part off
umbilical cord
■ Place patient in Trendelenburg position
■ Notify physician
■ Monitor fetal heart tones
■ Place sterile saline gauze over any exposed cord
■ Prepare patient for cesarean birth
74
75
Cesarean Birth
■ Indications for cesarean birth

■ Cephalopelvic disproportion (CPD)
■ Malpresentations
■ Placenta previa/abruption
■ Umbilical cord prolapse
■ Fetal intolerance to labor
■ Maternal medical conditions
■ Preoperative Care
■ Place signed consent on chart
■ Insert urinary catheter
■ Shave prep to the abdomen
■ Remove contact lenses, nail polish, jewelry, prosthetic
device, dentures
■ Perform preoperative teaching
■ Assist significant other to prepare for observation of
surgery
■ Administer preoperative medications
■ Continue to monitor vital signs and fetal heart rate
■ Postoperative care
■ Assess respiratory/cardiac status
■ Encourage patient to turn cough and deep breath
■ Assess level of pain and medication needs
■ Assess bowel sounds
■ Assess incision
■ Monitor vaginal bleeding and provide pericare
■ Assess vital signs and level of consciousness
■ Assess extremities for circulation
■ Assist with positioning for breastfeeding and holding baby
INTRA-
PARTUM
POST-
PARTUM
Postpartum
Fourth Stage of Labor
First 1–2 hours after birth
Immediate Nursing Care
■ Assess height, location, and tone of the fundus (upper portion

of the uterus)
■ Note amount and consistency of vaginal bleeding
■ Cleanse and apply ice pack to the perineum
■ Provide clean linen under patient
■ Provide warm blanket: patients often tremble/shiver imme-
diately after the birth
■ Assess level of consciousness/comfort
■ Encourage bonding of mother and infant
■ Assist with proper latch-on to initiate breastfeeding
■ Maintain IV fluids and additives as ordered
■ Oxytocic medications
• Promote uterine contractions
• Decrease amount of vaginal blood loss
Nursing Assessment of the Postpartum Patient
■ Assess every 15 minutes for the first hour

■ Assess every 30 minutes for the second hour
■ Assess every 4 hours for the first 24 hours
■ Uterine tone
■ Bleeding
■ Perineum
■ Bladder status
■ Vital signs
• Blood pressure
• Pulse
• Respiration
• Temperature every 1–4 hours
76
77
■ Fluid balance
■ Circulation to extremities
■ Comfort/level of consciousness
■ Newborn interaction
Postpartum Education
■ Education of the postpartum family is an essential role of the

postpartum nurse
■ New skills should be discussed, demonstrated, and reinforced
■ Document education and validate knowledge through
verbalization and/or return demonstration
Postpartum Assessment and Nursing Care

Remember the acronym BUBBLE
B breasts
U uterus
B bowel
B bladder
L lochia
E episiotomy
Breast assessment
■ Consistency: soft, filling, or firm

■ Nipple type and integrity
■ Type: Inverted or everted
■ Integrity: Bleeding, cracked, intact
■ Redness
■ Comfort
■ Breast care (lactating)
■ Patient should wear a supportive bra
• Montgomery glands secrete oil to keep nipples supple;
soap should not be used on breasts
• After feedings, leave colostrum/breast milk on nipples
and expose the breasts to air
POST-
PARTUM
POST-
PARTUM
■ Encourage frequent nursing (8–12 feedings in 24 hours)

■ Teach positioning of infant for increased comfort
• Side-lying
• Football hold
• Cradle hold
Breastfeeding positions. (Used with permission from Ross Products

Division Abbott Laboratories Inc.)
78
79
■ Instruct on proper latch-on
• Elicit the rooting reflex by stroking the infant’s lower lip
• As the infant’s mouth opens wide, bring the infant to the
breast, ensuring both the nipple and part of the areola
are in the infant’s mouth
• Correct latch-on: infant’s jaws will rhythmically move
with an audible swallow; mother will express comfort
• Incorrect latch-on: clicking noise as infant sucks with
nipple pain expressed by mother; break suction by
placing one finger by the infant’s mouth and relatch
Latch-on. (Used with permission from Ross Products Division Abbott

Laboratories Inc.)
■ If separated from newborn, initiate breast pump

■ Breast care (nonlactating)
■ Supportive bra, breast binder or sports bra
■ No nipple stimulation
■ Do not express breast milk
■ Ice packs/analgesics for engorgement
■ Teach breast self exam (BSE)
POST-
PARTUM
POST-
PARTUM
TEACHING TIPS: BREASTFEEDING

Advantages to Breastfeeding
■ Cost
■ Convenience
■ Immunoglobulins, which protect the infant from infection, are
passed via breast milk
■ Decreased incidence of infant:
■ Allergies
■ Otitis media
■ Upper respiratory infections
Positioning
■ The infant’s body should face the breast, with the ear,
shoulder, and hip aligned
■ Position pillows to support the weight of the infant
■ Demonstrate positions for breastfeeding
Supply and Demand

■ The newborn should be fed on demand; prolactin release in
response to suckling will stimulate the alveolar cells of the
breast to produce the appropriate amount of milk to meet the
infant’s needs
■ The mother should initiate breastfeeding when the infant
demonstrates hunger cues:
■ Increased alertness or activity
■ Smacking of the lips
■ Suckling motion
■ Moving of the head in search of the breast
■ Continue to feed until the infant detaches spontaneously, burp
the infant, and continue feeding on the other breast
■ Start breastfeeding on the breast ended with the last feeding
■ Unless medically indicated, supplemental feeding should be
avoided
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81
Engorgement (Firm, tender breasts)
■ May occur on postpartum day 3–5, when the volume of breast
milk increases
■ Prevent engorgement with frequent feedings; avoid skipping
any feedings
■ Treatment for engorgement
■ Express a small amount of breast milk either manually or
with a breast pump so that the breasts will soften and the
baby can latch
■ Apply cold packs to breasts intermittently
■ Apply cleaned, cooled cabbage leaves to breasts until
warm/wilted
■ Warm shower or warm compress right before feeding
Nutrition
■ Add 500 calories over nonpregnant diet
■ Continue prenatal vitamins
■ Stay well hydrated
■ Avoid alcohol, smoking, or recreational drugs
■ Consult with pediatrician before using any over-the-counter or
prescription medication
Pumping and Storing
■ Demonstrate use of breast pump
■ Discuss appropriate storage containers
■ Write the date of expression on storage container and use
oldest milk first
■ Length of storage dependent on location
Location Guideline
Room temperature Up to 8 hours
Refrigerator 3–5 days
Refrigerator freezer (with separate door) 3 months
Deep freeze 6–12 months
POST-
PARTUM
POST-
PARTUM
Weaning
■ Gradual weaning suggested to decrease the likelihood of
engorgement
■ Remove one feeding per week
■ If infant is less than 1 year, infant formula, instead of cow’s
milk, must be given
Breast Care
■ Breast pads inside a supportive bra will collect leaking breast
milk
■ Teach signs of mastitis
■ Unilateral breast pain, warmth and redness
■ Malaise and flu-like symptoms
■ Fever
Breastfeeding Concerns
■ Mother should report breastfeeding concerns to the primary
healthcare provider
■ Feedings that are consistently short with the infant
appearing hungry after feedings and the breasts remaining
full
■ Swallowing is inaudible once milk is established
■ The infant is not gaining the expected amount of weight
■ The infant has fewer than 6 wet diapers a day; urine is
amber-colored
■ Nipple pain or cracking is present
Community Resources
■ Lactation consultant
■ La Leche League
■ Primary health-care provider
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83
Uterus
■ Uterine Involution
■ Process by which the size of uterus decreases in a
predictable pattern
■ Documented in fingerbreadths above or below the
umbilicus
Postpartum Period Level of the Fundus Documentation

Immediately after at the umbilicus at U or U/U
birth
12 hours 1 fingerbreadth (FB) 1/U
above the umbilicus
24 hours 1 FB below the umbilicus U/1
Day 2 2 FB below the umbilicus U/2
Day 3 3 FB below the umbilicus U/3
U Umbilicus
■ Measures that promote uterine involution

• Breastfeeding
• Voiding
• Fundal massage
• Oxytoxic medications
Fundal massage.
POST-
PARTUM
POST-
PARTUM
Assess the tone, height, and location of the fundus

■ TONE of the uterus assessed while patient is supine
■ Fundus should be firmly contracted
■ If fundus is not firm, perform fundal massage
■ Support the lower uterine segment during massage to
prevent inversion of the uterus
■ If fundus is boggy (not firm) after massage:
• Check bladder status and encourage voiding
• Catheterize (as ordered) if unable to void
• Notify primary care provider
■ Assess the HEIGHT and LOCATION of the uterus in relation
to the umbilicus
• Immediately after birth, fundus is located at or just above
the umbilicus
• The fundus should be midline and not deviated to the left
or right
Uterine involution. (From Dillon PM. (2003). Nursing Health Assessment:

A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis,
p. 744.)
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TEACHING TIPS: UTERINE/VAGINAL CHANGES
The Fundus
■ The fundus lowers one fingerbreadth below the umbilicus
each day until returning to pelvis (day 10–14)
Normal Progression of Lochia
■ Lochia progresses from bright red to brown to light pink with
decreasing amount
■ If lochia returns to bright red or increases in amount, decrease
activity
■ Persistent bright red lochia or lochia with a foul odor should
be reported
■ Report saturating one pad per hour or passing golf-ball size
clots
Return of the Menstrual Cycle
■ Dependent on method of infant feeding
■ If breastfeeding, lactation amenorrhea while exclusively
breastfeeding infant (first 6 months)
■ If bottle feeding, menses usually returns 6–8 weeks
postdelivery
Sexuality
■ Sexual intercourse may be resumed after lochia ceased and
episiotomy healed; 4–6 week delay generally recommended
■ Vaginal lubrication may be diminished; use water-soluble gel
■ Female superior or side-lying position may assist in comfort
■ Discuss family planning methods
POST-
PARTUM
POST-
PARTUM
Bladder Status
■ Postpartum women may have difficulty voiding after birth

due to:
■ Decreased urethral sensation from pressure exerted by the
passage of the fetus
■ Side effects of local/epidural anesthesia
■ Delivery trauma to the perineum
■ Palpate for bladder distention
■ Track fluid balance: intake and output
■ Assess for periurethral edema/trauma
■ Postpartum diuresis, which occurs in response to decrease in
estrogen, helps rid the body of extracellular fluid and causes
the bladder to fill quickly
■ Starts within 12 hours of birth and continues for up to 5
days
■ Urine output may be 3,000 cc/day
■ Catheterization may be necessary if unable to void or with
urinary retention
Bowel
■ Auscultate for bowel sounds

■ Assess for abdominal distention
■ Assess for presence/status of hemorrhoids
■ Educate on prevention of constipation
■ Increased roughage in the diet
■ Increased oral intake of fluids
■ Temporary use of prescribed stool softeners
Lochia
■ Vaginal discharge after delivery called lochia

■ Blood loss with vaginal birth approximately 500 cc
■ Blood loss with cesarean birth approximately 1000 cc
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■ Assess the amount of lochia
■ Note time of last perineal pad change
■ Document amount of lochia on perineal pad (scant, small,
moderate, large)
• If weighing perineal pads, 1 gm 1 ml of blood loss
■ Assess the color of lochia
• Lochia rubra (red): day 1–3
• Lochia serosa (brownish-pink): day 4–9
• Lochia alba (yellow-white): day 10–14
■ Document number and size of blood clots
■ Turn patient to assess blood loss under buttocks
Assessment of the Perineum
Requires a direct light source and positioning of the patient in

side-lying with top leg forward
■ Assess Episiotomy or laceration
■ Redness
■ Swelling
■ Ecchymosis
■ Color, consistency of discharge
■ Approximated edges
■ Lacerations described by degree of tissue involvement
Degree Definition
1st Vaginal mucous membrane and skin of
perineum
2nd Subcutaneous tissue of the perineal body
3rd Involves fibers of the external rectal
sphincter
4th Through rectal sphincter exposing the
lumen of the rectum
■ No enemas or rectal suppositories should be used with 3rd
and 4th degree lacerations
POST-
PARTUM
POST-
PARTUM
TEACHING TIPS: PERINEAL HYGIENE

Perineal Cleansing
■ Stress importance of hand washing before and after perineal
care
■ Demonstrate use of perineal cleansing bottle
■ Change perineal pads after each void
■ Keep perineal pad/underwear from touching floor
Comfort Measures
■ Apply perineal ice packs intermittently for the first 24 hours
after birth
■ Sitz baths may be ordered after 24 hours
■ Apply creams, sprays, and ointments to perineum as ordered
■ Discuss bowel habits and steps to avoid constipation
Kegel Exercises
■ Encourage patient to perform Kegel exercises throughout the
day to strengthen perineal muscle tone
■ To locate muscle, tighten perineal muscles as though stop-
ping the flow of urine (this technique is only used to locate
the muscles, not to perform the exercise)
■ Hold contraction for several seconds, release, and repeat
10–15 times; discourage breath-holding
Emotional Response
■ Assess interaction with newborn

■ Eye contact with infant
■ Talks to infant
■ Holds infant close
■ Feeds infant
■ Assess emotional status
■ Assess for postpartum blues
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TEACHING TIPS: EMOTIONS
Postpartum Blues
■ Symptoms of postpartum blues include tearfulness, insomnia,
and moodiness
■ Postpartum blues common in the early postpartum period
■ Duration less than 2 weeks
■ Possible cause
■ Hormonal changes after birth
■ Exhaustion
■ Physical discomfort
Emotional Support
■ Encourage patient to discuss feelings
■ Encourage private time when baby naps
■ Discuss the difference between “blues” and depression;
encourage patient to report symptoms of postpartum
depression
■ Extreme or unswerving sadness
■ Compulsive thoughts
■ Feelings of inadequacy
■ Inability to care for infant and/or self
■ Suicidal thoughts
Extremities
■ Assess circulation to lower extremities

■ Pedal pulse
■ Color, temperature, blanching
■ Assess for signs of deep vein thrombosis
■ Pain
■ Swelling
■ Redness
■ Increased skin temperature
POST-
PARTUM
POST-
PARTUM
TEACHING TIPS: ACTIVITY

Activity Level
■ Frequent rest periods will help with healing of body and mind
(nap when baby sleeps)
■ Do not lift anything heavier than the baby
■ Limit activities to care of newborn/self
■ Ask for assistance with housework/shopping
Vital Signs
■ Temperature
■ Slight increase in temperature in first 24 hours common
due to dehydration; encourage oral fluids
■ If temperature 100.4F call physician
■ Pulse: assess rate, rhythm, and amplitude
■ Blood pressure
■ Watch for signs of shock (↓ blood pressure and ↑ pulse)
■ Be alert for orthostatic hypotension upon rising
■ Dangle at bedside before rising
■ Respirations:
■ Note rate and depth
■ Lungs should be clear on auscultation
Level of Comfort
■ Pain location and intensity

■ Afterbirth cramps: intense contractions of the uterus that
are more intense with multiparity and occur with nursing
■ Incisional pain
■ Hemorrhoid pain
■ Postpartum diaphoresis: intense sweating that occurs in the
early postpartum period ridding the body of excess fluid
■ Effects of epidural anesthesia
■ Leg movement/strength
■ Presence of numbness and tingling
■ Assist with ambulation
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Nutrition
■ Assess dietary needs and concerns

■ Average weight loss 12 pounds at birth
Laboratory Data
■ Examine postpartum laboratory findings and compare to

prenatal levels (usually drawn at 24 hours postpartum)
■ Hemoglobin/hematocrit
■ White blood cell count
■ Platelet count
■ If mother is RH negative check Rh status of infant
Mother Infant Rho(D) Immune globulin (300 g)

Negative Negative No treatment needed
Negative Positive Administer within 72 hours of birth
Cesarean Birth
In addition to routine postpartum assessment, the nurse should

assess the following
■ Effects of anesthesia
■ Level of consciousness
■ Ability to hold and care for infant may be limited due to
• Comfort level
• Limitation in movement
■ Respiratory status
• Pulse oximetry
Patient Controlled Anesthesia (PCA)
■ Effectiveness
■ Number of attempts/amount given
■ Side effects
Abdominal Assessment
■ Bowel sounds
POST-
PARTUM
POST-
PARTUM
■ Abdominal distention
■ Ability to pass flatus
■ Avoid straws and carbonated beverages
■ Incision/dressing
■ Circle drainage and mark with date and time
■ Assess incision with dressing change
• Approximation
• Redness
• Drainage
• Edema
• Hematoma
• Odor
Nutrition
■ Intake and output
■ Nausea/vomiting
■ Presence of bowel sounds
■ Progression of diet
Progression of Activity
■ Turn/cough/deep breathe
■ Dangle at side of bed
■ Sit up in chair
■ Ambulate with assist
Complications in the Postpartum Period

Hemorrhage
■ Risk factors
■ High parity
■ Overdistention of the uterus
■ Precipitous labor or prolonged labor
■ Medications (oxytocin, magnesium sulfate)
■ Etiology
■ Uterine atony (hypotonia of the uterus)
■ Retained placental fragments
■ Vaginal/cervical laceration
■ Hematoma
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■ Clinical findings
■ Perineal pad saturated in less than 1 hour
■ Continuous trickle of vaginal bleeding
■ Firm, bruised area on perineum
■ Interventions
■ Fundal massage
■ Monitor urine output
• Check bladder status
• Catheterize if needed
■ Increase mainline IV fluids
■ Closely monitor vital signs
■ Administer oxygen
■ Call primary health-care provider
• May need suturing of laceration
• May need evacuation of hematoma
• May need evacuation of placental fragments
■ Administer medications that promote uterine contraction as
ordered
■ Oxytocin
■ Methylergonovine maleate (Methergine)
• If blood pressure 140/90, hold and call primary care
provider
■ Ergonovine maleate (Ergotrate)
■ Prostaglandin F2a (Prostin/Hemabate)
Infection
■ Symptoms
■ Temperature elevation 100.4F
■ Elevated white blood cell count
■ Complaint of chills and aching
■ Malaise
■ Interventions
■ Obtain culture of discharge as ordered
■ Report abnormal laboratory findings
■ Administer antibiotic therapy as ordered
■ Consider medications contraindicated for breastfeeding
■ Monitor temperature
■ Clean and monitor site
■ Teach patient reportable signs and symptoms
POST-
PARTUM
POST-
PARTUM
■ Endometritis (uterine infection)

■ Contributing factors
• Operative birth
• Long labor with multiple vaginal exams
• Internal monitoring
• Premature rupture of membranes
• Manual removal of placenta
• Subinvolution of the uterus
• Foul-smelling vaginal discharge
• Lower abdominal cramping
■ Mastitis (breast infection)
• Alteration in nipple integrity
• Delayed emptying of breast milk
• Unilateral breast pain, warmth and redness
• Malaise and flu-like symptoms
■ Incisional infection
• Inadequate care of incision
• Operative delivery
• Laceration
• Incision not well approximated
• Incision red with purulent drainage
■ Urinary tract infection
• Catheterization of bladder
• Retention of urine in bladder
• Dysuria
• Frequency of urination
• Flank pain
Postpartum Depression
■ Risk factors
■ History of depression or anxiety disorder
■ Prenatal depression
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■ Inadequate social or partner support
■ Large number of life stressors
■ Symptoms extend beyond 2 weeks postpartum; may occur
3–12 months after birth
■ Interventions
■ Psychotherapy
■ Medications
Thrombophlebitis/Deep Vein Thrombosis

■ Risk factors
■ Varicosities
■ Advanced maternal age
■ Obesity
■ Long periods of bed rest
■ Occupation that requires long periods of standing
■ Clotting disorder
■ Etiology
■ Increased clotting factors in postpartum period
■ Infection in the vessel lining to which a clot attaches
■ Pain with dorsiflexion
■ Affected site hot to touch
■ Swelling, redness, and pain to affected leg
■ Interventions dependent on severity of findings
■ Administer anticoagulants
■ Monitor coagulation profile
■ Compression stockings
■ Apply warm, moist heat
■ Rest
■ Observe for symptoms of pulmonary embolism
• Dyspnea
• Chest pain
• Hemoptysis
• Patient fearful
POST-
PARTUM
POST-
PARTUM
TEACHING TIPS: POSTPARTUM COMPLICATIONS

Teach the patient to report the following signs and symptoms to
the primary health-care provider.
Signs of infection
■ Elevated temperature
■ Localized redness or pain to either breast
■ Persistent abdominal tenderness
■ Persistent pain to perineum
■ Burning, frequency, or urgency of urination
■ Foul odor to lochia
■ Redness, pain, or discharge at incision
Sign of Uterine Subinvolution
■ Change in the character of lochia
■ Increased amount of lochia
■ Resumption of bright red color
■ Presence of clots
Signs of Thrombophlebitis/Deep Vein Thrombosis
■ Pain, increased temperature and redness to legs
Signs of Postpartum Depression
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Nursery Care of the Newborn
■ Keep infant warm during all care and procedures
■ Assess and record daily weight
■ Role model back sleeping
■ Keep bulb syringe at bedside
■ Check identification bands at each encounter with parents
Physical Assessment of the Newborn

Reportable findings in red
Vital Signs
■ Axillary temperature 97.8–98.6F
■ Decreased body temperature may be a sign of sepsis
■ Auscultate apical pulse for one full minute
■ 110–160 beats per minute
■ Sustained resting heart rate below 100 or above 160
■ Respirations counted for one full minute
■ 30–60 per minute
■ Sustained resting respiratory rate below 30 or above 60
Extremities/Activity
■ Newborn posture flexed
■ Extremities equal length with full range of spontaneous
motion
■ Gluteal folds even
■ Ten fingers and 10 toes without webbing (syndactyly) or extra
digit (polydactyly)
■ Grasp reflex intact
■ REPORT
■ Poor muscle tone or asymmetry of muscle tone
■ Failure to spontaneously move all extremities or decreased
range of motion
■ Chewing type mouth movements combined with noticeable
changes in eye and/or body movements (may represent
neonatal seizure activity)
■ Unequal knee height, leg length, or asymmetrical gluteal
folds (hip dysplasia)
■ Resistance to neck flexion
POST-
PARTUM
POST-
PARTUM
TEACHING TIPS: NORMAL NEWBORN BEHAVIOR

Pattern of Sleep
■ Newborns sleep in short periods for a total of 13–16 hours per
day
■ Lying the baby on the back for sleep is recommended
Communication
■ Crying is a means of communication and a late sign of hunger
■ Teach parents hunger cues
■ Teach techniques for comforting the fed newborn
■ Swaddling
■ Burping
■ Massage
■ Soft music
■ Diaper change
■ Gentle rocking
■ Encourage parents to talk, sing and hold newborn close
Skin
■ Color uniformly pink
■ Normal variations
■ Acrocyanosis (bluish hue to hands/feet)
■ Milia (plugged sebaceous glands on nose)
■ Lanugo (downy hair on arms, back, face)
■ Mongolian spot (area of increased pigmentation, resembles
bruise)
■ Telangiectases “stork bites”
■ Erythema toxicum (newborn rash)
■ REPORT
■ Cyanosis (other than in hands and feet)
■ Skin lesions, bruises, abrasions
■ Jaundice
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TEACHING TIPS: SKIN CARE AND BATHING
■ Sponge baths recommended until the umbilical cord stump has
fallen off and circumcision has healed
■ Stay with baby and hold securely at all times when bathing
■ All supplies should be within easy reach
■ No soap is needed on the face
■ The eye area can be cleansed with wet cotton balls (inner to
outer canthus)
■ Only soap recommended for newborn skin should be used
■ Dry the baby quickly to avoid chilling
■ Wash hair last to avoid heat loss
■ Encourage frequent diaper changes
■ Cleanse genital area with mild soap and water
■ Cleanse the female genitalia from front to back
■ Do not forcibly retract the foreskin of uncircumcised boys
Head
■ Head round with slight molding (cone-shaped with overriding
cranial bones) or caput succedaneum (tissue edema that crosses
suture lines)
■ Anterior and posterior fontanels (soft spots) flat
■ REPORT
■ Sunken or bulging fontanels when infant is at rest
■ Cephalhematoma, unilateral swelling of scalp tissue caused
by collection of blood between the skull and periosteum
Face
■ Face symmetrical with rest and crying
■ Eyes symmetrical in size and shape with intact red and corneal
reflex
■ Nose midline with nares patent
■ Ears aligned with outer canthus of eyes; pinna well-formed and
hearing intact
■ Oral mucosa pink and moist; tongue mobile
■ Hard and soft palate intact
■ Strong suck; able to coordinate suck and swallow
■ REPORT
■ Absence of red reflex
■ Purulent discharge of eyes immediately after birth
POST-
PARTUM
POST-
PARTUM
■ Low set ears

■ Lack of response to sound
■ Nasal flaring
■ Cleft lip or palate
■ Large, protruding tongue (possible Down syndrome)
■ White patches in mouth (Candidiasis)
■ Absent rooting, suck, or Moro reflex
■ Severe drooling and/or coughing or gagging
TEACHING TIPS: BOTTLE FEEDING

Types of Formula
Directions for dilution of formula on the container must be
followed exactly to ensure adequate infant health and nutrition
■ Ready-to-feed
■ Most expensive, but most convenient
■ Use without dilution
■ Opened cans can be stored in the refrigerator for 48 hours
■ Concentrated
■ Dilute with equal parts of water
■ Prepare enough bottles for the day
■ Prepared bottles can be stored in refrigerator for 48 hours
■ Powdered
■ Least expensive
■ Add water for every one scoop of powder per manu-
facturer’s instructions
■ Shake well to distribute powder
Formula Preparation
■ Clean off can with soap and water before opening
■ If water supply questionable, use bottled nursery water
■ Prepared bottles can be fed at room temperature; run
refrigerated bottles under warm water to bring to room
temperature
■ Avoid use of microwave for heating formula
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Bottle Preparation
■ Bottles should be washed with a brush and rinsed thoroughly;
if water supply is questionable, sterilization recommended
■ Choose nipples that allow a steady flow of formula but not so
large as to cause choking
Technique for Feeding
■ Encourage parents to hold the baby close and talk to the
infant during feedings
■ Do not prop bottles
■ On-demand feeding recommended/watch baby for hunger
cues (usually every 3–4 hours)
■ Increased alertness or activity
■ Smacking of the lips
■ Suckling motion
■ Moving of the head in search of the breast
■ Newborns generally drink about 0.5–2 ounces of formula per
feeding for the first several days of life
■ Elicit the rooting reflex to initiate feeding
■ Keep bottle tipped to ensure the nipple remains full of
formula
■ Burp every 1–2 ounces
■ The type, amount and pattern of feedings should be dis-
cussed with the pediatrician before hospital discharge
■ Formula remaining in the bottle must be discarded
Chest
■ Respirations unlabored
■ Chest rises and falls symmetrically
■ Lung sounds clear bilaterally
■ Clavicals intact
■ REPORT
■ Nasal flaring, chest retractions, or expiratory grunting
■ Asymmetrical breath sounds
■ Chest asymmetrical or circumference greater than head
circumference
■ Loud cardiac murmur with thrill
POST-
PARTUM
POST-
PARTUM
Abdomen/Genitals
■ Abdomen round and soft without palpable masses
■ Three vessel umbilical cord with drying base
■ Bowel sounds present
■ First void within 24 hours (may be rust-stained from uric acid
crystals)
■ Meconium stool passed within 24 hours
■ Female genitalia
■ Labia majora covers minora
■ May have mucoid vaginal discharge or pseudomenses
■ Male genitalia
■ Urinary meatus at tip of penis
■ Testes descended
■ REPORT
■ Drainage of urine or feces from umbilicus
■ Liver more than 3 cm below right costal margin
■ Abdomen markedly distended or flat
■ Palpable abdominal mass
■ Visible peristaltic waves
■ Poor feeding or excessive spitting or vomiting
■ Failure to urinate or pass meconium within 24 hours
■ Hypospadias or epispadias
■ Mass in scrotal or inguinal area
■ Imperforate anus
TEACHING TIPS: NEWBORN CARE

Umbilical Cord Care
■ The cord will fall off spontaneously in 10–14 days; do not tug
at cord
■ Cleanse cord insertion site at diaper changes
■ Fan fold diaper to expose cord to air
■ REPORT redness, drainage, bleeding, foul odor from cord
Circumcision
■ Site may be covered with petroleum gauze dressing; tell parents
when to remove dressing
■ Clean area with warm water for diaper change
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■ Apply petroleum jelly to head of penis to decrease friction
with diaper
■ A yellow exudate forms on the head of the penis on day 2–3;
this is part of the healing process and removal should not be
attempted
■ Reportable symptoms
■ Difficulty urinating
■ Persistent bleeding from the site
■ Pus oozing from the site
■ Redness or swelling
Back
■ Spine straight, intact, and easily flexed
■ REPORT
■ Arched back
■ Tuft of hair on spine
TEACHING TIPS: SAFETY, HEALTH MAINTENANCE

Safety
■ Discuss choking hazards and demonstrate the proper use of
the bulb syringe
■ Properly installed car seats must be consistently used with
safety straps on
■ Crib mattress should be firm and fit snugly; crib slats should
be no more than 2 3/8” apart
■ Never leave baby unattended on household furniture other
than crib
■ Test bath water and formula temperature to prevent burns
■ Shield skin from excessive sun exposure
■ Supervise pets around the baby
■ Reduce the risk of Sudden Infant Death Syndrome (SIDS)
■ Back sleeping recommended
■ Avoid pillows and stuffed toys in the crib
■ Use firm, well-fit mattress
■ No smoking around baby
■ Dress baby for comfort; do not overheat
POST-
PARTUM
POST-
PARTUM
Immunizations
■ Discuss importance of immunizations for disease prevention
■ Provide current schedule of recommended childhood
immunizations
■ Provide documentation of any immunization given in the
hospital
Neonatal Genetic and Hearing Screen
■ Blood test for metabolic defects are performed on all new-
borns after feeding is established
■ Exact tests vary by state
■ Infants who are discharged early may need to be brought
back for newborn screen
■ Hearing screen done before hospital discharge for early
identification of hearing deficits
Reportable Symptoms
■ Parents should call the pediatrician with the following signs or
any time they are concerned with their newborn’s behavior
■ Difficulty breathing
■ Vomiting or diarrhea
■ Less than expected voids/stools
■ Yellow hue to the skin or sclera
■ Constant crying
■ Difficulty awakening baby
■ Altered temperature
■ Body rash
■ Lack of interest in eating
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Peds Basics
Common Developmental Milestones (ages are aproximate)
0–6 mo
■ Physical
■ Ht ↑ 1 in/mo
■ Doubles wt by 5–6 mo
■ Wt ↑ 1.5 lb/mo
■ HC ↑ 0.5 in/mo
■ Gross/Fine Motor
■ Rolls back to side: 3 mo
■ Holds head erect: 4 mo
■ Voluntary grasp: 5 mo
■ Rolls from front to back: 5–6 mo
■ Language
■ Coos: 1–2 mo
■ Laughs: 2–4 mo
■ Makes consonant sounds: 3–4 mo
■ Imitative sounds: 6 mo
■ Personal-Social
■ Regards a person’s face: 1 mo
■ Displays social smile and follows object 180 degrees: 2 mo
■ Recognizes familiar faces: 3 mo
■ Stranger anxiety begins: 6 mo
6–12 mo
■ Physical
■ Ht ↑ 50% of birth ht by 1 yr
■ Wt ↑ 1 lb/mo
■ Triples wt by 1 yr
■ HC ↑ by 33%
■ Chest circumference 1 in HC
■ Post fontanel closes: 2–3 mo
■ Ant. fontanel closes: 12–18 mo
■ Central incisors erupt: 5–7 mo
■ Holds head erect: 4 mo
■ Grasps voluntarily: 5 mo
PEDS
BASICS
PEDS
BASICS
■ Begins to crawl: 7 mo
■ Sits unsupported: 8 mo
■ Pulls up to stand: 9 mo
■ Drinks from cup: 9 mo
■ Pincer grasp: 8–10 mo
■ Builds two-block tower: 12 mo
■ Walks alone or holding onto one hand: 12 mo
■ Language
■ Pronounces syllables (da-da, ma-ma) : 8 mo
■ Says 4–10 words: 12 mo
■ Personal-Social
■ Marked stranger anxiety: 8 mo
■ Emotions such as jealously: 12 mo
1–3 yr
■ Physical
■ Ht ↑ 3 in/yr
■ Wt ↑ 5 lb/yr
■ Weighs about 4 times birth wt: 2 yr
■ HC equals chest circumference: 1–2 yr
■ HC ↑ 1 in during 2 yr
■ 10–14 temporary teeth
■ Walks without help: 15 mo
■ Walks up and down stairs placing both feet on each step:
24 mo
■ Scribbles spontaneously: 15 mo
■ Builds 3–4 block tower: 18 mo
■ Jumps with both feet: 30 mo
■ Language
■ Says 300 words: 2yr
■ Uses 2–3 word phrases and pronouns
■ Understands speech: 2 yr
■ States first and last name: 2.5 yr
■ Personal-Social
■ Separation anxiety peaks
■ Ritualism
■ Negativism
■ Independence
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3–6 yr
■ Physicial
■ Ht ↑ 2.5–3 in/yr
■ Wt ↑ 4–6 lb/yr
■ HC ↑ 0.5 in/yr
■ Vision is 20/20 with color vision intact: 5–6
■ Rides tricycle: 3 yr
■ Climbs stairs using alternate feet: 3 yr
■ Stands on one foot: 3 yr
■ Broad jump: 3 yr
■ Builds 9–10 block tower: 3 yr
■ Draws a cross: 3 yr
■ Hops on one foot: 4 yr
■ Skips: 4 yr
■ Catches a ball: 4 yr
■ Walks downstairs using alternate feet: 4 yr
■ Laces shoes: 4 yr
■ Copies square: 4 yr
■ Adds three parts to stick figure: 4 yr
■ Balances on alternate feet: 5 yr
■ Ties shoelaces: 5 yr
■ Uses scissors well: 5 yr
■ Prints letters, numbers and name: 5 yr
■ Language
■ Says 900 words: 3 yr
■ Speaks 3–4 word sentences: 3 yr
■ Says 1500 words: 4 yr
■ Tells stories, sings songs: 4 yr
■ Asks “why” questions: 4 yr
■ Says over 2000 words: 5 yr
■ Knows and can name colors: 5 yr
■ Names days of week: 5 yr
■ Personal-Social
■ Shares toys with others
■ Imitates caregivers
■ Domestic role-playing
PEDS
BASICS
PEDS
BASICS
6–12 yr
■ Physical
■ Ht ↑ 2–3 in/yr
■ Wt ↑ 4.5–6.5 lb/yr
■ Secondary teeth erupt with central incisors and first molars
■ Tanner stage 2 may begin
■ Rides bicycle
■ Roller skates
■ Run, jumps, swims
■ Cursive writing: 8 yr
■ Computer and craft skills
■ Language
■ Devlops ability to read at grade level
■ Personal-Social
■ School relationships and work important
■ Separating from family
12 to 18–21 yr
■ Physical
■ Puberty beings in girls: 8–14 yr (lasts about 3 yr)
■ Puberty begins in boys: 9–16 yr (lasts longer)
■ Ht and wt ↑ variable during puberty
■ Progressive Tanner stages of development
■ Gross motor reaches adult levels
■ Fine motor continues to be refined
■ Language
■ Develops formal thought—includes idealism, egocentrism,
and ability to consider abstract possibilities
■ Personal-Social
■ Works through identity issues, status, and relationships
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Growth
■ Use Growth Charts from National Center for Health Statistics
(NCHS) www.cdc.gov/growthcharts, for ht, wt, wt for ht, HC,
and BMI
■ Use 5th and 95th percentiles as parameters in determining if
children are within normal limits for growth
Average Daily Caloric Requirements for Children
Age Caloric Expenditure Per Day

0–1 month 100—110 kcal/kg/day
2–4 months 90—100 kcal/kg/day
5–60 months 70—90 kcal/kg/day
5 years 1500 kcal for first 20 kg 25 kcal for each
additional kg/day
From Hay WW, et al. (2005). Current Pediatric Diagnosis & Treatment: (17th ed.).
New York: Lange Medical Books/McGraw-Hill, p. 309.
Number and Volume of Infant Feeds
Breast Feeding: Eight to 12 feedings/24 hours during the first

6 months
Formula Feeding: Six to eight feedings/24 hours of commercially
prepared iron-fortified (3–4 ounce) for each feeding for first
month to 5 feedings/24 hours for each feeding when solid foods
introduced at 6 months
Weaning: Should be gradual, based on infant’s desire—usually
between 8 to 9 months of age.
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Total Water Requirements/24 Hours
Infant 500–1300 mL; Child 6 yr 1150–2000 mL;

6 yr 2000–2700 mL
Daily Urine Output/24 Hours
0.5–2 mL/kg/hr depending on child’s age and hydration status

Infant 350–550 mL; Child 500–1000 mL;
Adolescent 700–1400 mL
From Behrman RE, Kliegman RM, Jenson TB. (2004). Nelson Textbook of
Pediatrics, (17th ed). Philadelphia: W.B. Saunders, p. 2415.
Average Ranges for Pediatric Vital Signs
Age Heart Respiratory BP BP

Group Rate Rate Systolic Diastolic
Infant 80–150 25–55 65–100 45–65
Toddler 70–110 20–30 90–105 55–70
Preschooler 65–110 20–25 95–110 60–75
School-age 60–95 14–22 100–120 60–75
Adolescent 55–85 12–18 110–135 65–85
Adapted from Behrman RE, Kliegman RM, & Jenson TB. (2004). Nelson Textbook
of Pediatrics (17th ed). Philadelphia: W.B. Saunders, p. 280; and National Heart,
Lung, and Blood Institute. (1987). Normal Blood Pressure Readings from the
Second Task Force on Blood Pressure Control in Children. Author, Bethesda, MD.
Rule of Thumb to Determine BP:

Normal systolic ranges: 1–7 yr age in yr 90; 8–18 yr (2
age in yr) 83
Normal diastolic ranges: 1–5 yr 56; 6–18 yr 52
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Page 111
Introduction of Food Types

Birth-6 mo 6 mo 8–9 mo 12 mo
12:26 PM
Types of Usually breast Begin with infant Finger foods such Eating normal table
Foods milk; rice cereal, then as teething foods; healthy
commercially vegetables, and crackers or raw habits—go to www.
prepared fruits with meats fruits mypramid.gov
iron-fortified the last food to
formula introduce; start
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BASICS
with 1–2 tsp
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Comments Sometimes give Introduce one food Watch sizes and Provide a variety of
rice cereal at a time for 3–5 types of food foods that meets
111
mixed with days to watch for possible child’s nutritional

breast milk or for food choking needs; avoid
formula allergies; do not allergenic foods
around 4 mo use honey on such as nuts, egg
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young infants whites, shellfish,

because of the strawberries, or
association with chocolate
infant botulism;
use small spoon
to feed infant
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BASICS
Pediatric Coma Scale

Pupils Right Size
Reaction
Left Size
Reaction
Eyes Open Spontaneously 4
To Speech 3
To Pain 2
None 0
Best Motor Obeys Commands 6
Response (use Localizes Pain 5
best arm or age- Flexion Withdrawal 4
appropriate
response) Flexion Abnormal 3
Extension 2
None 1
Best Response Age Appropriate
Auditory/Visual
Orientation 5
Stimulus
Confused 4
Inappropriate Words 3
Incomprehensible Words 2
None 1
Endotracheal Tube or Trach T
Coma Scale Total (7 coma; 3 deep coma)
Pupil Reaction: Brisk, Sluggish, — No reaction, C Eye
closed due to swelling
Adapted from Hahn YS, et al. (1988). Head injuries in children under 36
months of age. Child Nervous System 4: 34.
112
113
Normal Breath Sounds
■ Vesicular Breath Sounds: Soft, swishing noise heard over

entire area of lung surface except for upper scapular area
and beneath sternum; inspiration is louder, longer, and
higher pitched than expiration
■ Bronchovesicular Breath Sounds : Heard over sternum and
upper scapular regions where trachea and bronchi bifurcate;
inspiration is louder and higher pitched than vesicular breath
sounds
■ Bronchial Breath Sounds : Heard over trachea near
suprasternal notch with inspiratory phase short and expiratory
phase longer
Abnormal Breath Sounds
■ Decreased or unequal breath sounds : No or slight sound of

normal breath sounds that may indicate airway obstruction,
pneumothorax, pleural effusion, pneumonia
■ Rhonchi : Low-pitched, snoring-like, continuous sound
associated with respiratory infections
■ Crackles : Soft, high-pitched, intermittent sounds due to small
collapsed airways popping open
■ Grunting : Harsh sound on expiration due to early closure
of glottis and chest wall contraction, which causes increased
expiratory airway pressure to prevent airway collapse
■ Stridor : High-pitched, crowing sound on inspiration due to
upper airway obstruction associated with croup or foreign
body aspiration; low-pitched, muffled sound associated with
epiglottis
■ Wheezing : Musical, more continuous inspiratory or
expiratory sounds due to lower airway obstruction with
bilateral wheezing indicative of asthma or bronchiolitis and
unilateral wheezing suggestive of foreign body aspiration
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Endotracheal Tube Suctioning

■ Select size of suction catheter based on size of child (infant
5–8 F, child 8–10 F, older child 12–14 F)
■ Select vacuum pressure between 60 and 100 mm Hg for
infants and young children
■ Use oxygen before suctioning and after suctioning
■ Insert catheter no greater than 0.5 cm beyond tip of artificial
airway
■ Limit suction to less than 5 seconds
Pulse Oximetry
Normal ranges: 95%-100%
Mild hypoxia: 91%-94%
Moderate hypoxia: 86%-90%
Severe hypoxia: 86%
Watch for false lows associated with nonsecure connection
(movement of child’s foot or hand), cold
extremities/hypothermia, and hypovolemia. Watch for false highs
associated with carbon monoxide poisoning and anemia.
Cardiac/Apnea Monitors
Electrode placement for ECG monitoring:
White color for right side of chest
Green (or red) color for ground
Black color for left side of chest
Electrode placement for apnea monitoring:
Two electrodes placed two fingerbreadths below nipple on
midaxillary line of each side
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115
Cardiac/Apnea Monitors (Cont.)
Electrode Placement for Standard Chest

Electrographic Monitoring
Electrodes with attached wires are

often color coded:
White for right
Green (or red) for ground
Black for left
Apnea (if indicated)
Electrode placement for both ECG and apnea.
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Children’s Responses to Illness and Hospitalization

Separation Anxiety Loss of Control Fears
12:26 PM
Infant Develops ~6 mo and lasts until Disruption of care Strangers and strange
30 mo with reactions of from primary places, loud noises,
crying or agitation caregiver and sudden movements,
normal routines loss of physical and
emotional support
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Toddler Exhibits reactions such as Disruption from Strangers, dark, being

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agitation, temper tantrums, normal routine alone, physical

uncooperativeness and and rituals as contact/interventions
116
clinging to parents; well as care from strangers,
separation anxiety peaks from parents strange or unknown
12–15 mo equipment and
places
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Preschooler Fewer reactions but more Perceived Mutilation, the

somatic signs such as disruption in the unknown, any
vomiting, urinary frequency loss of their intrusive procedures
or incontinence, diarrhea, own power and
dizziness; still may become altered family
withdrawn or aggressive roles
Page 117
Children’s Responses to Illness and Hospitalization (Continued)

Separation Anxiety Loss of Control Fears
12:26 PM
School Age Anxious behaviors as well as Enforced Bodily injury, pain,

loneliness, boredom, dependency and inability to stay in
isolation or depression; altered family control, lack of
knows that parents may need roles control over mod-
to leave and will be back but esty, school and peer
may show aggression and concerns, death
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irritability toward family
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Adolescent Anxiety related to peers and Enforced Loss of peer
school life with behaviors dependency and interactions and
117
such as withdrawal, possible relationships, body

loneliness, or boredom identity/role disfigurement,
changes rejection by others,
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loss of physical
abilities, death
Eight Questions to Ask About Pain:
1. Are you having pain? 5. How long have you been having pain?
2. If yes, what does the pain feel like? (burning, 6. How often does it occur?
aching, pinching, stabbing?) 7. Does anything make it worse—or
3. When did the pain start? (Did anything happen better?
to start the pain?) 8. Has it changed what you do?
4. Where is the pain? (Point to where the pain is.)
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Developmental Differences in Children Related to Pain
Age Comments
Infants Preverbal. Signs of possible pain: diffuse body

movement, high-pitched cry, tearing, stiff
posture, fisting, and lack of play; obvious
sign is facial expression with brows lowered
and drawn together, eyes tightly closed, and
mouth open
Young child Limited vocabularies still make it difficult to
express pain; may use words such as
“owie;” can sometimes describe pain but not
the intensity. Signs of possible pain:
regression with arms and legs thrashing or
withdrawal such as clinging to parent or
significant other, loud crying or screaming
Older child Use pain scale for this group; may have
difficulty in distinguishing between types of
pain such as “sharp” or “dull;” may act
“tough” even when in pain; may show fewer
overt pain behaviors. Signs of possible pain:
muscular rigidity such as clenched fists,
gritted teeth, body stiffness, closed eyes,
wrinkled forehead or lying in fetal position
Adolescent Use pain scale for this group; may be stoic
because of fear of being labeled so may be
quiet and withdrawn. Signs of possible pain:
fist-clenching, clenched teeth, rapid
breathing, and guarding affected body part,
lack of interest and decreased ability to
concentrate
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Nursing Interventions Related
To Pain Management
■ Distraction—useful for mild pain relief (example: tell child to
say “Oh” when giving an injection or blow bubbles when
performing a procedure)
■ Guided imagery—aid the child in creating a pleasurable
mental image during the painful situation
■ Thought stopping—stop the painful thought with a positive
thought
■ Soothing music or aromatherapy–use to calm emotions and
state of mind
■ Thermotherapy–apply warm and cold to painful areas to
promote circulation or reduce edema with limited numbing
effect
■ Gentle massage–relax or focus child away from pain toward
more gentle soothing touch
■ Sucrose “Sweet” Nipple—calm young infants by allowing
them to suck on nipple dipped in sucrose solution—effective
method in reducing pain during procedure
■ Provide ordered pharmacological interventions such as
topical anesthetic creams, PO/IV/IM analgesia, patient-
controlled analgesia (PCA), conscious sedation, or epidural
analgesia
Numerical Scale Pain Assesment Tool
None 0—1—2—3—4—5—6—7—8—9—10 Worst Pain

(Scale of 0–10 to describe pain) Explain to older child: “0 means
you feel no pain and 10 means you feel the worst pain possible.”
Ask the child to choose number that best describes his or her
own pain.
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Page 120
FLACC Pain Assessment Tool

12:26 PM
Rating: 0 1 2
Face No particular Occasional grimace or Frequent to constant
expression or smile frown, withdrawn, frown, clenched jaw,
disinterested quivering chin
Legs Normal position or Uneasy, restless, tense Kicking, or legs drawn
relaxed up
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Activity Lying quietly, normal Squirming, shifting back Arched back, rigid or
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position, moves and forth, tense jerking

easily
120
Cry No cry (awake or Moans or whimpers, Crying steadily,
asleep) occasional complaint screams or sobs,
frequent complaints
Consolability Content, relaxed Reassured by occasional Difficult to console or
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touching, hugging, or comfort

“talking to,” distractible
Ages of use: 2 mo to 7 yr. Scoring range: 0 no pain, 10 worst pain.
From Merkel S, Voepel-Lewis T, Shayevitz J, Malviya, S. (1997). The FLACC: A behavioral scale for scoring
postoperative pain in young children. Pediatric Nursing 23(3): 293–297.
Page 121
Use of Play for Children

Age Group Type and Purpose of Play Safe Toys
12:26 PM
Infants Solitary (noninteractive but may be 1–3 mo: mobiles, music boxes,
imitative in later part of infancy) nonbreakable mirrors, stuffed
Stimulates psychological and animals, and rattles
sensorimotor development, offers 4–6 mo: squeezable toys, busy boxes,
diversion, means of communication play gyms
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7–9 mo: cloth textured toys, splashing
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bath toys, large blocks and large balls
10–12 mo: durable books with pictures,
nesting cups, push-pull toys, and
121
building blocks
Toddlers Parallel (along side but not interactive) Dolls, housekeeping toys, books, sing-
Enhances locomotion skills (gross and a-long tapes, rocking horses, pull
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fine), language development, toys, finger paints, clay, large piece

imitates adult roles puzzles, blocks, and balls
Preschoolers Associative (interactive and Tricycle/big wheels, wading
cooperative but defines own rules) pools/sandboxes, gym sets,
Promotes fine/gross motor skills, blocks/puzzles/simple crafts,
contact with playmates, and crayons/paints, puppets/dolls stuffed
encourages imagination animals, imaginary items, and age-
appropriate electronic games
Page 122
Use of Play for Children (Continued)

Age Group Type and Purpose of Play Safe Toys
12:26 PM
School Age Competitive and complex-”team” play Board games, card games, music and
Develops social skills through learning art, athletic activities, team activi-
rules and rituals of games and ties, movies, and interactive video
continued refinement of fine/ games
gross motor skills
Adolescent Group/peer type play Sports, camping, video and com-
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puter games, radios, disc players,

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Continues to enhance social skills and

roles, cognitive skills, and wellness phones, models, and collectibles
with sports or exercise activities
122
Safe Hospital Bed/Crib Choices
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Premature infants and newborns Isolette or radiant warmer

Infants/young toddler Open crib
Toddlers/young preschoolers When child is left alone, use the enclosed bubble-top crib
Older preschooler to adolescents Hospital bed with rails in lowered position
In general, bed/crib selection based on child’s age, developmental abilities, LOC, and
health conditions
123
Quick 10-Minute Assessment
Look At the Child and Environment
■ Is the child THERE? ALIVE?

■ In the crib or hanging from the sides? (Children can do
amazing stunts!)
■ Are the parents with the child?
■ What type of equipment is at the bedside?
Begin with Safety
■ Is the child breathing?

■ Do you observe any signs of distress? (Follow the ABCs you
learned in CPR)
■ What is the child’s color? (pale, red, blue …)
■ Is the child on a monitor? (What is the rate & pattern?)
■ Any IVs? (Note type, rate, & site)
■ Note last set of vital signs (Include other findings based on
child’s condition, PIC line, chest tubes, and so on) Abnormal?
If so, check again.
■ When was the last time the child voided?
■ Do you observe anything unusual that needs immediate
interventions? DO IT NOW!
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Check the Equipment
■ Are the monitor and respirator alarms set at the proper

limits?
■ Is the 02 set up correctly? Does it work?
■ Is the suction equipment set up and ready to be used? TEST
IT!
■ Is there an appropriate resuscitation bag with the proper size
mask?
■ Is the correct equipment at the bedside for the child on
seizure precautions?
■ Are the crib rails up?
■ Are restraints applied correctly? (Is there an order for the
restraints?)
■ Are tabletops and crib or bed cleared of unsafe articles?
Focus Assessment on Area of Major Diagnosis
■ This initial assessment takes about 2–3 minutes.

■ Do the same initial assessment on all patients then return to
do the more in-depth assessment.
■ If the patient is in critical condition do the in-depth
assessment NOW!
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Page 125
Quick Evaluation of Sick Child

Observation Normal Moderate Impairment Severe Impairment
12:27 PM
Quality of Cry Strong normal tone Whimpering or Weak, moaning, or

or content and not sobbing high pitched
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crying
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Reaction to Cries briefly, then Cries off and on Continual cry or
Parent Stimulation content and not hardly responds
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crying
State Variation If awake, stays Eyes close briefly Will not rouse or falls
awake; if asleep then awakens, or to sleep
125
and stimulated, wakes with

quickly wakes prolonged
stimulation
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Color Pink Pale hands, feet or Pale or blue or gray

acrocyanosis or mottled
Hydration Skin warm and dry, Skin and eyes Skin doughy or
eyes and mouth normal and tented and eyes
moist mouth slightly dry sunken and dry
Response to Smiles; alert Brief smile; or No smile, anxious
Social Overtures briefly alert face, not alert
From McCarthy PL, Sharpe MR, Spiesel SZ, et al. (1982). Observation scales to identify serious illness in febrile children.
Pediatrics; 78: 802.
Page 126
Communication with Child and Family

Age Group Important Aspects Examples
12:27 PM
Infant Trust is developing; communicates Provide gentle touching; firm

through coos, smiles, and cries at holding, and smiles to infant.
first. First words around 8–9 mo. Speak to primary caregiver first. If
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Understands simple one word not contraindicated, offer pacifier

commands at 1 yr. If primary and use security blankets and
caregiver is comfortable, many stuffed animals.
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times the infant is calm and

trusting. Allow infant to be held by
caregiver as much as possible.
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Toddler Sense of self and being independent First, direct eyes and questions to
is becoming important; caregiver. Assume eye level of
understands simple two- and child. Ask simple questions with
three-word commands. Has 300 appropriate choices such as
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word vocabulary. Short attention “would you like to sit on your

span of 1–5 minutes. mothers lap or up on the table?”
Use child’s language for specific
words in short and simple
sentences. Be attentive to
nonverbal cues. Use puppets and
dolls.
Page 127
Communication with Child and Family (Continued)

Age Group Important Aspects Examples
12:27 PM
Preschooler Developing a concept of self; Assume eye level of child. Provide

understands simple sentences. appropriate choices. Offer
Has 900 words in vocabulary. Let appropriate medical equipment for
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children know that they did not play to reduce fear of equipment.
cause the illness. Prepare child for Use concrete sentences. Allow
procedure right before the child to ask questions.
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treatment.
School-Age Interested in achievement; get child Show the child equipment and use
to help you. Understands most clear simple instructions. Use
127
mature thoughts especially when teaching aids and explain what

allowed to manipulate and see you do.
objects.
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Adolescent Transition between childhood and “Would you like to have your
adulthood; begin conversation mother leave the room while I
with them first then ask questions examine you?” Provide privacy
of caregivers. Verify with and ensure confidentiality.
adolescent that they understand.
Can use brochures and videos.
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Subjective Assessment by Age Group

Infant (Per parent)
■ Chief complaint and HPI
■ Past history including
■ Prenatal history
■ Natal history (type birth)
■ Postnatal (with APGAR)
■ Allergies
■ Developmental milestones
■ Immunizations, safety issues
■ Nutritional intake (type, amount)
■ Sleep
■ Family history
■ Review of systems
Young child (Per parent and child)
Same as infant plus:
■ Play/activity
■ Personality
■ Fluid intake
Older child (Per child)
■ Chief complaint and HPI
■ Past medical history
■ Immunizations
■ Safety issues
■ Allergies
■ Nutritional intake
■ Family history
■ Social history, school achievements, play
■ Sleep
■ Review of systems
All children
Include type of housing, others in household, car seat and
smoke detector use, type of home heating, pets, family cultural
beliefs and practices.
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Systems Approach to Assessment
Although the systems approach works well and is often used in the
documentation of your findings, remember you must adapt your
method to the individual child!
HEENT
■ Eyes (redness, drainage, alignment)

■ Ears (response to sound, pulling at ears)
■ Mouth (excessive drooling, white patches in mouth)
Neuro
■ Level of alertness, affect, and responsiveness (awake, verbalizes,

awareness of surroundings, lethargic, obtunded, etc.)
■ Pupil check (darken room before trying to check, simultaneous
closing of eyelids, movements of eyes—any deviations to right or
left, color of sclera and conjunctiva, any drainage, visual acuity)
■ Movement of extremities (involuntary, voluntary, on verbal
command—for older child, moves in response to painful or other
stimuli, uncoordinated movements, twitches, tremors)
■ Hand grasps and pedal pushes (equality, remember you need to
adapt to developmental age) Reflexes—deep tendon reflexes,
presence or absence of newborn reflexes
■ Speech (clear, slurred, etc.)
■ Signs of seizure activity (describe type, how often, when, etc.)
■ Nuchal rigidity
■ Head circumference and size of fontanels (adapt to the
developmental age)
Respiratory
■ Inspect shape and contour of chest (expose the patient’s chest to

get a good look! Posture, spinal curvature, any equipment such
as chest tubes—if present, describe site, type, etc.)
■ Palpate expansion of chest for full and equal excursion (Inspect
for retractions, unequal expansion, etc.)
■ Respirations—easy, quiet, unlabored? Abdominal breathing?
(Children are often abdominal breathers until 6–7 yr)
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■ Auscultate the lungs from the top to the bottom, front and back
and laterally, include over the neck and trachea (compare right
and left sides, abnormal sounds—describe)
■ Does child breathe through nose or mouth (any drainage? if
present describe amount, color, and consistency)
■ Note Pulse oximetry (%02 saturation)
Respiratory Equipment
■ Ventilator—start at the nearest point to the patient—ET or trach
and work distally toward the machine
■ Size of ET or trach tube, whether tube is cuffed, amount of air in
cuff for seal, whether seal is intact, appearance of trach site, tube
placement, equality of bilateral lung expansion, quality and
equality of breath sounds, tubing and integrity of connections
■ Make sure there is no water in the tubes, know tidal volume,
measure O2 concentration
■ Note settings your patient is on—check the system pressures—
any change needed? Recheck all settings and alarms. Is the alarm
on?
■ Suction the patient, if needed. Observe the patient’s tolerance to
the procedure and type and amount of secretions
■ Check other O2 equipment such as croup tents, etc. Do you have
the right set-up? Proper concentration of O2? Water in containers
that should have water? Patient’s tolerance to the equipment? Is
there any cyanosis?
Cardiovascular
■ Inspect and palpate the point of maximum impulse (PMI)

Auscultate the heart sounds. What is rate and rhythm? Run a
strip if you can. Check the P, QRS, and T waves—any
abnormalities? Are all peripheral pulses present and equal? Any
edema? (Check dependent areas like the sacral area)
■ Any signs of dehydration? (Sunken fontanels, lethargic, sunken
eyes, mucous membranes, etc.) Overall perfusion? (Skin warm,
dry and pink? Or cool, clammy, mottled?) Nail beds—(Good
capillary refill, pink, etc.?)
■ Check IV sites for signs of infiltration, phlebitis, etc., type and
rate of IV, infusion pump, etc. Hemodynamic monitoring: various
line—(Note the reading, equipment, sites, and dressing)
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131
Carotid Temporal
Apical
Brachial
Aortic
area Pulmonic
area
Tricuspid Mitral or
area apical
area
Femoral
Radial
Popliteal
Posterior Dorsal
tibial pedis
Auscultation areas and peripheral pulses.
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GI
■ Start from nose and mouth and work down. NG tube (Inspect
for patency, how long has it been in, any suctioning-type,
any drainage—describe odor, amount, color, consistency, pH,
quaiac, and so on)? Any other type of GI drainage? Abdomen
(Inspect, auscultate bowel sounds in all four quadrants,
palpate and percuss for size, consistency [soft or firm],
distention, rigidity, pain [location, intensity, quality]). Stool—
inspect for amount, color, consistency, guaiac, reducing
substance, when did child last have one? To decrease ticklish
or tense sensation, have child place feet flat on bed or table
with knees elevated and place child’s hand under your hand
as you palpate and percuss
GU
■ Foley (Describe type, when inserted, does it need to be

changed?). Foley care? Any urine? (What does it look like—
color, clarity, sediment or blood present? Test it for—specific
gravity, glucose, pH, etc.) Do you observe any urethral, penile,
vaginal discharge Circumcised? Determine weight of diaper: 1
g 1 cc (first weigh dry diaper and deduct weight of dry
diaper)
Skin
■ Look at it!! All of it.

■ Rashes, lesions—location, pattern, size, color elevation,
blanching? Breakdown?? Petechiae, purpura, bruising?
■ General skin condition—dry, oily, itchy, scaly? Skin turgor?
Lice? Color of the skin, any cyanosis, temperature, moisture?
■ Note dressings (dry and intact??)
■ Note mucous membranes (hydration, color)
■ Tongue (is it moist?)
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133
Musculoskeletal
■ Assess while doing other systems

■ Note if child is walking, sitting, or turning, ROM in all joints
■ Check spinal curvature and mobility, sacral dimples or tufts
of hair
■ Note strength, symmetry, and movement of extremities
Safety Education Topics for Specific Age Groups

Infant Car seats. Water temperature (water
heater setting lower than 130F),
smoke detectors, bath safety
Toddler/Preschooler Car seats, pedestrian safety, water
safety, medications, and household
poisons
School age Pedestrian safety, bicycle helmets, seat
belts, no firearms in household, water
safety
Adolescent Auto safety, alcohol/drug use,
occupational injuries, no firearms in
household
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MEDS/
ACUTE
5 Rights of Drug Administration

■ Right Drug
■ Right Dose
■ Right Time
■ Right Route
■ Right Patient
Determining Dosage and Route

■ Variations based on age, weight, body surface area (BSA), and
maturity of kidneys and liver
■ Physician orders, dosage, and route
■ Nurse checks for safety of dosage and route
Methods to Determine Safety of Dose
Dosage Based on Body Weight

■ Determine child’s weight in kg
■ Establish safe dose from pharmacy text
■ Calculate dose using weight
Body Surface Area (BSA)
■ Use nomogram to determine where straight line connects
height and weight levels and bisects the BSA
■ Divide the BSA in meters by 1.7
■ Multiply the quotient from step 2 by the adult dose
Administration of Medication
■ Check for drug allergy history prior to administration
■ Check ID band; do not ask child to verbally identify himself;
child may say “yes” to any name or give false name to avoid
taking medication; do not use name card on bed to ID
child—children may switch beds
134
135
■ Give choices when possible—”would you like to take your
medicine with water or juice?”
■ Ask parent for suggestions regarding how child prefers to
take medication
■ Allow parent to give medication if child prefers—be sure to
observe while entire dose is administered
■ NEVER leave med at beside
Routes for Medication Administration

Oral Route (by mouth)
■ Use tool that ensures accurate measurement: calibrated

dropper, syringe with needle removed, or plastic measuring
cup
■ Take care to prevent aspiration—hold child’s head up and
administer liquids to infant by carefully using a syringe or
dropper to place small amounts of med into infant’s cheek,
near back of mouth or by putting med into nipple for infant to
suck. Be prepared to suction med back into a small syringe for
oral administration if infant does not suck nipple
■ Do not dilute med in formula or large amount of liquid that
infant may not consume
■ May use small amount of flavored syrup to disguise
unpleasant tastes
Nasogastric (NG), Orogastric, or Gastrostomy Route
■ Crush pills finely to prevent clogging of tube

■ Check tube placement and infuse slowly
■ After med administration, flush line with water to ensure med
has cleared tube and to prevent clogging
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Optic Route (eye)
■ Ensure that med is room temperature

■ Drops—Place med in conjunctival sac; apply slight pressure to
inner puncta for 1 minute to keep drops from draining into
nose
■ If child is uncooperative, immobilize child’s head, place
drop(s) over inner puncta—med will drain into eye when
child opens his eye.
■ Explain to child that med may be tasted
■ Ointment—apply from inner to outer canthus
Otic Route (ear)

■ Position child with affected ear up—maintain position for one
full minute after administration of med
Child 3 yr, pull pinna down and back
Child 3 yr, pull pinna up and back
Nasal Route (nose)

■ Drops—Tip head back—may use towel roll between shoulders
of small child—maintain position for one full minute after
administration of med
■ Spray—Child should be seated with head up
Rectal Route
■ Suppository may be moistened with water or water soluble

jelly
■ Note that children usually consider this to be an invasive
procedure—drape child to provide privacy
■ Position child on left side
■ Insert rounded end of suppository gently into rectum
■ Hold child’s buttocks together for 5 minutes to avoid expulsion
of med
136
137
Intramuscular (IM), Subcutaneous (SQ), Intradermal Route
■ Use small syringe to ensure accurate measurement

■ Use proper needle length for size of child and route
of administration (needle usually not more than
1 inch)
■ Do not draw up air bubble (clearing med from the
syringe’s dead space may result in very small dose
being inaccurate)
■ Anticipate resistance from child—enter room with
assistant to immobilize child if needed
■ Do not ask parent to immobilize child
■ Ask older child about preference of administration site
■ Tell child that is it okay to cry
■ Complete procedure as quickly as possible
■ Offer bandage after administration
■ Praise child’s efforts
Intravenous (IV) Route
See comments regarding syringe size and clearing syringe’s

dead space under Intramuscular Route
If not specified in med order, consider desired effect and stability
of med to determine whether to administer:
■ Slow IV push (over several minutes)
■ Retrograde infusion (med is injected into a Y-port after
temporarily clamping IV line below Y-port)
■ Instilling med into mini IV chamber such as Buretrol
or using syringe pump
MEDS/
ACUTE
Page 138
IM Injection Sites
Age Group Preferred Site Needle Length/Gauge
12:27 PM
MEDS/
ACUTE
Newborn & Vastus lateralis 5/8 inch*/24–25 G no more

Young Infant than 0.5 mL
Infant Vastus lateralis 5/8–1 inch*/23–25 G no
more than 1 mL
Toddler Vastus lateralis or Ventrogluteal 1 inch*/22–23 G no more
12/28/05
(relatively free of major nerves and than 1 mL

blood vessels—large muscle with little
subcutaneous tissue, less painful than
vastus lateralis and easily accessible)
138
Older Children Deltoid (faster absorption rates than 1 inch*/22–23 G no more
gluteal and less painful; limit to 1 mL) than 1.5–2 mL
or ventrogluteal
07Holloway (F)-07
* Consider amount of body fat when selecting needle length

Notes: Use dorsogluteal in children older than 3 years because it takes more than a year of walking to
develop larger muscle mass appropriate for this route. Administer EMLA cream or topical vapocoolant spray
to injection site prior to giving the injection to decrease discomfort.
139
Pediatric Injection Sites
Greater
trochanter
Femoral nerve, Tensor

artery,vein fascia latae
Sartorius
Vastus
lateralis
Rectus
femorus
Vastus lateralis.
j
(gluteus medius)
Posterior
Anterior superior
iliac crest
iliac spine
Tensor
fascia
latae
Palm over
greater Gluteus
trochanter maximus
Ventrogluteal.
MEDS/
ACUTE
MEDS/
ACUTE
Clavicle
Acromion
process
Deltoid
Deltoid.
Intravenous Maintenance Fluids

Calculations by Body Weight
10 kg in weight 100 cc per kg of weight cc for

24 hours
11–20 kg in weight 1,000 cc 50 cc/kg for each kg
10 kg cc for 24 hours
20 kg in weight 1500 cc 20 cc/kg for each kg
20 kg cc for 24 hour
Surface Area – Fluid maintenance requirements in mL/day BSA in m2
1500 mL/day/m2 (1500–2000 mL/m2/day)
24 hour total divided by 24 hours rate in milliliters per hour

Maintenance Sodium: 2–3 mEq/kg/24 hours
Maintenance Potassium: 1–2 mEq/kg/24 hours
For initial IV, potassium is generally added to the IV fluids AFTER
the child voids
140
141
To Calculate IV Rates
Total Volume Drop Factor ÷ Infusion Time in Minutes
Drops/minutes
Microdrip Tubing 60 gtts/mL used in volume control chamber
(Buretrol, Soluset, Volutrol) in pediatrics
Macrodrip Tubing 10, 20, 15 gtts/mL depending on brand of
tubing—may be used for adolescent
Key Monitoring for Child on Parenteral Nutrition

■ Daily weight
■ Weekly height/length
■ Hourly intake and output amounts
■ Every 8 hours note urine specific gravity, glucose, and protein
Peripheral Intravenous Access In Children
Comments Related Needle

to Children Available Sites Gauge
Veins are more fragile External jugular and scalp 20–24 G
so protect with tape, veins: frontal, superficial
arm board, or surgical temporal, posterior
netting. Choose site auricular; upper
that will not interfere extremities veins: dorsal
with activity for specific hand, radial vein of wrist,
age group. Use EMLA anterior ulnar-forearm,
cream, Fluori-Methane median cephalic-lateral
vapocoolant spray, etc., antecubital fossa, median
for nonemergent basilica-medial antecubital
insertion. fossa; veins of the lower
During infusion, hang extremity: superficial
4 hours’ worth of veins of dorsum of foot,
IV fluid at any one saphenous vein anterior
time (to prevent fluid and superior to the medial
overload). Check site malleolus of the ankle,
frequently for signs of and along proximal length
infiltration or phlebitis on medial foreleg
MEDS/
ACUTE
Page 142
Pediatric I.V. Sites Median Median

12:27 PM
antebrachial v. cephalic v.
MEDS/
ACUTE
Supraorbital v.
Median Cephalic v.
basilic v.
Umbilical v. Frontal v.
Basilic v.
(newborn only)
12/28/05
Great
saphenous v. Superior
temporal v.
142
Posterior
Dorsal auricular v.
venous Jugular v.
07Holloway (F)-07
arch
Cephalic v.
Median Dorsal
marginal v. arch Basilic v.
5th inter-
digital v.
Preferred sites for peripheral intravenous access and venipuncture in infants and young children.
143
Central Venous Access Devices (CVADs)
Examples Comments Related to Use

of Types and Contraindications
Peripherally Inserted Used for long-term IV antibiotics,
Central Catheter chemotherapy, TPN, or blood
(PICC) products; contraindicated with
inadequate veins, bleeding
disorders, immunosuppression,
noncompliance, trauma to
extremity, severe burns, or
infections
Total Implantable Used for long-term IV fluids,
Device—Port-A-Cath medications, blood products, TPN,
and venous blood sampling and
analysis; use 19–22 gauge right-
angled needle with topical
anesthesia to access and typically
monthly flushing with heparinized
saline solution; same type of
contraindications as in PICC and not
used in child requiring less than 6
mo of intermittent IV therapy
External/Tunneled Long-term central venous catheter
Catheter—Broviac, used for same purposes as
Hickman, Groshong implantable device but better suited
in very small children and infants;
requires site care and frequent
flushing with heparinized saline or
saline solution
Complications related to CVADs include infections, phlebitis,
thrombosis, occlusions, breaks, migration, or accidental
removal
MEDS/
ACUTE
Page 144
ACUTE
Key Points for Pediatric Cardiopulmoary Resuscitation (CPR)

PEDS
1 yr old 1–8 yr old 8 yr old

12:28 PM
Assess If collapses suddenly and known cardiac Determine

responsiveness condition—activate EMS; otherwise unresponsiveness
activate after 1 min resuscitation then activate EMS
Open Airway and No trauma suspected—head-tilt/chin-lift position. If trauma, use jaw
Assess Breathing thrust only. Look listen, feel 10 sec
12/28/05
Perform Rescue 1 breath per 3 sec (20/min) 1 breath per 5 sec

Breathing begin (12/min)
with 2 breaths
144
Assess Pulse Brachial or femoral Carotid
Provide Compressions 1 finger below Heel of hand on Heel of one hand
intermammary line lower half on top of other
with 2 fingers sternum hand on lower
08Holloway (F)-08
depress chest and depress half sternum and

1/2–1 in—100/min chest 1–1 1/2 depress chest
in—100/min 1 1/2–2 in—
100/min
Compression/ 5:1; pause for ventilation if patient is not 15:2
Ventilation Ratio intubated
Count Sequence 1,2,3,4,5 1&2&3&4&5 1 & 2 & 3 & 4 & 5…
Adapted from the American Heart Association. (2002). PALS Provider Manual. American Heart Association, pp. 43–80.
Page 145
ACUTE
Key Points for Pediatric Choking – Foreign Body
PEDS
1 yr old 1–8 yr old 8 yr old
12:28 PM
Conscious Victim Assess breathing to determine if Ask, “Are you choking?”–Can the child
ineffective or no strong cry speak or cough? May demonstrate
universal choking sign
Give 5 back blows; then 5 chest Perform up to 5 subdiaphragmatic
thrusts abdominal thrusts (Heimlich)
Repeat until obstruction relieved or becomes unconscious
12/28/05
Child Becomes Unconscious Place child on back; active EMS after 1 min rescue effort
Open airway, if see foreign body Open airway and do finger
then remove sweep
145
Give rescue breaths, if airway blocked, reposition head according

to age requirements, try rescue breaths again
Give 5 back blows; then 5 chest Perform up to 5 subdiaphragmatic
abdominal thrusts
08Holloway (F)-08
thrusts
Repeat steps until foreign object is removed
Unconscious Victim Gently shake to determine “Are you okay?”
alertness level
If unresponsive, activate EMS after 1 min rescue effort
Proceed as outlined above and in CPR
Mouth-to-mouth-nose seal Mouth-to-mouth seal
Try rescue breath, if needed reposition & try again
Adapted from the American Heart Association. (2002). PALS Provider Manual., American Heart Association, pp. 43–80.
PEDS
ACUTE
Defibrillation Guidelines
Paddle Size 4.5 cm for infants; 8–13 cm for children.
Use largest electrode size to have good
chest contact and separation of electrodes
Paddle Placement One paddle on right upper chest below
clavicle and other paddle to the left of
nipple in anterior axillary-line; heart should
be situated between paddles
Energy Dose 2 Joules/kg for initial defibrillation with
2–4 Joules/kg for all subsequent attempts;
for cardioversion, use 0.5–1 Joules/kg with
2.0 Joules/kg for all subsequent attempts
Bradycardia in Children:
Definition: “too slow” for age; HR 60/min in infant and young
child with evidence of poor perfusion
Causes: Hypoxemia (most common cause), hypothermia, head
injury, heart transplant, toxins/poisons/drugs
Treatment: Assess ABCs, ensure patent airway, monitor vital signs,
attach ECG monitor, start IV/IO and oxygenation per order/protocol,
treat cause
Common Medications Used: Oxygen, epinephrine, atropine
Tachycardia in Children:
Definition: “too fast” for age; rapid heart rate associated with shock
and hemodynamic instability
Causes: Hypoxemia, hypovolemia, hyperthermia, electrolyte
disturbances, tamponade, tension pneumothorax,
toxins/poisons/drugs, thromboembolism, pain
Treatment: Assess ABCs, if no pulse-initiate CPR, if pulse
present–oxygenate, ventilate, and follow orders/protocols, treat
cause
Common Medications Used: Oxygen, amiodarone, procainamide,
lidocaine, adenosine, may also use vagal maneuvers or
cardioversion depending on type of tachycardia
146
147
Pulseless Arrest in Children:
Definition: Complete collapse confirmed by ECG in more than
one lead
Causes: Hypoxemia, acidosis, hypovolemia, tension
pneumothorax, cardiac tamponade, electrolyte imbalance, drug
overdose, and embolism
Treatment: Determine pulselessness and begin CPR
Ventricular fibrillation or Pulseless ventricular tachycardia:
Defibrillation up to 3 times, continue CPR, secure airway,
hyperventilate with 100% oxygen, secure IV/IO, administer
medications such as amiodarone, lidocaine, magnesium per
protocol.
Asystole/Pulseless Electrical Activity: CPR, secure airway and
IO/IV, hyperventilate with 100% oxygen, administer epinephrine
per protocol and treat cause.
Pediatric Trauma Score
Clinical
Assessment Score 2 Score 1 Score 1
Child Size 20kg 10–20 kg 10 kg
Airway Normal Maintainable Not
maintainable
Systolic 90 mmHg 50—90 mm Hg 50 mmHg
Blood (no pulse)
Pressure
Central Awake Obtunded/loss of Coma,
Nervous consciousness decerebrate
System
Open wound None Minor Major
penetrating
Skeletal None Closed fracture Open/Multiple
fractures
From Ford EG, Andrassy RJ. (1994). Pediatric Trauma Initial Assessment and
Management. Philadelphia: W.B. Saunders, p. 112.
PEDS
ACUTE
PEDS
ACUTE
Cardinal Signs of Respiratory Failure

■ Restlessness/Altered LOC
■ Tachypnea
■ Tachycardia
■ Evidence of ↑ Work of Breathing
■ Cyanosis
■ Diaphoresis
Recognizing Abuse/Neglect in Children

■ Physical signs of abuse/neglect reported by child
■ Repeated ED visits/previous history of abuse
■ Parents blaming siblings for injury
■ Inappropriate response to injury by child/caregiver to injury
■ Inconsistency between physical findings and cause of injury or
injury and child’s development
Emergencies Related to Diabetes
Hypoglycemia Hyperglycemia
Causes Too much insulin, delayed food Stress, infection,
intake, exercise without too little insulin
adjustment
Symptoms Shaky, weak, sweaty, hungry, Increased thirst,
dizzy, light-headed, increased
palpitations, visual changes, urination,
gait disturbances, changes in weight loss,
affect, confusion, slurred increased
speech, sleepiness, appetite,
unconsciousness, seizures decreased
energy level
Blood 60 mg/dL Fasting: 240
Glucose mg/dL
Levels Random: 300
mg/dL
Treatment Give glucose, IV/PO Give IV fluids,
insulin, K
148
149
General Types of Seizures
Obtain Seizure History: type, typical frequency, description and
frequency of corresponding events, auras experienced before
seizure, and any specific meds
Type Description & Treatment
Types of Partial: Confined to one hemisphere—change in
Simple posture, hallucinations, or flushing, no
aura and LOC alteration. Use
anticonvulsants such as carbamazepine
and phenytoin to control seizures.
Complex Starts in one focal area and spreads to
both hemispheres; consciousness not
completely lost—confusion, aura may
occur, postictal response. Use
anticonvulsants such as carbamazepine
or phenytoin to control seizures; may
need more than one drug.
Types of Sudden onset, lasts 5–10 sec, loose
Generalized: responsiveness but no falling, eyelids
Absence (petit twitching, lip smacking, no postictal
mal) response; anticonvulsants/ketogenic
diet.
Clonic Opposite muscles contract/relax in
rhythmic pattern, may occur in one or
more limbs; use anticonvulsants.
Tonic Muscles maintain continuous contracted
state (rigid posture) with variable loss
of consciousness; use anticonvulsants.
Tonic-clonic Violent total body tonic then clonic
(grand mal) movements with aura and postictal
response, loss of consciousness.
Phenobarbital, carbamazepine,
phenytoin, or other similar drugs may
be combinations.
PEDS
ACUTE
PEDS
ACUTE
General Types of Seizures (Continued)

Type Description & Treatment
Atonic Drop and fall attack with loss of posture
tone. Must wear helmet and use
anticonvulsants.
Types of Elevated temp leads to seizure activity
Miscellaneous: 5 minutes in young infants and
Febrile children, generalized, transient and
nonprogressive. Treat underlying
illness/fever, diazepam PO, monitor for
neurological deficits.
Status Epilepticus Prolonged or repetitive seizures without
interruption lasting longer than 30
minutes that results in anoxia, cardiac
and respiratory arrest; loss of
consciousness. Assess airway,
breathing, circulation. IV glucose and
other drugs such as diazepam,
phenytoin, phenobarbital used to
control problem within 20–60 minutes,
correct metabolic problems, may start
midazolam drip, treat underlying
cause, establish maintenance
anticonvulsant drugs.
For All Seizures:
Do: Stay with child; call for help; move to flat surface out of
danger; position on side with head supported and clothing
loosened. Maintain patent airway; record seizure activity and
assess neurological status and vital signs; document time
started and ended, aura–if present, color change, presence
of incontinence, oral tissue damage (if any), postictal
(postseizure) response.
Do Not: Try to interrupt seizure or restrain child; use tongue
blades.
150
151
Degree and Signs of Fluid Deficit (Dehydration) in Children
Mild (5% Moderate Severe

Common loss of (5%-9% loss (10% loss
Clinical body of body of body
Signs weight) weight) weight)
Skin Pale, warm Pale, Mottled to
mottled, cyanotic,
cool cool
Skin turgor Normal Decreased Markedly
decreased,
tenting
Eyes Normal Appears Sunken, no
sunken, tear
poor tear production
production
Mucous Slightly Dry Very dry and
membranes dry cracked
Anterior Normal Slightly Sunken
fontanel depressed
(if still open)
Heart rate Normal Increased Increased,
pulse often
not
palpable
Respiratory rate Normal Increased Increased
Blood Normal Slight Decreased
pressure decreased
Capillary Normal Slight delay Delayed
refill (4sec)
Mental Alert but Irritable, Lethargic to
status may be restless comatose
irritable
Urine Decreased Oliguria Oliguria to
output anuria
PEDS
ACUTE
PEDS
ACUTE
Calculation of Deficit Water & Electrolytes

■ Water Deficit % Dehydration Child’s Weight
■ Sodium Deficit Water Deficit 80 mEq/L
■ Potassium Deficit Water Deficit 30 mEq/L
From Behrman RE, Kliegman RM, Jenson TB. (2004). Nelson Textbook of
Pediatrics (17th ed.). Philadelphia: W.B. Saunders, p. 247.
Type of Dehydration Based on Electrolyte Deficits
Type of Deficit Serum Sodium Level

Isotonic 130–150 mEq/L
Hypotonic 130 mEq/L
Hypertonic 150 mEq/L
Oral Rehydration for Mild to Moderate Dehydration
Use solution such as WHO solution or Rehydralyte:

■ 50 mL/kg over 4–6 hours—mild dehydration
■ 100 mL/kg over 4–6 hours-moderate dehydration
■ 10 mL/kg or 4–8 oz of ORS for each diarrhea stool
■ If vomiting: 5–10 mL every few minutes
Adapted from Behrman, p. 250.
Quick Restoration of Circulatory Volume:
■ If 10% dehydration—fluid boluses intravenously

■ 20 mL/kg of crystalloid solution such as normal saline over 20
minutes, or
■ 10 mL/kg of colloid solution such as 5% albumin
■ Continue as ordered until clinical status improved
Adapted from Behrman, p. 247.
152
Page 153
ACUTE
Selected Emergency Drug Information
PEDS
Drug Use Route Dose in mg
12:28 PM
Adenosine Antiarrhythmic especially Rapid IV, IO 0.1–0.2 mg/kg/dose,

(3 mg/ml) for SVT (maximum single dose
12 mg) repeat q 2–3 min
Amiodarone Antiarrhythmic—prevent Rapid IV, IO 5 mg/kg/dose, (maximum
Hydrochloride or treat Vfib, Vtach, dose 15 mg/kg/day)
SVT especially artial F may infuse IV 20–60 min
12/28/05
Atropine Sulfate Anticholinergic used for IV, IO, ET 0.01–0.02 mg/kg/dose, may
(0.4 mg/ml) bradycardia and to repeat q 2 minutes
restore normal heart (maximum dose 1 mg
153
contraction during children; 2 mg in

cardiac arrest adolescent)
CaChloride Electrolyte used to Slow IV, IO 10–30 mg/kg/dose of 10%
08Holloway (F)-08
10% (100 mg/ml) maintain cardiac Ca Chloride, use with

contractility, treat caution, not for asystole
hypocalcaemia,
hypomag.
Diazepam Anticonvulsant used to Slow IV, IO 0.1–0.2 mg/kg/dose
(5 mg/ml) treat seizures and for (maximum single dose
intubation 5 mg in 5 yr, 10 mg in
5 yr)
Page 154
ACUTE
Selected Emergency Drug Information (Continued)

PEDS

12:28 PM
Dobutamine Beta-adrenergic agonist IV, IO infusion 2.5–15 mcg/kg/minute (see

(12.5 mg/ml) used to depress drug insert for further
myocardial instructions)
contractility
Dopamine Beta-adrenergic IV, IO 2–20 mcg/kg/minute (see
(40 mg/ml) agonist–vasopressor in drug insert for further
12/28/05
cardiogenic or septic instructions and infusion)

shock or to maintain
renal perfusion
154
Epinephrine Adrenergic agonist, IV, IM, IO 0.01 mg/kg/dose; this
1:10,000 sympathomimetic concentration is first
(0.1 mg/ml) used to treat asystole, drug of choice for
08Holloway (F)-08
bradyarrhythmias, Vfib pediatric arrest

Epinephrine See above IV, IO, ET 0.1–0.2 mg/kg/dose; second
1:1,000 and subsequent doses,
(1.0 mg/ml) repeat 3–5 min (may also
infuse at 0.1–1
g/kg/minute)
Page 155
ACUTE
Selected Emergency Drug Information (Continued)
PEDS
12:28 PM
Lidocaine (0.1 ml/ Antiarrhythmic Rapid IV, IO, ET 0.5–1 mg/kg bolus;
kg-10 mg/ml (maximum dose 3
concentration) mg/kg) Infusion 10–50
g/kg/min of 20 mg/ml
solution
Na Bicarbonate Electrolyte used to Slow IV, IO 0.5–1 mEq/kg/dose;repeat
12/28/05
(1 mEq/ml) correct metabolic 5–10 min only if

dilute 1:1 acidosis oxygenated and
with saline ventilated 0.3 wt. kg
155
base deficit efficient

dosing
Naloxone Narcotic antagonist used IV, ET, IO 5 yr: 0.1 mg/kg/dose; 5
08Holloway (F)-08
(Narcan) for narcotic overdose yr: 2.0 mg/kg/dose;

(1 mg/ml) repeat 2–3 min to 10 mg;
ET dose 2- to 10-fold
higher
Refer to pharmacological inserts and other resources for complete information regarding drug use, side
effects, contradictions, etc.
Adapted from Guidelines 2000 for Cardiopulmoary Resuscitation and Emergency Cardiovascular Care, American
Heart Association; and Hay WW, Levin MJ, Sondhelmer JM, Deterding RR. (2005). Current Pediatric Diagnostic
Treatment (17th ed.). New York: Lange Medical Books/McGraw Hill, p. 324.
09Holloway (F) REF 12/28/05 12:28 PM Page 156
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Shelton TL, & Stepanek J. (1994). Family-Centered Care for
Children Needing Specialized Health and Developmental
Services. Association for Care of Children’s Health.
158
159
Simpson K, & Creehan P. (2001). Association of Women’s Health,
Obstetric and Neonatal Nurses’ Perinatal Nursing (2nd ed.).
Philadelphia: Lippincott.
U.S. Preventive Services Task Force (USPSTF). (2005). The Guide
to Clinical Prevention Services. Silver Spring: Agency for
Healthcare Research and Quality Publications. Retrieved August
31, 2005, from http://www.ahrq.gov/clinic/uspstfix.htm.
U.S. Food and Drug Administration. (2001). Pregnancy and the
drug dilemma. FDA Consumer magazine, May-June 2001.
Retrieved August 12, 2005, from
http://www.fda.gov/fdac/features/2001/301_preg.html.
U.S. Food and Drug Administration. (2003). FDA approves new
labeling and provides new advice to postmenopausal women
who use or who are considering using estrogen and estrogen
with progesterone. FDA Fact Sheet. Retrieved June 27, 2005,
from http://www.fda.gov/oc/factsheets/WHI.html.
Hormone therapy for the prevention of chronic conditions in
postmenopausal women: Recommendations from the U.S.
Prevention Services Task Force. (2005). American College of
Physicians; 142(10): 855–860.
Wong D, Perry S, & Hockenberry M. (2002). Maternal Child
Nursing (2nd ed.). St. Louis: Mosby.
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10Holloway (F) Credit 12/28/05 12:29 PM Page 16
TOOLS
Illustration Credits
Pages 5, 6, 25, 35, 36, 54, 84 from Dillon PM: Nursing Health
Assessment: A Critical Thinking, Case Study Approach. FA Davis,
Philadelphia. 2003
Pages 78, 79 from Ross Products Division Abbott Laboratories Inc.
Page 109 from Hay WW, et al: Current Pediatric Diagnosis &
Treatment (17th Ed.) New York: Lange Medical Books/McGraw-Hill.
2005
Pages 110, 152 from Behrman RE, Kliegman RM, Jenson TB:
Nelson Textbook of Pediatrics, 17/e. Philadelphia: W.B. Saunders.
2004
Page 112 from Hahn YS, et al: Head injuries in children under 36
months of age, Child Nervous System. 4:34, 1988
Page 120 from Merkel S, Voepel-Lewis T, Shayevitz J, Malviya, S.
The FLACC: a behavioral scale for scoring postoperative pain in
young children. Pediatric Nursing, 23(3): 293–297. Copyright 2002,
The Regents of the University of Maryland.
Page 125 from McCarthy, PL, Sharpe, MR, Spiesel, SZ, et al (1982).
Observation scales to identify serious illness in febrile children.
Pediatrics, 78:802
Page 147 from Ford EG, Andrassy RJ. Pediatric Trauma Initial
Assessment & Management, p.112, Philadelphia: WB Saunders.
(1994)
160
11Holloway (F)-Index 12/28/05 12:29 PM Page 160
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Index
Note: Page numbers followed by “f” and “t” indicate figures and
tables, respectively.
A Bowel, postpartal assessment,
Abortion, spontaneous, 41 86
Abruptio placentae, 44, 45f BPP. See Biophysical profile
Abuse, child, 148 Bradycardia
Activity level in children, 146
in newborn, assessment of, fetal, 58
97 Breast, infection of (mastitis),
postpartum, 90 94
Adenosine, 153 Breast self exam (BSE), 5–7, 5f,
AIDS. See HIV 6f
Amiodarone, 153 Breastfeeding
Amniotomy, 72–73 advantages to, 80
Apgar score, 69 breast care during, 82
Apnea monitors, 114 engorgement, 81
electrode placement for, nutrition during, 81
115f positioning, 79f, 80
Atropine sulfate, 153 pumping and storing, 81
supply and demand, 81
B
Basal body temperature, fertil- C
ity awareness and, 9 Calcium chloride, 153
Bathing, newborn, teaching Calendar method, of fertility
tips, 99 awareness, 9
Bed/crib choices, by age Caloric requirements, for chil-
group, 122 dren, 109
Biophysical profile (BPP), 51 Cancer. See specific types
Bishop’s score, 71 Cardiac monitors, pediatric,
Bladder, postpartal status, 86 114
Blood pressure, pediatric, electrode placement for,
normal ranges, 112 115f
BMI. See Body mass index Cardiopulmonary resuscitation
Body mass index (BMI) (CPR), pediatric, key points
pediatric, calculation of, 109 for, 144
Bottle feeding, teaching tips, Cardiovascular health, promo-
100–102 tion of, 16
160
161
Cardiovascular system, assess- gastrointestinal, 132
ment of, 130 genitourinary, 132
heart sounds and peripheral musculoskeletal, 133
pulses, 131f neuromuscular, 129
Catheters, pediatric suction, respiratory, 129–130
114 respiratory equipment,
Central venous access devices 130
(CVAD), 143 skin, 132
Cervical cancer screening, 10-minute assessment of,
ACOG/ACS guidelines for, 1 123–124
Cervical mucus, fertility aware- use of play for, by age
ness and, 9 group, 105t–108t
Cervical ripening, 72 Chlamydia, symptoms and
Cesarean birth, 75 detection, 3t
postpartal assessment in, 91 Choking, pediatric, key points
vaginal birth after, 73–74 for, 145
Child abuse, recognizing, 148 Circumcision, teaching tips,
Children 102–103
caloric requirements for, 109 Clonic seizures, 149
communications with, Colorectal cancer, early signs
126t–128t of, 17
developmental milestones Coma scale, pediatric, 112
in, by age group, Communication
105t–108t with child and family,
pain in 126t–127t
developmental differences in newborn, teaching tips,
in, 118 98
nursing interventions Condoms, 11–12
related to management Contraception
of, 119 barrier methods, 10–11
questions in assessment educating women on, 7
of, 117 emergency, 15
responses to illness/hospi- fertility awareness methods,
talization, by age group, 8–9
116t–117t hormonal methods, 11–14
safety education topics, 133 contraindications to, 12
sick, quick evaluation of, intrauterine system, 14–15
125 lactation amenorrhea
systemic assessment, 129 method, 10
cardiovascular, 130, 131t permanent methods, 15–16
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Contraction stress test (CST), intramuscular, 137

50–51 sites for, 139f, 140f
CPR. See Cardiopulmonary intravenous, 137
resuscitation sites for, 142f
CST. See Contraction stress nasal, 136
test nasogastric/orogastric/
CVAD. See Central venous gastrostomy, 135
access devices optic, 136
oral, 135
D otic, 136
Deep venous thrombosis, 95 rectal, 136
signs of, teaching tips, 96 subcutaneous, 137
Defibrillation, pediatric guide-
lines, 146 E
Dehydration, pediatric Eclampsia, 48
degree/signs of, 151 Ectopic pregnancy, 41
water/electrolyte deficit, Electrode placement, pediatric
calculation of, 152 cardiac/apnea monitors, 115f
Delivery, estimated date of, 20 Electrolyte/water deficit, calcu-
Depo-medroxyprogesterone lation of, 152
(DMPA), 14 Emotional response,
Developmental milestones postpartal
0–1 year, 105 assessment of, 88
1–3 years, 106 support for, 89
3–6 years, 107 Endometrial cycle, 8
6–12 years, 108 Endometritis, 94
12–18/21 years, 108 Epinephrine, 154
Diabetes Estrogen
emergencies related to, 148 contraindications to, 12
gestational, 49–50 effects of, 11
Diaphragms, 10 Extremities, assessment of
Diazepam, 153 in newborn, 97
DMPA. See Depo-medrox- in postpartal patient, 89
yprogesterone
Dobutamine, 154 F
Dopamine, 154 Family planning. See
Drug administration, 134–135 Contraception
5 rights of, 134 Fears, in children as response
routes of to illness/hospitalization,
determination of, 134 116–117
intradermal, 137 Febrile seizures, 150
162
163
Fertility awareness methods, H
8–9 Health maintenance, in
Fetal heart tones (FTH), newborn, teaching tips, 103
Doppler placement for, 36f Heart rate, fetal
Fetal monitoring changes to baseline, 58–62
baseline heart rate accelerations, 59, 59f
changes to, 58–62 early decelerations, 59,
evaluating, 56, 57f 60f
continuous late decelerations, 60–61,
external, 55f 60f
internal, 56f nursing interventions for,
intermittent auscultation, 62
54–55 variable decelerations, 61,
nursing responsibilities in, 61f
54 evaluation of, 56
Fetoscope, 54f normal, 57f
FLAAC pain assessment tool, Heart sounds, 131f
120t HELLP syndrome, 48–49
Fluid deficit. See Dehydration Hemorrhage, in postpartal
Food pyramid, 31f patient, 92–93
Formula, infant, 100 Hepatitis, symptoms and
Fundus detection, 3t
height of, 25f Herpes simplex virus
by weeks of gestation, 24 (HSV), 2
massage of, 83f symptoms and detection, 4t
postpartal assessment of, History(ies)
84–85 intrapartum, 52–53
pediatric, concerns by age
G group, 128
Gastrointestinal system, prenatal health, 21–22
assessment of, 132 HIV, symptoms and detection,
Genetic screening, in 4t
newborn, teaching tips, 104 Hormonal contraceptives, 11
Genitourinary system, assess- combined methods, 12–14
ment of, 132 contraindications to, 12
Gestational trophoblastic Hormonal replacement ther-
disease, 41–42 apy (HRT), 18
Gonorrhea, symptoms and Hospitalization, children’s
detection, 3t responses to, by age group,
Grand mal seizures, 149 116–117
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HPV. See Human papillo- Intravenous access sites, pedi-

mavirus atric, peripheral, 141, 142f
HRT. See Hormonal replace- Intravenous maintenance
ment therapy fluids, calculations
HSV. See Herpes simplex virus by body weight, 140
Human papillomavirus of IV rates, 141
(HPV), 2 IUD. See Intrauterine device
symptoms and detection, 3t
Hyperemesis gravidarum, 45 K
Hyperglycemia, 148 Kegel exercises, 88
Hypoglycemia, 148
Hysteroscopic tubal steriliza- L
tion, 16 Labor
active phase (stage 1), 64–66
I epidurals in, 66
Illness, children’s responses to, expulsion (stage 2), 67–69
by age group, 116–117 fourth stage, 76
Immunizations induction of, 71–73
genetic and hearing screen, latent phase (stage 1), 64
teaching tips, 104 monitoring contractions,
in newborn, teaching tips, 62–63
104 nursing care in, 63
Infants placenta delivery (stage 3),
developmental milestones, 70
105 preterm, 46–47
feeds, number/volumes, 109 systemic pain medications
food types, introduction of, in, 65
111 transition phase (stage 1),
vital signs, 110 66–67
See also Newborns Lactation amenorrhea method
Infection, in postpartal patient, (LAM), 10
93–94 LAM. See Lactation amenor-
Injections rhea method (LAM)
intradermal, 137 Leopold’s maneuver, 35f
intramuscular sites, 138, Lidocaine, 155
139f, 140f Lochia, 86
intravenous, 137 assessment of, 87
sites for, 142f normal progression of, 85
subcutaneous, 137 Loss of control, in children as
Intrauterine device (IUD), response to illness/hospital-
14–15 ization, 116–117
164
165
M food pyramid, 31f
Mastitis, 94 in pregnancy, education on,
Menopause 31
hormonal replacement ther-
apy in, 18 O
symptoms of, 17 OCT. See Oxytocin challenge
Menstrual cycle, 7 test
postpartal return of, 85 Osteoporosis, prevention and
Musculoskeletal system, treatment of, 16
assessment of, 133 Ovarian cycle, 8
Oxytocin, in induction of labor,
N 71–72
Naegele’s Rule, 20 Oxytocin challenge test (OCT),
Naloxone, 155 50–51
Neglect, child, 148
Neuromuscular system, P
assessment of, 129 Pain
Newborns developmental differences
breastfeeding of, 78f, 79–82, in children related to,
79f 118
care of, teaching tips FLAAC assessment tool,
bathing/skin care, 99 120t
bottle feeding, 100–102 nursing interventions
circumcision, 102–103 related to management of,
communication, 98 119
reportable symptoms, 104 questions in assessment of,
safety and health mainte- 117
nance, 103 Parenteral nutrition
sleep patterns, 98 calculations
umbilical cord care, by body weight, 140
100 of IV rate, 141
immediate care of, keys for monitoring child on,
68–70 140
nursery care of, 97 Pediatric coma scale, 112
physical assessment of, 97 Pediatric trauma score, 147
Nonstress test (NST), 50 Perineum, postpartal assess-
NST. See Nonstress test ment, 87
Nutrition Petit mal seizures, 149
of children, caloric require- Pitocin. See Oxytocin
ments, 109 Placenta previa, 42, 43f, 45
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Play, type/purpose of, by age preeclampsia, 47–48

group, 121–122 preterm labor, 46–47
Postpartum blues/depression, vaginal bleeding, 42
89, 94–95 delivery date estimating in,
signs of, teaching tips, 96 20
Postpartum patient early
breast assessment, 77 diagnostic testing in,
cesarean, assessment of, 27–28
91–92 education in, 28
complications in establishing, 19
hemorrhage, 92–93 exercise in, 33
infection, 93–94 fetal surveillance in, 50–62
education of, 77 biophysical profile, 51
in breastfeeding, 78–82 contraction stress test,
emotional response, assess- 50–51
ment/support of, 88–89 nonstress test, 50
laboratory data in, 91 hormonal changes in,
nursing assessment of, 23
76–77 low-risk, prenatal visits,
return of menstrual cycle in, scheduling of, 21
85 physiological changes in, 23
sexuality in, 85 second/third trimester,
uterine involution in, 83–84, education in, 38–40
84f sexuality in, 34
Preconception counseling, teratogen exposure in, 30
7 trimesters of, 20
Preeclampsia, 47–48 warning signs during,
Pregnancy 34
classification of medications weight gain in, 33
in, 31 Prenatal visits
common laboratory tests in, first
26 diagnostic tests for, 26
complications in history taking in, 21–22
abruptio placentae, 44f nursing care with, 24
eclampsia, 48 patient education in
gestational diabetes, in early prenatal period
49–50 on discomforts/
HELLP syndrome, 48–49 reportable symptoms,
hyperemesis gravidarum, 28t–29t
45 on exercise, 33
placenta previa, 42, 43f, 45 on nutrition, 31, 32f
166
167
on sexuality, 34 in newborn, teaching tips,
on teratogen exposure, 103
30 of toys, by age group,
on warning signs, 34 121–122
on weight gain, 33 Screening, cervical cancer,
in second/third trimester, ACOG/ACS guidelines for, 1
38 Seizures, general types of,
on discomforts/ 149–150
reportable symptoms, Separation anxiety, in children
39t–40t as response to illness/hospi-
return talization, 116–117
diagnostic tests for, 37 Serum pregnancy test, 19
nursing care for, 35–36 Sexuality
scheduling, 21 postpartal, 85
Preterm labor, 46–47 in pregnancy, 34
Progestin Sexually transmitted diseases
contraindications to, 12 (STDs), 2, 3t–4t
effects of, 11 Skin
single agent preparations, assessment of, 132
14 care of, in newborn, teach-
Pulse oximetry, pediatric, 114 ing tips, 99
Pulseless arrest, in children, Skin cancer, early
147 detection/prevention of,
Pulses, peripheral, 131f 17
Sleep patterns, in newborn,
R teaching tips, 98
Rehydration, 152 Sodium bicarbonate, 155
Respiratory failure, cardinal Status epilepticus, 150
signs of, 148 STDs. See Sexually transmit-
Respiratory system, assess- ted diseases
ment of, 129–130 Suctioning, pediatric, 114
Syphilis, symptoms and detec-
S tion, 4t
Safety
of drug dose, determination T
of, 134 Tachycardia
education topics, by age in children, 146
group, 133 fetal, 58
in infant/child assessment, Teratogens, in pregnancy,
123–124 education on, 30
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Thrombophlebitis, 95 V
signs of, teaching tips, 96 Vaginal birth after cesarean
Tonic seizures, 149 (VBAC), 73–74
Toys, safe, by age group, Vaginal bleeding, in preg-
121–22 nancy, 42
Trauma, score, pediatric, 147 VBCA. See Vaginal birth after
Trichomoniasis, symptoms and cesarean
detection, 3t Venipuncture sites, pediatric,
Tubal ligation 142f
hysteroscopic, 16 Vital signs
incisional method, 15 newborn, 97
pediatric, average ranges,
U 110
Ultrasonography, in establish- postpartum, 90
ing pregnancy, 19
Umbilical cord W
care of, teaching tips, 100 Water/electrolyte deficit, calcu-
prolapse of, 74 lation of, 152
Urinary tract infection, in post- Water requirements, pediatric,
partal patient, 93–94 110
Urine output, pediatric, 110 Weight gain, in pregnancy,
Urine pregnancy test, 19 33
Uterus Weight loss, at birth, 91
infection of (endometritis), Weight management, promo-
94 tion of, 16
involution of, 83 Women, health promotion in,
subinvolution signs, teach- 16–17
ing tips, 96 nurses’ role in, 1
168
Notes

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00Holloway (F) FM 12/28/05 12:23 PM Page 2

A Davis’s Notes Book

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ACOG Guidelines Annually

■ Women 30 years of age and older, with three consecutive

Sexually Transmitted Infections (STIs)

■ Abstinence from sexual activity (both oral and genital) is the

(Continued text on following page)

Sexually Transmitted Infections (STIs) (Continued)

Gonorrhea Yellow-green vaginal discharge Endocervical culture

Trichomoniasis Frothy malodorous vaginal discharge Saline wet mount of vaginal

Sexually Transmitted Infections (STIs) (Continued)

Syphilis Primary Serological testing

Tertiary ■ Effective treatment will result

Malaise (Pretest and posttest counseling

BSE positions. (From Dillon PM. (2003) Nursing Health Assessment: A

BSE palpation patterns. (From Dillon PM. (2003). Nursing Health

Family Planning Options

follicle stimulating hormone (FSH), encouraging maturation

Ovarian Cycle Endometrial Cycle

■ Refraining from sexual activity is the only 100% effective way

Fertility Awareness Methods

■ Teaches familiarity with body in order to recognize signs of

Subtract 18 from the shortest menstrual

Subtract 11 from the longest menstrual

Lactation Amenorrhea Method (LAM)

■ Prolactin suppresses follicle stimulating hormone (FSH), and

Prevents conception by blocking entry of sperm into the cervix

■ May cause serious health issues; advise hormonal contra-

Combined Hormonal Methods

Combination Oral Contraceptives (OC)

Progestin Only Preparations

■ Progestin-only preparations are indicated for women who

Intrauterine system (IUS)/Intrauterine Device (IUD)

■ Inhibits fertilization by altering fallopian tube transport of

Emergency Contraception (EC)

Contraceptive agents used after unprotected intercourse

■ Prevent conception by mechanically blocking the fallopian

Hysteroscopic Tubal Sterilization (Nonincisional method)

Health Promotion in Adult Women

■ Cholesterol screening every 5 years after age 20

Promotion of Weight Management and Fitness