NCLEX Review of Maternity Nursing NP07L018 / Version 1.

1 01 Jan 2004
SECTION III. PRESENTATION

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Learning Step / Activity 1. Check your mastery of Maternity Nursing

1. Review a. Read the comprehensive nursing content review b. Answer review questions on Maternity Nursing c. Review answers and rationales for each test questions (1) The rationales for correct answers reinforces learning (2) The rationales for incorrect answers corrects knowledge deficits and identifies areas of focus for further study 2. Fetal development a. Terms (1) Zygote-Formed by the union of the sperm and ovum. (2) Embryo-Developing baby from the 3rd week to the end of the 8th week after fertilization. (3) Fetus- From the 9th week after fertilization until delivery, the developing baby is called a fetus. b. Zygote Stage: The Zygote develops in 2 distinct areas, the amniotic cavity and the yolk sac. (1) Amniotic cavity-The walls of this cavity are lined with ectoderm (outer layer of embryonic tissue that develops the skin, hair and nails) and filled with amniotic fluid. (2) Yolk-Sac-Lined with the endoderm (innermost cell layer that develop into the lining of the cavities and passages of the body, and develops into the covering of most internal organs). It supplies nourishment until implantation. (3) Mesoderm-This is a third area where Zygote development occurs. It is located between the 2 germ cells (ectoderm and endoderm) and develops into all types of muscles, connective tissue, bone marrow, blood, lymphoid tissue and epithelial cells. (4) The embryo develops at the location of implantation, where all 3 of the above listed layers (ectoderm, endoderm and mesoderm) meet. This location is known as the trilaminar embryonic disk. c. Embryonic Stage (1) The 3 primary cell layers differentiate into tissue and layers from the placenta and embryonic membranes. (2) Growth is rapid! A simple heartbeat begins and basic forms of all the major organ systems begin. (3) By the end of this stage, the embryo has developed a human appearance.

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(4) During this stage, teratogenic agents (drugs, viruses, radiation, infectious agents) can cause serious harm to the embryo. d. Stages of Development of the Embryo (1) Week 3: The first body segments appear: (a) Neural tube forms. (b) Primitive Brain. (c) Primitive Spinal Cord. (2) Week 4: The embryo is now 1/5th inch long, and the head is a third of its total length. The following begins to form: (a) Heart pumps blood. (b) Neural tube closes. (c) Digestive Tract- esophagus and trachea separate; stomach forms. (3) Week 5: (a) The heart starts to pump blood, has 2 chambers. (b) Limb buds appear. (c) Major divisions of the brain can now be discerned. (4) Week 6: (a) Heart has 4 chambers. (b) External ears develop from skin folds. (c) Eyes begin to take shape. (5) Week 7: Development is proceeding rapidly. (a) The face is now formed with eyes, nose, lips and tongue. (b) Tiny bones and muscles appear beneath the thin skin. Even tiny primitive milk teeth can be seen. (6) Week 8: (a) The embryo is now a little more than 1 inch long. (b) Fingers and toes are formed. (c) Purposeful movements occur but mother can't feel these yet. (d) Heart beats at 40-80 beats/minute.

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e. The fetus- at 9 weeks the genitalia are well developed and sex of the baby determined. (1) Week 10: The fetus assumes a more human shape as the lower body rapidly develops. (a) Heartbeat detected by Doppler. (b) The first movement begins. (2) Week 16: All organs and structures have been formed, and a period of simple growth begins. (3) Week 20: (a) The fetus is now following a regular schedule of sleeping, turning, sucking, and kicking. (b) May be considered as the point of viability. (c) Lanugo covers the fetal body. (4) Week 24: (a) The fetus now weighs about 820 grams. (b) The eyes are complete, and are capable of opening and closing. (5) Week 28: (a) Fetal weight increases to 1300 grams. (b) Nervous system begins some regulatory functions. (6) Week 32: Fully developed skeletal system is soft and flexible. 3. Fetal vs. Neonatal Circulation a. Fetal circulation provides oxygen and nutrients to the fetus and disposes of carbon dioxide and other waste products from the fetus. (1) Oxygenated blood is brought to the fetus by the umbilical vein and enters the fetal liver, where it branches. (2) The first branch (portal sinus) carries some of the oxygenated blood to the portal circulation and empties, via the hepatic vein, into the inferior vena cava. (3) The second branch (ductus venosus), carries most of the blood directly into the inferior vena cava, where it mixes with blood returning from the lower limbs, abdomen, and pelvis of the fetus to the fetal heart. (4) Blood entering the heart from the vena cava is directed across the right atrium through the foramen ovale to the left atrium. (5) Blood is then ejected from the left ventricle into the aorta and further circulated to the coronary arteries, brain, and upper extremities. (6) Venous blood returning from this region returns to the right atrium through the superior vena cava and is directed downward through the tricuspid valve into the right ventricle. (7) It is then pumped into the pulmonary artery, where the majority of the blood is shunted to the

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4. e.SBP > 160 mmHg and DBP>110 mmHg on two separate occasions 6 hours apart. the newborn's lungs expand and the fluid within them is absorbed into the pulmonary circulation. (2) Ectopic Pregnancy. (2) Abruptio Placentae-is the premature separation of a placenta that is normally implanted. 5. (3) Eclampsia .when the fertilized ovum (zygote) is implanted outside the uterus. The powers . (2) Severe Preeclampsia . proteinuria and generalized edema. (1) Mild Preeclampsia . d. which can result in the mother's antibodies destroying the newborn's red blood cells. Pregnancy induced hypertensio-Elevation of blood pressure in a previously normotensive woman after 20 weeks gestation. which ends before viability (20 weeks gestation) from natural causes. b. Urine output less than 500cc/24 hours. b.descending aorta through the ductus arteriosus and perfuses the lower body. (2) With that first breath. (3) The foramen ovale closes as the pressure in the left atrium exceeds the pressure in the right atrium. which significantly hinders nutritional status and fluid balance and causes electrolyte and metabolic imbalances. Blood incompatibilities-a condition that occurs after maternal exposure to Rh-positive blood. 4 .Generalized seizures with oliguria (Preeclampsia progresses to eclampsia when convulsions occur). Components of the Birth Process a. Hyperemesis gravidarum-excessive nausea and vomiting. Liver enzymes are markedly elevated. Urine protein is >5g/24h. (8) Only a small amount of blood enters the fetal lungs as a result of high pulmonary resistance. Late pregnancy bleeding (1) Placenta Previa-occurs when the placenta develops in the lower part of the uterus. (1) Spontaneous Abortion-pregnancy. . Circulation Changes at Birth (1) With the first breath. c. Common Complications of Pregnancy a. Trace protein in urine and liver enzymes are minimally elevated. pulmonary and right heart pressures fall and systemic pressures begin to rise with the removal of the placenta. (4) The ductus arteriosus closes with the increased oxygen content of the newborn's blood.SBP 140-160 mmHg and DBP 90-100 mmHg.forces that cause the cervix to open and that propel the fetus downward through the birth canal. Occurs between an Rh-negative mother and an Rh-positive fetus. Bleeding disorders of early pregnancy.

1) Effacement . Moderate contractions feel similar to the chin and strong or firm contractions feel similar to the forehead. 1) Uterine contractions are the primary power of labor during the first stage. it feels similar to the tip of the nose. 126.Thinning of the cervix. (c) Phases of contractions 1) Increment . When the cervix is 100% effaced or “completely” effaced it feels like a thin (paper thin). and described in centimeters. described as a percentage. and vaginal examinations.the period of greatest strength of the contraction.involuntary smooth muscle contractions. Refer to Figure 6-4. 2) Acme or peak .contractions cause the cervix to efface and dilate so that the fetus may descend into the birth canal. For example.is the approximate strength of the contraction. Usually described as “mild”.the period of increased strength of the contraction. (d) Characteristics of contractions 1) Frequency . 3) Intensity or strength . p.is the elapsed time from the beginning of one contraction until the beginning of the next contraction. it is about one-half of its original length. Duration is described as the average number of seconds for which contractions last.(1) Uterine contractions (a) Definition . (b) Effect of contraction .is the elapsed time from the beginning of a contraction until the end of the same contraction. 2) Duration . slick membrane over the fetus. 2) Intensity and effectiveness of contractions are influenced by a variety of factors. (2) Maternal pushing (a) When the cervix is fully dilated (10 cm) the woman adds voluntary pushing with the contractions. (b) Factors affecting pushing 5 . ”moderate.is the amount of time the uterus relaxes between contractions. With mild contractions the uterus can easily be indented with the fingertips.the period of decreasing strength of the contraction. 3) Decrement . women cannot consciously cause them to stop or start. if the cervix is 50% effaced. NOTE: Persistent contraction intervals shorter than 60 seconds may reduce fetal oxygen supply.” or “strong”. 2) Dilation . maternal anxiety. The combined powers of the contraction and the maternal pushing propel the fetus downward through the pelvis. Leifer. full dilation being 10 cm.Opening of the cervix. 4) Interval . drugs. such as walking. is determined by a vaginal examination. such as “40-60 seconds long”.

(3) Soft tissues (a) Cervix. muscles. (c) Soft tissue may yield less readily: 1) In older mothers 2) After cervical procedures that have caused scarring (cone biopsy. and the outlet near the perineum.consists of the mother’s bony pelvis and the soft tissues (cervix. laser surgery) 3) After many years between births c. the midpelvis in the middle. it’s shaped like a curved cylinder. ligaments. The true pelvis is divided into the inlet at the top. and fascia (b) Women who have had previous vaginal births generally deliver more quickly because their soft tissues yield more readily to the forces of the contractions.is the fetus. (c) Fontanel .1) Maternal exhaustion 2) Epidural anesthesia (c) Some women may want to push prematurely due to the fetal head causing rectal pressure.a tiny triangular depression formed by the intersection of three sutures (the sagittal and two lambdoid) (d) Molding .the lower part of the pelvis. the sutures.a wide area formed where the sutures meet. the true pelvis is directly involved in childbirth. b. (2) Bony pelvis (a) False pelvis . 6 . and fascia) of her pelvis and perineum. The passage (1) Definition . muscles. and two coronal) 2) Posterior fontanel .Sutures and fontanels of the fetal head allow the head to change shape as it passes through the pelvis. ligaments.the upper flaring part of the pelvis (b) True pelvis . (b) The fetal head is composed of several bones linked together with tough connective tissue. 1) Anterior fontanel . The passenger (1) Definition .a diamond-shaped area formed by the intersection of four sutures (frontal. along with the placenta and membranes (2) Fetal head (a) The fetus usually enters the pelvis headfirst. The fontanels and sutures play an important role in determining how the fetus is oriented within the mother’s pelvis. sagittal.

both fetal legs are flexed at the hips and flexed at the knees. 2) Sacrum is used to describe how a fetus in a breech presentation is oriented within the pelvis. (b) Types 1) Longitudinal lie . NOTE: Refer to Figure 6-7.the fetal head is the first to enter the pelvis. with this presentation fetus must be delivered by cesarean section.(3) Lie (a) Describes how the fetus is oriented to the mother’s spine. with the head flexed forward and the arms and legs flexed. There are three variations of the breech presentation.is the second most common presentation (3-4% of term births). (6) Position (a) Refers to how a reference point on the fetal presenting part is oriented within the mother’s pelvis. This is the most common presentation (95% of births at term). arms and/or legs sometimes occurs.(the most common). 1) Occiput is used to describe how the head is oriented if the fetus is head down. c) Footling breech . p. with both feet presenting. or double. 128. This is the most common lie. (5) Presentation (a) Refers to the fetal part that enters the pelvis first (b) Types: 1) Cephalic or vertex presentation . 7 .the fetus is at a right angle to the mother’s spine.the fetus is parallel to the mother’s spine. May also be called shoulder presentation. fetal legs flexed at the hips and extending toward the shoulders. (b) Extension of the head. This is the only breech presentation that may be delivered vaginally.the fetus is in a transverse lie with the shoulder entering the pelvis first. 3) Shoulder presentation . b) Full or complete breech . (99% of births) 2) Transverse lie . Leifer. (4) Attitude (a) The fetal attitude is normally one of flexion.may be single with one foot presenting. NOTE: Refer to Figure 6-6. a) Frank breech . Leifer. 2) Breech presentation .the fetus is between a longitudinal and a transverse lie. 129. 3) Oblique lie . p.

3) The shoulder and back are used as reference points if the fetus is in a shoulder presentation or transverse lie. (b) The pelvis is divided into four imaginary quadrants: 1) Right anterior 2) Left anterior 3) Right posterior 4) Left posterior (c) Abbreviations describe the fetal presentation and position within the pelvis. such as Occiput Anterior (OA). Transverse (T) denotes a fetal position that is neither anterior nor posterior.Right Mentum Anterior c) LMP.Right Mentum Posterior 3) Breech presentation 8 . 2) Second letter .Left Mentum Anterior b) RMA. and sacrum) 3) Third letter . Three letters are used for most abbreviations: 1) First letter .Left Mentum Posterior d) RMP.is the fetal reference point (occiput. This letter is omitted if the fetal reference point is directly anterior or posterior.front or back of the mother’s pelvis (anterior or posterior). mentum.is the right or left side of the women’s pelvis. (d) Classifications of fetal positions 1) Cephalic presentations a) LOA Left Occiput Anterior b) ROA Right Occiput Anterior c) LOP Left Occiput Posterior d) ROP Right Occiput Posterior e) ROT Right Occiput Transverse f) LOT Left Occiput Transverse g) OA Occiput Anterior h) OP Occiput Posterior 2) Cephalic presentations (face): a) LMA.

(e) Cultural influences. (b) Irritation or itching with the increased secretion is not normal and should be reported to the health care provider. better able to tolerate discomfort and work with the labor process. The psyche (1) Definition .a) LSA Left Sacrum Anterior b) RSA Right Sacrum Anterior c) LSP Left Sacrum Posterior d) RSP Right Sacrum Posterior NOTE: To simplify reference to the various positions. effaces. (c) Anxiety and fear also cause secretion of stress compounds from the adrenal glands (catecholamines) that inhibit uterine contractions and divert blood flow from the placenta. a woman may quietly endure labor pain without a complaint. (b) Anxiety can increase her perception of pain and reduce her tolerance of it. it softens. and dilates slightly.are irregular contractions that begin during early pregnancy and intensify as full term approaches (2) Increased vaginal discharge (a) Fetal pressure causes an increase in clear and nonirritating mucous secretions. then point of reference used (on the fetus) and then adjectives anterior. include a culture that value stoicism. Process of Childbirth a. 9 . 6. posterior. the descriptive phrase usually begins with the right or left (of mother's pelvis). Impending labor (1) Braxton-Hicks contractions . (d) Individual values influence how the woman views and copes with childbirth. She may or may not feel comfortable with the husband’s presence. Other cultural groups express their feeling openly. (3) Bloody show (a) Thick mucus mixed with pink or dark-brown blood (b) Bloody show occurs: 1) When the cervix undergoes changes in preparation for labor.how the influence of a women’s mental state affects the course of her labor (2) Influences: (a) Relaxed and optimistic. these women may respond loudly to labor. or transverse (referring to part of mother's pelvis) toward which a particular point on the fetus is directed. When the cervix makes these changes a mucus plug that has sealed the uterus during pregnancy is dislodged from the cervix. d. tearing small capillaries in the process.

is the fetus moving downward into the maternal pelvis. or a woman may not have bloody show until labor is under way.occurs when the fetal presenting part is at a zero station or lower (a) Nullipara .Occasionally the woman may notice that she losses 1-3 pounds shortly before labor begins as hormone changes cause her to excrete extra body water. plus stations are below the ischial spines.The fetal umbilical cord may slip down and become compressed between the mother’s pelvis and fetal presenting part. because the amniotic sac seals the uterine cavity against organisms from the vagina.Engagement usually occurs before the onset of labor. (5) Energy spurt (a) Nesting . (a) Station is measured from the level of the ischial spines in the mother’s pelvis.2) If the woman has had a recent vaginal examination. this must occur for all other mechanisms to occur and for the baby to be born.a sudden burst of energy shortly before the onset of labor. (4) Rupture of the membranes (a) The amniotic sac (bag of waters) usually breaks during or immediately before labor. the curved. (b) Minus stations are above the ischial spines. 0. Mechanisms of labor (1) Descent . (c) Bloody show may begin a few days before labor.is a higher risk if many hours elapse between ROM and birth. 10 . even if they feel a burst of energy. (c) As the fetus descends. (c) Risks of ROM (Rupture of the Membranes) 1) Infection . As labor progresses. 2) Cord prolapse .describes the level of the presenting part. if the presenting part of the fetus (usually the head) were even with the ischial spines it would be a zero station. (2) Engagement .To pass most easily through the pelvis.As the fetus is pushed down into the maternal pelvis by contractions. (3) Flexion . (b) The nurse should teach women to conserve their strength. the minus numbers get smaller (-2. (b) The patient should go to the birthing facility as soon as she thinks her membranes have ruptured even if she is not in labor due to the increased risks.Engagement may not occur until after labor begins. (b) Multipara . +1. +2) and the plus numbers get higher. Station . 3) If the woman has recently has sexual intercourse. uterine contractions increase the amount of fetal head flexion until the fetal chin is on the chest. b. (4) Internal rotation . -1. the fetal head should be flexed. (c) Weight loss .

(5) Extension . 2-3 minutes apart lasting as long as 90 seconds. As the fetal head continues to rotate the shoulders turn within the pelvis so that they can be born. (6) External rotation . Stages of labor (1) First stage (stage of dilation) (a) From the onset of labor until full dilation of the cervix (10 cm) (b) This is the longest stage. May complain of lower back pain.As the fetal head passes under the mother’s symphysis pubis.As the fetal head is born it spontaneously turns to one side as it realigns with the shoulders (restitution). (c) Three phases occur within the first stage of labor: 1) Latent phase . 2) Active phase a) The cervix dilates from 5-7 cm. mentally turns inward and concentrates on the task of giving birth. c. contractions gradually increase in strength and intensity.from the onset of labor until about 4 cm of cervical dilation a) During the latent phase. (7) Expulsion . b) Effacement is complete. quickly followed by the rest of the body. it must change from flexion to extension. (2) Second stage (stage of expulsion) 11 . b) The woman is usually sociable and excited. may become uncooperative and even hostile. This is the phase that most laboring women will ask for pain medication. they intensify until they are about 3 minutes apart lasting 45 seconds. c) Contractions are firm. d) The woman in labor often feels as if she is losing control. b) This is the shortest phase of labor. averaging 8-10 hours for the nullipara and 6-8 hours for the multipara. 3) Transition phase a) The cervix dilates from 8-10 cm. c) Contractions are moderate to firm.The anterior shoulder and then the posterior shoulder are born. cooperative but anxious. d) The woman become less sociable.cylindrical shape of the pelvis caused the head to turn until the occiput is directly under the symphysis pubis. they are mild and infrequent about 5 minutes apart.

full bladder may cause increased bleeding. (d) The woman’s bladder may fill rapidly due to I. lacerations or episiotomy.if the rough maternal side of the placenta delivers first (c) The uterus must promptly contract and remain contracted after placental expulsion. and 20-45 minutes in multiparas. (4) Fourth stage (recovery) (a) One to four hours following birth (b) The uterus should be easily felt through the abdominal wall as a round firm object about the size of a grapefruit. to help the uterus to contract. fluid. 7. 12 . Amniotomy (1) Definition . (d) Oxytocin (Pitocin) is usually given in the mother’s I.5 hours in the nullipara. The infant’s suckling at mother’s breast also stimulates uterine contractions.of the amniotomy is to stimulate contractions or to enhance contractions that have already started. (d) The woman that has not had regional anesthesia has an involuntary urge to push or bear down with each contraction. (3) Third stage (placental stage) (a) Extends from the birth of the baby until the placental is expelled (b) Two ways the placenta may deliver: 1) Schultze mechanism .is artificial rupture of the membranes (AROM) by using a sterile sharp instrument. she may feel some brief cramping.if the shiny fetal side of the placental delivers first 2) Duncan mechanism . (c) There is usually minimal pain during this stage. Be sure the woman empties her bladder. There may be perineal discomfort from bruising. fluids and loss of retained fluid. (e) The woman usually regains control during this stage and often says that pushing feels good or makes her feel useful.(a) Extends from the time of full cervical dilation until the baby’s birth (b) The average duration of the second stage is 1. but may be slightly less frequent and shorter in duration. (e) The fourth stage of labor is an ideal time to promote bonding between the family and the new baby. about halfway between the umbilicus and symphysis pubis.V. (2) Purpose . Obstetric procedures a. to control bleeding from the vessels that supplied the placenta before birth. (e) Pain is usually minimal during the third stage.V. (c) Contractions are firm. The uterus should be centered at midline.

2) Record the color. 2) The underpads need to be changed frequent enough to keep patient dry and to reduce the moist. It may suggest infection. (4) Complications (a) Prolapse of the umbilical cord . Thick meconium may be associated with fetal compromise during labor. 5) Green fluid means that the fetus passed the first stool (meconium) into the fluid before birth.is the initiation of labor before it begins naturally. and reported to the charge nurse or doctor. 13 . 3) The woman’s temperature is taken every 2 hours after the amniotic sac is broken. or malodorous fluid is noted. If the rate is outside the normal range (110-160 beats/minute) it is noted. usually above 160 beats/minute. (b) Infection . but the placenta stays the same size and no longer fits its implantation site. and the amniotic sac is snagged to create a hole and release the amniotic fluid. warm environment that favors growth of microorganisms. it may suggest infection and must be noted and reported. Induction or Augmentation of Labor (1) Definitions (a) Induction of labor . b.4 F or higher.(3) Technique (a) To determine if an amniotomy is safe the doctor or nurse-midwife does a vaginal exam to evaluate the cervix and the station of the baby. and amount of the amniotic fluid. Report the patient’s temperature if it reaches 100. (b) Promoting Comfort 1) Place several underpads under the woman’s hips to absorb the fluid. 4) An increase in fetal heart rate. If cloudy. The fluid should be clear and may contain vernix. may suggest infection. yellow. 2) May happen with amniotomy because the uterus becomes smaller with discharge of amniotic fluid. (5) Nursing Care (a) Identifying Complications 1) The fetal heart rate is recorded for at least 1 minute after an amniotomy. odor. (b) A disposable plastic hook is passed through the cervix.the cord may slip down with the gush of fluid. (c) Abruptio Placentae 1) Separation of the placenta before birth.may occur because the membranes no longer block vaginal organisms from entering the uterus. May vary from thin meconium (green-tinged) to thick meconium (“pea soup”).

(c) High station of the fetus. 2) Ruptured membranes without spontaneous onset of labor. (4) Technique (a) Amniotomy may be the only method needed to initiate labor. 2) Laminaria .Labor is not induced in these situations: (a) Placenta previa. (b) Reasons may include: 1) Pregnancy . (b) Cervical Ripening. Start at a very low dose and increase the dose 14 . (2) Indications to induce labor (a) Labor is induced if continuing the pregnancy is more hazardous for mom and fetus than delivery. 1) Prostaglandin gel (Prepidil) is a gel placed on the cervix to soften it before induction of labor. 5) Fetal problems. (d) Active herpes. (e) Abnormal size or structure of the mother’s pelvis.(b) Augmentation of labor .is a narrow cone of a substance (seaweed) that absorbs water and swells inside the cervix causing dilation of the cervix. 2) Pitocin is diluted in an intravenous solution. 6) Fetal death. 4) Medical problems in the woman that worsen during pregnancy.induced hypertension. (g) Previous classic cesarean incision. 3) Pitocin is regulated with an infusion pump. Some women begin labor soon after the gel is placed. (b) Umbilical cord prolapsed. (f) Abnormal fetal presentation. The Pitocin is the secondary line so that it may be shut off quickly while the main IV continues to infuse. 3) Infection within the uterus. (c) Oxytocin Induction and Augmentation of Labor 1) Pitocin (oxytocin) is the most common method of induction and augmentation of labor. (3) Contraindications .is the stimulation of contractions after they have begun naturally.

b) Brushing the nipples with a dry wash cloth. pulse and respirations every 30-60 minutes. (b) Monitor FHR and contractions during induction. (c) B/P. (c) Nursing Interventions with Complications of oxytocin. 2) Nipple Stimulation of Labor . Stop oxytocin if either is abnormal. 2) In addition to turning off the Oxytocin the nurse may: a) Increase the non-medicated IV fluid.directed by an RN (a) Baseline vital signs and fetal monitor tracing to detect contraindications to induction. c. a) Pulling or rolling the nipples. 4) Continuous electronic fetal monitoring is the usual method to assess and record fetal and maternal responses to Pitocin. fetal compromise and uterine rupture. b) Keep the woman off her back. 1) Oxytocin is discontinued or rate is reduced if the fetal heart rate is out of the normal range or if there are excessive uterine contractions. Version 15 . c) Give the woman oxygen via face mask.stimulates contractions. (6) Nursing Care. d) Applying suction with a breast pump. eases pressure of the fetus on the mother’s back. (e) Intake and output to assess for water intoxication. and adds gravity to the downward force of the contraction. (d) Temperature every 2-4 hours. (b) Water intoxication sometimes occurs because oxytocin inhibits excretion of urine and promotes fluid retention. (5) Complications of Oxytocin (Pitocin) (a) The most common complications are related to over-stimulation of contractions. c) Using water in a whirlpool tub or a shower.stimulating the nipples causes the woman’s posterior pituitary gland to secrete natural oxytocin. (d) Non-drug Methods to Stimulate Contractions 1) Walking .according to the doctor’s orders.

(3) Risks. (d) Observe for contractions. 3) The woman receives a tocolytic medication (terbutaline) to relax the uterus. 2) Internal Version. 1) Report to the doctor if contractions don’t stop shortly after the procedure. (b) Most cases of previous cesarean birth. causing cord compression. (b) Observe the mother and fetus for 1-2 hours after the procedure. (4) Technique (a) External Version 1) Done after 37 weeks gestation. 2) Teach the patient the signs and symptoms of labor before sending the patient home. (b) Internal Version 1) Is an emergency procedure. usually from breech to cephalic. (5) Nursing Care (a) The nurse assists the doctor with the procedure. the doctor pushes the fetal buttocks upward outward and at the same time pushes the fetal head toward the pelvis. Episiotomy and Lacerations 16 . (c) Abnormal placental placement. d. (c) Observe for leaking of vaginal fluid. The fetus may become entangled in the umbilical cord.(1) Definition (a) A method of changing the fetal presentation. 4) Using ultrasound to guide the procedure. 2) The procedure begins with a nonstress test or biophysical profile. which may indicate that the membranes are ruptured. (b) Types 1) External Version (most common). (2) Contraindications (a) Abnormal uterine or pelvic size or shape. 2) The physician performs internal version during vaginal birth of twins to change the fetal presentation of the second twin.

17 . 2) Greater scarring. 3) More likely to affect the rectum.are usually uncomplicated and heal quickly because they don’t affect the rectal sphincter. (3) Indications for Episiotomy (a) Better control over the direction and amount that the vaginal opening is enlarged (instead of tearing). (5) Technique . (b) Risk of extension of the episiotomy with a laceration into or through the rectal sphincter. (4) Risks (a) Infection is the primary risk. 1) Provides more room. (b) An opening with a clean edge. this increases blood flow and promotes healing.Episiotomy is done with blunt-tipped scissors just before birth. or cervix (2) Classifications: (a) 1st and 2nd degree laceration . (7) Nursing Care (a) Place cold packs on perineum to reduce pain.the surgical enlargement of the vagina during birth. (b) Lacerations . (6) Types of episiotomy: (a) Median (midline)--extending directly from the lower vaginal border toward the anus.extends completely though the rectal sphincter. 2) Heals neatly. bruising and edema during the first 12-24 hours. (c) 4th degree laceration .extends from the lower vaginal border toward the mother’s right or left.a tear in the perineum. (b) After the first 24 hours apply warm applications. (b) Mediolateral . (b) 3rd degree laceration .(1) Definitions (a) Episiotomy . 3) May cause painful sexual intercourse.extend to the rectal sphincter. 1) Easier to repair. (c) Provide mild PO analgesics for pain management. rather than the ragged opening of a tear. vagina.

intracranial hemorrhage. (b) The infant may have facial bruising. and suction is increased by a hand pump to hold it in place. (3) Contraindications (a) These procedures are not done if a cesarean section is less traumatic. to deliver the fetal head during a breech delivery. because prolonged pushing can worsen these conditions. (b) If the woman has regional anesthesia and is unable to push effectively. where the vacuum was placed.After the forceps are applied. (b) Vacuum Extractor 1) Uses suction applied to the fetal head so that the physician can assist the mother’s pushing. 2) The vacuum does not take up the room in the mom’s pelvis like the forceps do. the doctor pulls in line with the pelvic curve. cephalohematoma. 2) Piper forceps are a special type. (5) Technique (a) Forceps . (4) Risks.instrument with curved blades that fit around the fetal head without compressing it. Trauma to the maternal and/or the fetal tissues is the main risk. (2) Indications (a) Mother is exhausted and is unable to push.the doctor places the cup over the fetal occiput. (a) The woman is at risk for lacerations and hematomas in her vagina. assists in delivery of the fetus. (c) Women with cardiac or pulmonary disorders often have forceps or vacuum extraction birth. (b) Vacuum . (6) Nursing Care 18 . (b) They are not done if the fetus is too high in the pelvis. called chignon. (c) The vacuum may cause an area of circular edema. After the head is born. Forceps and Vacuum Extraction Births (1) Definitions (a) Forceps . (d) Fetal compromise toward the end of labor. (c) They are not done if the fetus is too big for the pelvis. lesions or abrasions. the forceps are removed and the rest of the body is delivered naturally.e. 1) Forceps may also assist the doctor to extract the fetal head during a cesarean section. an episiotomy is usually done.

the cord is visible at the vaginal opening. (4) Medical Treatment (a) Displace the fetus upward to stop the compression. 1) Knee-chest position. (b) Maternal 1) After birth. (2) Classifications (a) Complete . 2) Trendelenburg. Prolapsed Umbilical Cord (1) Definition . to include a catheter to empty the woman’s bladder. place ice to the perineum to reduce edema and bruising.the prolapse is hidden and cannot be seen or felt. 8. it can be compressed between the fetal body and the woman’s pelvis thus interrupting blood supply to and from the fetus. (d) Hydramnios.the umbilical cord prolapses if it slips downward in the pelvis after the membranes rupture. but it can be felt as a pulsating structure when a vaginal examination is done. (a) May happen immediately after the membranes are ruptured. (c) Occult .the cord cannot be seen. may indicate a vaginal hematoma. (c) Infant 1) Examine the infant’s head for lacerations. it is suspected on the basis of abnormal fetal heart rates.(a) The nurse places the sterile equipment on the delivery instrument table. (b) Very small fetus. (b) May occur much later in labor. 2) Notify doctor of severe and poorly relieved pelvic or rectal pain. Emergencies a. This usually resolves on its own. (b) Palpated . 19 . 2) Watch for facial asymmetry. (3) Risk Factors (a) Fetus is high in the pelvis when the membranes rupture. may indicate injury of the infant’s facial nerves. bruising or abrasions. (c) Abnormal presentation (breech).

separates. 20 .a tear in the uterine wall that occurs if the uterine muscle cannot withstand the pressure inside the organ. as with use of Pitocin. (b) Shock due to bleeding into the abdomen. or with inspiration. (5) Nursing Interventions (a) Assist with emergency procedures. such as a ligament. (3) Risk Factors (a) Previous surgery on the uterus. (e) Cessation of contractions. (c) After the birth. explain to the patient and family what happened. between the scapulae. there may be no signs or symptoms. usually from a previous cesarean birth. b.3) The nurse or doctor may push the fetus upward from the vagina. (c) Dehiscence 1) An old uterine scar. Uterine Rupture (1) Definition .there is a hole through the entire uterus.) (b) The baby is usually delivered by cesarean section. (4) Signs and Symptoms (a) May have no symptoms. (d) Blunt abdominal trauma (Motor Vehicle Accident). (b) Incomplete rupture . quick actions to reduce anxiety in patient.the uterus tears into a nearby structure. (c) Intense contraction. 2) Dehiscence is a common occurrence. (f) Abnormal or absent fetal heart rates. (c) Abdominal pain. (d) Pain in the chest. (Do not remove pressure until the baby is born. from the uterine cavity to the abdominal cavity. (2) Variations: (a) Complete rupture . (b) Calm. but not all the way into the abdominal cavity. (b) Many previous births.

occurs if the uterus turns inside out after the baby is born. (2) Risk Factors (a) A boggy uterus. (c) May occur during postpartum if the uterus is pushed downward when the uterus is not firm. Report output less than 30 cc/hr. 2) Place Foley catheter. (6) Nursing Interventions (a) If signs or symptoms of uterine rupture occur. and can keep a close eye on output. c. (b) More likely to occur if the birth attendant pulls on the umbilical cord when delivering the placenta. (4) Nursing Interventions (a) During the emergency. Uterine Inversion (1) Definition . (b) After the uterus is replaced Pitocin is use to cause the uterus to contract and decrease bleeding. (3) Medical Treatment (a) The doctor will try to replace the inverted uterus while the woman is under general anesthesia. (b) Comfort measures to decrease patient’s anxiety. 3) Falling blood pressure. two intravenous lines are started to administer fluids. (c) Uterine rupture is sometimes not discovered until after birth. 21 .(g) Palpation of the fetus outside the uterus. (b) For a large tear a hysterectomy may need to be done. (c) A smaller tear may be repaired. the nurse should observe for: 1) Bright red continuous bleeding. (c) If replacement of the uterus is not successful. surgery is performed to deliver the baby and stop the bleeding. notify the physician immediately. not firmly contracted. the woman needs a hysterectomy. (b) During Recovery Period: 1) Vital signs and assessment every 15 minutes. so uterus can contract well. because the fetus is pushed through the torn area. (5) Medical Treatment (a) If fetus is living and/or there is excessive bleeding. 2) Rising in pulse.

(4) Medical Treatment (a) Begin immediate cardiac and pulmonary support. with its particles such as vernix. 2) Chest pain or dyspnea. Fundus 22 . 1) Sudden hypotension. e. 4) Frothy blood tinged mucus.3) Provide explanations and emotional support to the patient. especially if there was meconium in the fluid.The likelihood of death from amniotic fluid embolism is high. (b) Coagulation abnormalities (DIC) may occur because amniotic fluid is rich in factors that promote blood clotting. (b) Correct clotting defects with appropriate blood factors. (5) Prognosis . d. Trauma (1) Trauma during pregnancy may be encountered anywhere. to the emergency room. (b) Once the woman is stabilized the fetus is considered. 3) Restless and cyanotic. from an accident scene. (c) Place a wedge under one of the woman’s hips to improve blood flow to the placenta. her partner and family. Amniotic Fluid Embolism (1) Definition . fetal hair. (d) Remain alert to signs and symptoms that suggest abruptio placentae and uterine rupture. enters the woman’s circulation and obstructs the small blood vessels in her lungs. (2) Nursing Interventions (a) The priority is management of the woman’s life-threatening injuries. (3) Signs and Symptoms (a) Abrupt and severe respiratory distress and circulatory collapse.an uncommon embolism occurs when amniotic fluid. 9. (c) The embolism may occur during or after the infant is born. Self-care and recovery a. and sometimes meconium. (2) It is more likely to occur during a very strong labor because the fluid is pushed into small blood vessels that rupture as the cervix dilates.

breast feeding is not protective. Lochia (1) Report foul smelling. (b) Avoid stimulation. h. (2) Use contraceptives. g. (2) No strenuous activity until primary care provider gives okay. i. f. Exercise (1) Gradually increase activity. Sexuality (1) Delay resuming sexual activity until after 6 week check up. b. (2) Postpartum blues. e. (2) May cramp when breast feeding. Cesarean birth 23 . Perineum (1) Sitz baths and cleansing. If does not subside. Nutrition (1) Continue prenatal vitamins until after 6 week check-up (2) Increased needs if breast feeding. (2) Dry breasts (a) Supportive bra and ice. rest. Breasts (1) Breast feeding (a) Demonstrate proper technique (b) Breast care: air dry.(1) Report bogginess to primary care provider immediately. Emotions (1) Bonding. d. supportive bra and break suction properly when baby done nursing. (2) Tucks for discomfort. report to primary care provider. c. (2) If flow increases. bright red discharge or large clots.

character. support. amount. and location. (4) Signs of mastitis. ecchymosis.fullness. Leifer (4) Perineum. Postpartum assessment a. Leifer (3) Lochia. p. odor. edema. (5) Urinary urgency. (1) Vital signs. drainage. Signs and Symptoms of postpartum complications 24 . burning or frequency. defecation (8) Pain.see box 9-1. k.engorgement. relief measures (9) Extremities. 205. Every 4-6 hours unless risk factors exist.check for firmness.4 F or abnormal pulse/respirations (2) Fundus. bowel sounds. edema. signs of depression (11) Attachment. redness. 206. See figure 9-3. response to cries (12) Cultural variations. episiotomy (REEDA. Routine assessment. Homan's sign (10) Emotional state. color. nipple tenderness. degree of discomfort (5) Bladder.report temperature > 100. 10. Leifer.family interaction. tenderness. clots. (2) Car seat usage.character.(1) Notify primary care provider for signs of infection.location. Report the following to primary care provider: (1) Temperature above 100. eye contact. See figure 9-2.signs of thrombophlebitis.incorporate into plan of care when appropriate b. (2) Unexpected change in lochia. ability to ambulate.interest in newborn. 205. p. (2) No lifting heavier than baby until primary care provider gives okay. (3) Calf pain. pain (6) Breasts.4 F. approximation). Safety (1) Infant safety. height. j. breastfeeding (7) Bowels.hematoma. p. intensity. (6) Severe or incapacitating depression.passage of flatus. burning. hemorrhoids. touch contact.redness. output.

maintenance of warmth and nutrition and close monitoring of vital 25 . which leads to decreased gas exchange (a) There is a deficient synthesis or release of surfactant. grunting. and may not be apparent for several hours. (4) Bright-red bleeding after lochia has changed to serosa or alba. Handicaps of preterm newborn a. Apnea is related to immaturity of the nervous system (7) Bradycardia. Sepsis (1) Generalized infection of the bloodstream (2) Signs of infection include a low temperature. Inadequate respiratory function (1) Muscles that move the chest are not fully developed (2) Abdomen is distended causing pressure on diaphragm (3) Stimulation of the respiratory center in the brain is immature (4) Gag and cough reflexes are weak because of immature nerve supply (5) Respiratory distress syndrome (RDS) is a result of immaturity of the lungs. a chemical in the lungs. poor feeding and respiratory distress. Bronchopulmonary dysplasia is the toxic response of the lung to oxygen therapy (6) Apnea may occur in the premature infant. may occur with apnea. Symptoms include tachypnea. cyanosis and retractions (c) Surfactant may be given to preterm infants via the endotracheal tube NOTE: Oxygen toxicity is a high risk for infants receiving prolonged treatment with high concentrations of oxygen. (5) Edema. (3) Excessive vaginal discharge.4 with or without chills. heat. defined as the cessation of breathing for 20 seconds or longer. erythematous or painful legs.(1) Fever >100. (7) Pain. (6) Pain or burning with urination or unable to void. b. (2) Foul odor to vaginal discharge. 11. lethargy or irritability. Maternal infection and complications can predispose the preterm infant to sepsis (3) Treatment includes IV antibiotics. (8) Perineal or pelvic pain. Surfactant begins to appear in the alveoli at approximately 24 weeks gestation and is at a level to enable the infant to breathe adequately at birth by 34 weeks gestation (b) Symptoms of respiratory distress occur after delivery. edema or smelly discharge from breasts. nasal flaring. fewer than 100 beats/minute.

Poor Nutrition (1) The stomach capacity of the preterm infant is small (2) The sphincter muscles at both ends of the stomach are immature. Hypocalcemia (1) Calcium is transported across the placenta throughout the pregnancy. RDS) increased glycogen use by the brain. may have lower calcium (2) Treated with IV calcium. Nurse must monitor neuro status and report bulging fontanels. Hypoglycemia (1) Defined as plasma glucose levels less than 40 mg/dl (2) Increased stress of prematurity (asphyxia. lethargy. which contributes to regurgitation and vomiting (3) Sucking and swallowing reflexes are immature (4) Ability to absorb fats is poor (5) Inadequate store of nutrients and need for glucose and nutrients to promote growth and prevent brain damage contribute to the nutritional problems (6) Gavage feedings are required until infant is strong enough to tolerate oral feedings without compromising cardiorespiratory status 26 . There is no "safe" oxygen level (4) Treatment includes consult with an ophthalmologist and possible cryosurgery h. If infant born early. Increased tendency to bleed (1) More prone to bleeding because blood is deficient in prothrombin (2) Fragile capillaries of head may bleed due to injury during delivery. sepsis. poor feeding and seizures g.signs c. heart and other tissues (3) Hypoglycemia must be treated immediately. Nurse must monitor for bradycardia f. but mainly in third trimester. Poor control of temperature (see ELO D below) d. Retinopathy of prematurity (ROP) (1) Condition in which there is separation and fibrosis of the retina (2) Caused by high concentration of oxygen and other problems common to the preterm infant (3) Nurse needs to monitor oxygen saturation with a pulse oximeter. May require gavage or IV feedings if preterm infant too weak to suck e.

312. Problems associated with post maturity (1) Asphyxia (2) Meconium aspiration (3) Poor nutrition status. depleted glycogen reserves cause hypoglycemia 27 . diarrhea and bilious vomiting (4) Treatment includes antibiotics and parenteral nutrition to rest the bowel. tissue turgor. resume feedings slowly as ordered j.i. measure abdomen and listen for bowel sounds. Jaundice (1) See Leifer. Physical characteristics of the post-term infant (1) Infant long and thin. which predisposes the infant to hyperbilirubinemia (3) Goal of treatment is to prevent kernicterus and reverse the hemolytic processes that cause the bilirubin level to rise (4) An increase in bilirubin levels of more 5mg/dl in 24 hrs requires careful investigation 12. table 13-1. on neonatal jaundice (2) In preterm infants the normal rise in bilirubin levels is slower than in full-term infants and lasts longer. Postterm Newborn a. maintain infection control techniques. Document status of fontanels. weight and urine output k. related to hypoxia or sepsis. looks as if weight has been lost (2) Skin is loose (3) Little vernix. bloody stools. skin is dry (cracks and peels) (4) Nails are long and may be stained with meconium b. result in a decrease in protective mucous and bacterial invasion (3) Signs include abdominal distention. May need to surgically remove necrosed bowel (5) Nursing interventions: Observe vital signs. p. Immature kidneys (1) Dehydration may occur easily (2) Need to weigh diapers to determine urine output (between 1 and 3 ml/kg/hr) (3) Need to observe for signs of over hydration and dehydration. Necrotizing enterocolitis (NEC) (1) Acute inflammation of the bowel that leads to bowel necrosis (2) Decreased blood supply to the bowel.

eyes. A tough membrane covers these areas.often indicates dehydration. but it is confined to a particular bone and does not cross suture lines. paralysis. They protect the head during delivery by the process of molding and allow further brain growth during the next 1-1/2 years. The hemotoma may not be apparent immediately after birth. It is the result of edema. and there is little chance of injury with ordinary care. in the soft tissue of the scalp. (4) Fontanelles.5 cm (13-14 inches). NOTE: Large hematoma may lead to anemia and jaundice. This is usually a result of hard labor.(4) Polycythemia. 1-2 cm larger than chest.broad area or soft spot consisting of a strong band of connective tissue contiguous with (touching) cranial bones and located at the junction of the bones should be palpable. (2) Examine symmetry of facial movements. Resolves in a few days and generally disappears without treatment. which require medical intervention. Normally resolves within a few weeks without treatment. shape. and ears. It may be seen on both sides of the head. Normal Newborn a. (b) Caput Succedaneum. Nursing care (1) Prepare parents for labor induction or cesarean (2) Observe infant for the following: (a) Respiratory distress (b) Hypoglycemia (c) Hyperbilirubinemia 13. The head may appear elongated and misshapen.is commonly seen with molding. Measure just above the eyebrows (frontal) and over the occiput (occipital). generally appearing 1 to 2 days after birth. The tissue feels spongy and may be felt over suture lines. 28 . caused by pressure during labor and delivery. The head may appear elongated and misshapen. swelling and movement. Characteristics of a Newborn's Head and Face (1) Examine head and face for symmetry. (a) Enlarged or bulging-may indicate increased intracranial pressure if it occurs while infant is at rest. due to hypoxia c. (3) Measure head circumference. (a) Molding.overlapping of the parietal bones caused by compression of the head as it passes through the birth canal. Resolves gradually within a day or two. (b) Depressed or sunken.33-35. because of intrauterine hypoxia (5) Difficult delivery due to increased size (6) Birth defects (7) Seizures.caused by bleeding within periosteum or a flat cranial bone. (c) Cephalohematoma.

(b) May be folded and creased. 2) Anterior.normally enlarged usually palpable. the newborn infant's cries are characteristically tearless until after 1-3 months of age. (d) The lacrimal glands function minimally at birth. (a) Overriding. (c) Neonate usually responds to sound at birth. dark-skinned races iris may appear darker. (7) Ears (a) The ears are normally positioned with the upper insertion of the pinna located even with the outer canthus of the eye. midline tongue and movable. (f) Newborns are nearsighted and can see objects best at 8 to 10 inches.extensive separation may be found in malnourished infants and infants with increased intracranial pressure. (6) Eyes (a) May not track properly and may cross (strabismus) or twitch (nystagmus). (d) Low set ears may indicate a congenital anomaly. (5) Sutures. Blinking is an inborn protective reflex. Are commonly seen as a result of the newborn's immature nervous system. Not significant unless persists beyond 4 months of age.junctions of adjoining skull bones. Most prefer simple patterns in black and white and human faces. (e) Edema of eyelids may result from pressure on the head and face during labor and delivery or from irritation caused by erythromycin installation.smaller and triangle-shaped. It is believed that the fetus becomes familiar with the mother's voice while still in utero.(c) Size 1) Posterior. NOTE: High pitched sounds and the mother's voice generates the greatest attention. and intact soft and hard 29 . Generally closes in 12-18 months. 1 cm in diameter or may be obliterated because of molding. diamond shaped. because eye contact with the baby is an important part of bonding. (c) Pupils react (constrict equally) to light. moist mucous membranes. Generally closes by the end of the 2nd month. True eye color is seldom determined until 3 to 12 months of age.irises of Caucasian neonates are slate blue or grayish brown.skull bones overlap due to molding during labor and delivery.assess for patency. (b) Separation. (8) Nose. NOTE: It is important for parents to know this. 3-4 cm long by 2-3 cm wide. discharge and septal deviation. (b) Color. (9) Mouth (a) Inspect for pink.

(3) Tissue Turgor (a) Refers to the hydration or dehydration of the skin. b. and sometimes found in abundance only in the body creases. c. back. (2) Lanugo (a) Long. soft growth of fine hair often observed on the shoulders. (b) Disappears early in postnatal life. (4) Desquamation (peeling of the skin) of the term infant does not occur until a few days after birth. It should spring back to place immediately. (b) Caused by an accumulation of old cutaneous cells mixed with an early secretion from the oil glands. Its presence at birth is an indicator of postmaturity. and cheeks. (c) Sometimes the baby is thickly covered with vernix at birth. Characteristics of the Newborn Respiratory System. The more mature the newborn. the less vernix remains. tissue turgor is considered poor.palate. (b) Epstein's pearls. The birth process stimulates a series of events that transform the fluid-filled lungs into organs capable of gas exchange. (d) Good turgor and tissue elasticity are normally observed. The skin of African American babies may appear as pinkish or yellowish brown. Characteristics of the Newborn's Skin and Tissue Turgor (1) Vernix caseosa (a) A yellowish-white cream cheese-like substance that protects the fetus skin from its watery environment. soles of the feet. (c) When skin remains distorted. The lungs then take on the function of breathing oxygen and removing carbon dioxide. (b) To test tissue turgor (elasticity) the nurse gently grasps and releases the skin. (1) The lungs are not inflated and are almost completely inactive. 30 . Newborns of Spanish descent may have an olive tint or slight yellow cast to the skin. (2) The first breath helps to expand the collapsed lungs. until the umbilical cord is clamped and cut. Pre-term infants have more visible lanugo.small white glistening cysts found midline on the hard palate. but found on nearly all parts of the body. (b) The health care provider assists the first breath by removing mucous from the passages to the lungs. and the scalp. except the palms of the hands. (a) Full expansion does not occur for several days. forehead. are commonly noted during the first week. (d) The skin of newborn Caucasian babies is usually pink to slightly reddish in appearance.

The first stool should occur in 824 hours following birth. (a) Green cord. but very tenacious material. Auscultate lung fields. notify the physician. Meconium is a greenish-black. a mixture of amniotic fluid and secretions of the intestinal glands.hands and feet are typically blue. (c) Majority of the heart murmurs are not serious. The cord has three vessels with white.first stools. tarry. which is attached to the placenta at birth. which pass over the placenta to the baby. 31 . (b) Murmurs may be functional (innocent) or organic (due to improper heart formation). (b) Bowel sounds should be auscultated. (a) Murmurs are caused by blood leaking through openings that have not yet closed. (3) Stools (a) Meconium stools. thus. (5) Most common cause of respiratory difficulty in the first few hours of birth is due to the use of sedatives. The stools gradually change during the first week. Characteristics of the Newborn Cardiovascular System (1) Peripheral circulation: Acrocyanosis. Any slur or slushing sound may indicate a murmur. analgesics and anesthetics during labor. making the newborn sleepy.(c) The baby's cry should be strong and healthy. (d) The most critical period is the first hour of life. murmurs should be examined periodically in order to rule out other possibilities.infection (c) 2 vessels.meconium staining (b) Red cord. due to sluggish circulation after birth-blood is shunted to vital organs immediately after birth. (4) Periodic breathing is common. Characteristics of the Newborn Gastrointestinal System (1) The attending physician or Certified Nurse Midwife (CNM) cuts the umbilical cord. rate and color. d. However. odorless. (3) Observe the infant's respiratory effort.associated with congenital anomalies (2) Abdomen (a) Cylindrical and protrudes slightly. when the drastic change from life within the uterus to life outside the uterus takes place (e) The nurse can assist the newborn to maintain a patent airway by positioning them on their back or side and dressing them in clothing to maintain warmth while allowing full expansion of the lungs. the newborn may require stimulation to elicit spontaneous respirations. Resumption of respirations should occur within 5-15 seconds. tranquilizers. glistening tissue and no bleeding: The cord is clamped and inspected to determine if it has two arteries and one vein present. e. (2) Listen to heart sounds throughout heart region for normal "lub-dub" sound.

(e) Constipation refers to the passage of hard dry stools a. Characteristics of the Newborn Endocrine System (1) Newborn endocrine system is supplemented by maternal hormones that have crossed the placental barrier. yellow-brown (almost mustard-like in appearance). If eating solid foods. (3) For newborn males. and whole-grain cereals. (b) Bleeding (pseudomenstration) may occur as a result of withdrawal from maternal hormones at the time of birth.(b) Transitional stool. Increasing water intake may be all that is necessary f. it becomes browner and then yellow green and looser in consistency. it is not considered constipation if the stool passed is large in volume and soft or pasty in character d. usually only a few blood spots seen on the diapers. areusually softer. A white cheesy substance called smegma is found under the foreskin. and during the first few weeks are more frequent. (4) Hiccoughs (a) Appear frequently in newborns and are normal. May be seen when formula is changed e. (2) Vaginal discharge and/or bleeding may occur in female infants. along with swollen labia. (c) Stools of formula-fed babies are characteristically pasty. It is more solid than breast fed babies. urethral opening should be located at the tip of the penis. These maternal contributions of hormones. when withdrawn from the baby through the act of birth bring about certain phenomena that may cause parents concern and should be explained. Characteristics of the Newborn Genitourinary System (1) Newborn voids within first 24 hours. (2) Usually 6 wet diapers per day. vegetables. g. After the second month of life the infant will increase stool volume and decrease frequency c. It occurs during the first week. Newborns differ in regularity b. (d) Stools of breast-fed babies have a more yellow "cottage cheese curds" like appearance. 32 . Infant will have 3-6 stools per day. (a) Generally a white mucoid discharge. but gradually decreases to one or two stools per day. Maybe one to four times a day at first.Products of ingested milk begin to change the color of the stool. increase fruits. Even if 5-6 days pass without a stool. (b) Most disappear spontaneously (c) Burping the infant and offering warm water may help f. Usually disappears by 2-4 weeks of age. Routine retraction of the foreskin of the newborn for cleansing is not recommended.

there will be a reciprocal flexion and extension of the leg. (2) Reflex actions present at birth serve the infant until neuromuscular development is improved. and opening of the hands follow. arm and leg will extend on that side. (6) Tonic Neck Reflex. Suck reflex is very strong in full term newborn.Head is brought forward (about 30 degrees) and then allowed to fall back suddenly .(3) Swelling (engorgement) of the breasts may affect both male and female infants (Gynecomastia). (3) Absence of reflex activity often indicates abnormalities of the nervous system. and opposite arm and leg will reflex. The newborn grasps the fingers tightly. (5) Plantar. (4) Grasping reflex. to be replaced by symmetric positioning of both sides of body. h. Disappears after 3 to 4 months. posture resembles a fencing position. Constant tremors during sleep may be pathological. (b) Secretion of milk from the breast may occur. Infant turns head toward that side and opens the lips.If infant is held so that sole of foot touches a hard surface. (c) Swelling usually subsides in 2-3 weeks. Elicited by placing a finger in the newborn's palm. j. 33 . Toes curl down in response to stimulation.abduction of the upper extremities at the shoulder.Stimulated by touching the side of the newborn's mouth or cheek.Stimulated by placing a nipple or gloved finger into the infant's mouth.Elicited by placing thumb against the ball of the foot. (3) Moro reflex (startle reflex). Reflexes of the Newborn (1) Rooting. (8) Dance or stepping reflex.When the sole of the foot is stroked along side of sole beginning at heel and then moving across ball of foot to big toe. Characteristics of the Newborn Musculoskeletal System (1) Bones of the newborn are soft because they are composed mostly of cartilage. Newborn lacks the muscular control to hold the head steady. (2) Sucking. Characteristics of the Newborn Nervous System (1) Nervous system of the newborn is immature.When infant's head is quickly turned to one side. (2) Movements of the newborn are random and uncoordinated. i. extension of the elbows. (a) Particularly noticeable about the third day of life. toes will fan out with dorsiflexion of big toe. (7) Babinski. simulating walking. (3) Tremors of the lips and extremities during crying are normal. breasts should not be squeezed. Disappears by 3 to 4 months of age.

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