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OB > Breastfeeding/Pain/High Risk Newborn > Flashcards

Breastfeeding/Pain/High Risk Newborn Flashcards

1
Q

When should you exclusively breastfeed? When can you introduce solids? When should breastfeeding continue until?

A

Exclusive breastfeeding for first six months

Introduction of solids and other fluids at six months

Continued breastfeeding until at least 12 months

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2
Q

What are the baby benefits of breastfeeding?

A

Less- GI problems, SIDS, allergies/asthma, diabetes, childhood cancers, obesity, infections
Better cognitive development, higher IQ

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3
Q

What are the mother benefits of breastfeeding?

A

Promotes uterine involution, decreased risk of postpartum hemorrhage, enhanced pregnancy weight loss, bonding, decreased risk of breast cancer, decreased stress

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4
Q

What are the mother financial of breastfeeding?

A

Save on average $400/year for infant medical costs
Cost of formula, bottles, etc.– On average $3-5/day for formula

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5
Q

When milk is produced what occurs in the breast?

A

Breast divided into 15–20 lobes which are separated by fat, connective tissue

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6
Q

What occurs r/t estrogen, progesterone, and prolactin after delivery?

A

After delivery sudden drop in estrogen and progesterone –> stimulate secretion of prolactin from anterior pituitary and breast milk is produced

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7
Q

What is the role of oxytocin r/t milk production?

A

secreted by posterior pituitary and responsible for milk ejection, “Let down”

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8
Q

What is the difference between casein and whey proteins?

A

Whey predominant protein in human milk
60:40 whey/casein ratio
Easily digested
More frequent feedings

Casein predominant in cow milk
20:80 whey/casein ratio
Less easily digested, forms curds

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9
Q

What vitamins are in breast milk?

A

Fat soluble – A, D, E, K
Water soluble - Bs, C

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10
Q

What is breast milk made of?

A

Fats (50% of calories)
Immunoglobulins - prevent infection
Vitamins
Carbs (40% of calories) - lactose

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11
Q

What is the primary carbs in formula?

A

Lactose
Lactose/corn maltodextrin

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12
Q

In lactogenesis stage I what kind of milk is made? What does it look like? How long is it produced for? When is production started?

A

Colostrum - liquid gold

Clear yellowish fluid

First 3-4 days

Production begins in mid pregnancy

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13
Q

What does colostrum do for the baby?

A

Small amount to allow the baby to learn to suck, swallow and breathe at the same time
High in protein, immunoglobulins & minerals
High protein level facilitates bonding bilirubin
Acts as a laxative to pass meconium and pass bilirubin

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14
Q

In lactogenesis stage 2 what occurs? When does this phase occur?

A

“Milk coming in” phase:
Breast milk continues to ‘mature’

Day 3-5 to day 10

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15
Q

When does engorgement start to occur? Causes? Symptoms?

A

Lactogenesis stage 2

Response to hormonal changes
Milk production
Engorged blood vessels & lymphatic swelling

Full, hard, tender, warm breasts

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16
Q

What are the 3 types of milk produced in lactogenesis stage 3?

A

Mature milk
Foremilk
Hind milk

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17
Q

When does mature milk come in? What increased as neonate feeds?

A

Day 10

Fat content of BM increases as neonate feeds

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18
Q

What is the color of fore milk? What does it contain?

A

bluish-white (60% skim & 30% whole milk)

Lactose, protein & WS vitamins

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19
Q

What is hind milk? What is it for? When does it occur?

A

cream (5%)

For calories

Occurs 10-20 minutes in to feeding
Reason why you must try & ‘empty’ breast q feeding

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20
Q

When would you use supplement for breastfeeding? What should be avoided?

A

Only when medically indicated

Avoid finger feed and cup feed

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21
Q

What are the use of pacifiers? When should they be introduced?

A

For non-nutritive sucking

Use after breastfeeding is well established (2-4 weeks of age)

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22
Q

When should the first feed occur? After the first feed how often?

A

First feeding during first period of reactivity

Feed on demand or at least q 1.5-3 hours

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23
Q

When assess a breastfeeding patient, what should you assess?

A

Feeding effectiveness: LATCH score at least once a shift

Breast structure and signs of problems

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24
Q

What does a low LATCH score require?

A

Assess every feeding until >6
Assist and provide education
Consult a Lactation Specialist for evaluation, assistance, and intervention

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25
Q

When providing nursing care during breastfeeding you need to be.. .

A

Supportive and assist patient with positioning and latch
Educate patient
Have a lot of patience

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26
Q

What does LATCH assess? A higher score means? By 12 hours what score is expected?

A

Assessment of the effectiveness of the breastfeeding session

The higher the score the more effective the feeding

A score of 6 or higher by 12 hours of age is expected

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27
Q

When helping with latching what should be done?

A
  1. Nose to nipple- goal is to achieve an asymmetric latch- bottom jaw further onto areola than top jaw
  2. Stimulating rooting reflex- stroke nipple downward over bottom lip
  3. Newborn will open wide with tongue down and will drop head back
  4. Once the mouth is open wide the BABY is brought to the breast, not breast to baby
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28
Q

What needs to be assess regarding the nipple?

A

Assess type of nipple

Assess for cracking, bleeding or redness because those are signs of inappropriate latch

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29
Q

What does the breast shell do? When do you use it?

A

Can help to cause flat or inverted nipples to protrude

Begin use in late 3rd trimester

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30
Q

What do breast shields do? What should you do before using breast shields?

A

Used to assist with latching

Important to work with lactation before and during use of the breast shields.

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31
Q

What are the benefits/risks of breast shields?

A

With continued use the milk supply can be reduced by 50% or more.

These can be beneficial for extremely damaged nipples or flat nipples.

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32
Q

What is the cross cradle hold?

A

Mother to sit in upright position using good body alignment and can use pillows for support
Baby placed on lap- belly to belly or baby in side-lying position with baby’s nose at nipple
Head supported with hand opposite breast she is feeding on positioned on nape of neck
Breast supported by hand on same side

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33
Q

What is the cradle hold?

A

Mother to sit upright using good body alignment
Baby placed on lap belly to belly position, side-lying with nose at nipple
Head cradled in crook of arm on the same side as the breast
Breast is supported by hand opposite breast she is feeding on

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34
Q

What is the football hold?

A

Mother to sit upright and pillows are used to raise baby’s body to breast level
Baby’s bottom rests near mother’s elbow and body turned slightly to face breast
Head supported at nape of neck and body is supported by mother’s arm
Breast is supported with hand opposite breast she is feeding on

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35
Q

What is the side lying position?

A

Mother lies on side and pillows used to support head and back, between bent knees
Baby placed in side-lying position next to mother, belly to belly, nose lined up with nipple, pillow or roll placed behind back
Breast supported by hand opposite breast she is feeding on (top arm)

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36
Q

What should be used, scissor hold or C-hold?

A

C-hold should be used

Scissors hold is discouraged because moms are unable to keep fingers at least 1 ½ inches from base of aerola

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37
Q

What are sings of effective breastfeeding?

A

Infant nursing ≥8 times in 24 hours
Mother can hear infant swallow
Mother’s breasts soften after feeding
Number of wet diapers increases
Infant’s stools begin to lighten and transition from meconium to breastfeeding stools

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38
Q

How many wet diapers should baby have by day 5?

A

6-8 wet diapers a day beginning on day 5

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39
Q

What can help comfort women with engorgment?

A

Empty breasts q2h; preferably by the baby
Ibuprofen, massage, ice
Not recommended to pump/hand express milk between/ after feedings causes increased milk production and worsens engorgement
If engorgement causes nipples to flatten and become hard use breast pump/hand expression just to soften nipple to allow latch
Cabbage leaves no longer recommended due to risk of food borne illness

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40
Q

What can be used to help comfort mom with cracked, bleeding and bruised nipples? What are these a sign of?

A

Lansinoh cream- no need to wash off
Gel pads- “soothies”
Nipple Shields until nipples are healed

signs of poor latch

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41
Q

What are s/s that patient is coping with pain?

A

Using breathing & relaxation techniques
Moaning, chanting
Inward focus
Says “I am coping”
Rocking, Swaying

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42
Q

What are s/s that patient is not coping with pain?

A

“I can’t do this”
Crying, screaming
Tremulous voice
Unable to focus
Panicky during contractions
Thrashing
Scratching, biting, writhing
Sweaty, Shaking

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43
Q

What are the causes of pain in the first stage of labor?

A

Cervical effacement & dilatation
Hypoxia of uterine muscle cells
Stretching of lower uterine segment
Pressure on adjacent structures (low back, thighs, buttocks, groin, iliac crest)

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44
Q

Where is the pain during the first stage of labor?

A

enter spinal cord at L1, T10-12
Low back and low belly

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45
Q

What causes pain in the 4th stage of labor? What could cause this pain to be worse?

A

“After birth pains” are those contractions of the uterus to help prevent hemorrhage and may actually exceed the pain experienced by labor contractions.

The more babies the woman has the harder the uterus has to work to contract and the worse the after birth pains may be

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46
Q

What are the physiologic response to pain in labor?

A

Tachycardia
Increased O2 consumption
Lactic acid
Hyperventilation (risk of resp alkalosis)

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47
Q

What psychologically occurs in labor?

A

Unrelieved pain may prolong labor
Post traumatic stress disorder

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48
Q

The pain and stress of labor can lead to metabolic acidosis and release of catecholamines which leads to…

A

maternal blood vessel to constrict, decreased O2 to baby

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49
Q

If pain management if offered too soon what occurs? Offered too late what occurs?

A

Offered too soon will stop/slow labor

Offered too late risk un-medicated delivery when she really wanted an epidural

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50
Q

When is the best time to offer meds for labor?

A

Active

Takes the “edge” off, usually does not slow labor progress, can cause decreased FHR variability

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51
Q

What helps the uterus function? What aids descent of baby? An empty bladder causes? What happens if muscles are tense? What can be as effective as narcotics?

A

Uterus functions effectively when well hydrated & fed

Contractions and descent of the presenting part are aided by position changes

An empty bladder allows more room in the pelvis for the head to come down

The more tense other body muscles are, the less work the uterus can do AND the more painful the contractions feel

Support, touch and hydrotherapy can be as effective as narcotics

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52
Q

What are non-pharm pain relieving methods?

A

Childbirth preparation
One-on-one support
Relaxation
Breathing
Massage & Acupressure
Hydrotherapy
Alternative therapies (Hypnosis, TENS unit, Sterile water papule)

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53
Q

What are some things mom can do to prepare for childbirth?

A

Awareness of the labor & birth process
Relaxation Techniques
Visualization Techniques
Breathing Techniques
Consumer information

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54
Q

How does visualization/guided imagery help with birth pains?

A

Visualize sights, sounds, feelings of a pleasant place
a “focal” point helps to focus concentration away from pain
Closing eyes vs. keeping eyes open
Visualizing the cervix opening or the baby moving down can be helpful to the progress

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55
Q

Why does helping mom loosen up her muscles help with pain?

A

The more tense other body muscles are, the less work the uterus can do AND the more painful the contractions feel

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55
Q

What does hydrotherapy do for pain in labor?

A

relax muscles, decreases pain perception and decreases length of labor

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56
Q

What types of massage can be done to decrease pain in labor?

A

Effleurage- light feather stroking of any area of body- may do herself

Counter pressure applied for back pain-place fist against back and apply constant pressure

Knead arm and leg muscles from proximal to distal and encourage release of tension (flowing out of body) as digits are reached

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57
Q

What does movement, adulation and position changes for for labor?

A

Shorten labor
Lessens pain
Promotes fetal descent

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58
Q

How can birthing balls help with labor?

A

Increase the diameter of pelvis

Assists with fetal rotation and descent

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59
Q

What do sterile water papules do for pain in birth?

A

Reduces low back pain severity and provides relief for up to 2 hours

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60
Q

What is the TENS unit? How does it do?

A

Electrical stimulation of the nerves

Blocks pain perception, reduces excitation of central neurons and there is activation of the opioid receptors in the CNS

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61
Q

What are the benefits of breathing techniques?

A

Increases pain threshold
Encourages relaxation
Provides distraction
Enhanced coping ability
More efficient uterine functioning

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62
Q

When should breathing techniques be initiated? When do they work best?

A

Don’t start any technique too early- she will exhaust herself

Best if learned and practiced prior to labor

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63
Q

What is lamaze breathing?

A

Cleansing breath before and after - Deep breath in through nose out through mouth
Slow chest breathing - Usually used in latent and active labor
Modified paced - Usually used in active labor and 2nd stage
Pattern paced- “Hee, hee, hee, hoo” - Usually used active labor and 2nd stage
Quick method - Pant-pant-blow
Puffing - Used when urge to push prior to complete dilation

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64
Q

When is it too late for an epidural?

A

patient unable to sit still for procedure

pushing the baby out

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65
Q

IV pain meds will have what effect on labor?

A

will not slow down labor if given in latent labor

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66
Q

When giving pain meds, they affect mom and ____

A

Baby - cross placental barrier by simple diffusion some more readily than others

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67
Q

How do analgesics help with pain in labor?

A

Affects perception of pain, does not take pain away

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68
Q

How do anesthetics help with pain in labor?

A

Deadens the pain, either by blocking a nerve, or knocking you out

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69
Q

What sedative could be used in labor? Why a sedative?

A

Ambien 5-10 mg PO

Maternal exhaustion in prodromal albor

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70
Q

What are the benefits for sedation? Risks?

A

Decreases anxiety
Allows for rest
Inhibit uterine contractions (good for prodromal labor)

Neonatal CNS depression
Maternal response

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71
Q

What antihistamine is used in labor? Why?

A

Benadryl 25-50 mg PO

Induces relaxation and sleepiness

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72
Q

What H1 receptor antagonist is used in labor? Why?

A

Promethazine HCL (Phenergan) 12.5 25 mg IM or PO

Relieves nausea & vomiting
Does not relieve pain, but potentiates narcotics
Decreases anxiety

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73
Q

What true narcotics are used in labor?

A

Fentanyl 50-100 mcg IVP Q10-15 minutes x 5 doses
Morphine Sulfate:2 mg IV + 10 mg IM with PO Phenergan for prodromal labor

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74
Q

What partial opioid agonist is used in labor?

A

Nalbuphine (Nubain): 5-10 mg IVP

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75
Q

How does fentanyl affect fetus? What is the 1/2 life? Onset?

A

Fentanyl has a rapid onset and has a short half life.
There is limited placental transfer and therefore FHR variability is not affected as much as the other narcotics

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76
Q

What is the MOA of nitrous oxide?

A

Exact mechanism unknown
May stimulate endogenous endorphin, corticotropins, and dopamine release
Dulls perception of pain

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77
Q

What is the onset of nitrous oxide? Clearance? Administration?

A

Within 30-60 seconds of inhalation

Maternal: within 30-60 seconds of discontinuation

Self administered by the woman via inhalation
Concentration: 50% nitrous and 50% oxygen

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78
Q

What are the advantages of nitrous oxide?

A

During all stages of labor
Can be used with ambulation, hydrotherapy, etc.
Does not require IV catheter or continuous fetal monitoring (but this may be dependent on institution)
Useful for other painful procedures (Forceps or vacuum assisted deliveries, manual removal of placenta or uterine exploration and laceration or episiotomy repairs)

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79
Q

What are the SE of nitrous oxide?

A

Nausea & vomiting-5-36%
Vertigo-39%

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80
Q

What are the contraindications for nitrous oxide?

A

Alcohol or drug impairment
Hemodynamically unstable
Cannot hold own mask
Vitamin B12 deficiency

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81
Q

What effects does nitrous oxide have on the fetus/newborn?

A

Crosses placenta-80% of maternal serum levels
No increase in CNS or respiratory depression
APGARS unaffected
No FHR changes
Cleared rapidly with initiation of effective respirations

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82
Q

What patient safety and education should be given with nitrous oxide?

A

Education on self-administration; no one may help her administer it
Will need assistance with ambulation
Supervise patient during hydrotherapy, birth ball use, and squatting
Obtain informed consent from the patient (done by anesthesia)

83
Q

What is a walking epidural?

A

Epidural without lidocaine

84
Q

Does a spinal or epidural have a faster onset? Which lasts long?

A

Epidural - Continuous dose throughout labor. Takes longer to take affect

Spinal - Faster onset, lasts 1-3 hours

85
Q

What is used for a c-section?

A

Spinal

86
Q

What is an epidural inject? What does it block? What kind of drug is used?

A

L-2 to L-4 vertebrae

T-8 to S-5 block

Variety of “caine” drugs + narcotics

87
Q

What are the contraindications of an epidural?

A

Allergy to the agent
Clotting disorders or hemorrhage
Hx of spinal injury or abnormality
Sepsis
Hypertension
Local or systemic infection
Uncorrected hypovolemia
Increased intracranial pressure (ICP)

88
Q

Where is the epidural space?

A

between the Dura mater and the ligamentum flavum, extending from the base of the skull to the end of the sacral canal

89
Q

What are the advantages of epidurals? (6)

A

Provides good pain relief and assists with coping
Allows woman to be fully awake
Avoidance of general anesthesia if unplanned c/s
May mediate maternal exhaustion and stress effects and allow her to rest—wake up when ready to push
Great for women with a history of sexual abuse
Vasodilation—improve placental perfusion and decrease maternal HTN for a time

90
Q

Because it epidural is continuous….

A

Allows for different blocking during each stage of labor
Dose can be adjusted

91
Q

What are the advantages for spinals?

A

Local anesthetic agent injected directly into spinal canal
Onset of anesthesia is immediate
Mostly used for cesarean birth but can be used for vaginal delivery if delivery imminent
Lower risk of failure
Smaller drug volumes

92
Q

What is the difference between level of anesthesia for a vaginal vs. c-section

A

c/s: above fondus

Vaginal: at the hips

93
Q

What are the complications of regional anesthesia?

A

Inadequate block

Breakthrough pain

Procedure-Related Events

Sympathetic nerve blockade

Itching

PP findings of localized tenderness, backache, migraine, increased temp

94
Q

What are the nursing responsibilities of regional anesthesia?

A

Informed Consent
Void prior to administration
IV Access
Preload with 500-1000ml IV fluids (dependent on hospital)
Monitor vital signs, PO2, and fetal heart rate
Assist with positioning
Explain and reassure

95
Q

What are types of inadequate blocking?

A

“Hot spot”
One sided
Block Failure

96
Q

What are 3 instances that breakthrough pain can occur?

A

Full bladder
Complete dilation
Uterine rupture

97
Q

What are procedure-related events that are associated with anesthesia complications?

A

Nerve Root Injury (0.2 %)
Accidental Dura (spinal) Puncture (1 - 2 %)
Intravascular Injection (5 %)

98
Q

What are 3 things that occur d/t sympathetic nerve blockade?

A

Maternal Hypotension (1 - 10 %) –> late decelerations
Urinary Retention (15 - 35 %) - treat w/ Foley
Fever ( 15 - 17 %) possibly similar to spinal cord injury

99
Q

How do you treat maternal hypotension d/t sympathetic nerve blockade?

A

Ephedrine 5-10 mg IV
Fluid bolus
Oxygen via facemask
Side-lying position

100
Q

What is the treatment of itching r/t regional anesthesia?

A

Nubain or Benadryl

101
Q

What are some PP complications r/t regional anesthesia?

A

Localized tenderness (40%)
Backache (30 - 40 %)
Migraine Headache (2.9%)
Transient Neurological Deficits (0.1 %)
Elevation in temperature

102
Q

What is a spinal HA treated with?

A

Blood patch

a few millimeters of the woman’s blood drawn and before coagulation occurs is injected into epidural space- forms a clot and seals leak of spinal fluid providing almost instantaneous relief

103
Q

What interventions on fetus could an epidural lead to?

A

Continuous fetal monitoring
Increased risk of C-section or assisted vaginal delivery (forceps or vacuum)

104
Q

Where is pudendal anesthesia inject? Where does it provide anesthesia to?

A

Injection of local anesthesia into pudendal nerve (near vaginal lips)

Produces anesthesia to lower vagina, vulva, and perineum

105
Q

When does a pudendal anesthesia give relief? Effects on labor or fetus?

A

Only produces pain relief at end of labor

Has no effect on fetus or progress of labor

106
Q

What are the complications of pudendal anesthesia?

A

Hematoma
Perforation of rectum
Trauma to sciatic nerve

107
Q

Where is local anesthesia injected? When is it used?

A

Injection of anesthetic into soft tissues of perineum

Prior to episiotomy
Prior to de-infibulation
Repair of lacerations

108
Q

How does local anesthesia affect fetus/labor? What type of effect? What pain does it not help?

A

Does not affect fetus or labor progression

Effect is only locally

Not effective for pain prior to crowning

109
Q

When is general anesthesia used? What does it require? Risks? What should you be aware of?

A

Used rarely only for emergent C-sections with no or ineffective regional anesthesia

Requires intubation

High rate of neonatal depression

Beware of aspiration pneumonia b/c laboring woman’s stomach is never empty

110
Q

What are the nursing responsibilities for general anesthesia?

A

IV access
Assess when mother ate or drank last
Administer prescribed premedication such as antacid
Wedge under right hip

111
Q

RBC breakdown to become ____. They are transports by _____ to the _____.

A

RBC breakdown produces UNCONJUGATED bilirubin (fat soluble)
Transported to liver by Albumin

112
Q

What occurs once unconjugated bilirubin gets to the liver? Where is it excreted?

A

Liver converts to water soluble bilirubin (CONJUGATED)

Conjugated bilirubin excreted into bile duct and then into intestines

Excreted via urine and stool

113
Q

What causes hyperbillrubinemia?

A

Short ½ life of fetal RBCs (70-90 days) and increased red cell volume –>
More unconjuguated bilirubin produced –>
Decreased conjugation d/t lack of glucuronyl transfused in liver –>
Lack of gut bacteria and low GI motility causes increased reabsorption of bili

114
Q

How common is hyperbilirubinemia?

A

50% of term neonates
85% of preterm infants

115
Q

What are modifiable risk factors of hyperbilirubinemia? (10)

A

Delayed/ineffective feedings
Excessive weight loss
Iatrogenic prematurity/ Prematurity
Rh incompatibility (give RhoGAM)
Use of oxytocin
Infections
Epidural bupivacaine
Hypoxia/asphyxia
Birth trauma
Maternal diabetes

116
Q

What are non-modifiable risk factors of hyperbilirubinemia?

A

Male gender
Sibling with jaundice
Race: Asian, Native American, Greek
ABO incompatibility

117
Q

What are the 4 types of hyperbilirubinemia?

A

Physiological
Pathological
Breastfeeding
Breast milk

118
Q

What is the progression of hyperbilirubinemia?

A

Head to toe progression

119
Q

When is breast milk jaundice? How long does it last/peak?

A

Occurs 3-5 days after mature milk

May last several months but peaks around 2-3 weeks

120
Q

What are the causes of breast milk jaundice?

A

Increased free fatty acids in some breast milk
Free fatty acids compete with bilirubin binding sites on albumin
Inhibits conjugation
Increased reabsorption of bilirubin in GI tract

121
Q

What is the treatment for breast milk jaundice? When does total serum bilirubin peak?

A

Continue to breastfeed if bili levels <20mg/dl

Interrupt breastfeeding and formula feed for few days if bili 20 mg/dl

Peaks at 5-10 mg/dl by 2-3 weeks

122
Q

When does breastfeeding jaundice appear in a newborn? Causes?

A

Appears in first few days

Ineffective breastfeeding
Dehydration
Delayed meconium stool passage (one good meconium stool reduces bili level ~1 mg/dl)

123
Q

How do you treat breastfeeding jaundice?

A

Support effective breastfeeding by Frequent feedings and Lactation consultation
Promote stooling (Colostrum is a great laxative)
Avoid supplementation

124
Q

What is physiologic jaundice? When does it appear? Peak? Resolve?

A

Normal adaptation

Appears after 24 hours

Peaks around 3-5 days

No longer apparent by 14 days

125
Q

What are the causes of physiologic jaundice?

A

Increased breakdown of fetal RBCs
Impaired conjugation of bilirubin- lack of glucuronyl transferase
More bilirubin reabsorbed by GI tract

126
Q

When does pathologic jaundice appear? How long does it last?

A

Appears within the first 24 hours

Lasts longer than 1 week

127
Q

What causes pathologic jaundice?

A

ABO incompatibility
Hemolytic disease of the newborn
Maternal disease processes such as diabetes, intrauterine infections, drugs-sulfa, salicylates, novobiocin, diazepam, oxytocin

128
Q

What is phototherapy? What does it do?

A

Blue lights most effective

Converts to water soluble form
Excreted via urine and stool

129
Q

What circumstances is exchange transfusion used? What does it do?

A

Used when phototherapy ineffective or severe hemolytic disease present

Replaces 85% of RBCs
Corrects anemia
RBCs with maternal antibodies removed
Other hemolysis toxins removed

130
Q

What are the complications of an exchange transfusion?

A

Thrombocytopenia, hypocalcemia most common
Metabolic acidosis, clots

131
Q

What is the correct positioning of the lights for phototherapy? How do you make sure maximum exposure?

A

45-50 cm from infant

Frequent position changes
Naked
Limit time out

132
Q

What should you monitor during phototherapy?

A

Vital signs-especially temperature
Intake and output
Side effects
TSB levels- should drop 1-2 mg/dl within first 4-6 hours
Protect eyes

133
Q

What are side effects of phototherapy? (7)

A

Loose stools, dehydration, hyperthermia, lethargy, rashes, impaired bonding, eye damage

134
Q

where does the blanching begin for hyperbilirubinemia?

A

Blanch skin beginning on face and moving down body

135
Q

How do you decrease the risk of hyperbilirubinemia?

A

Prevent cold stress
Promote early feedings
Monitor stools

136
Q

What lab testing should be done on patients with suspected hyperbilirubinemia? When is it visually apparent?

A

Cord blood typing for newborns of mother’s with O blood types
Direct Coombs test (DAT)
Total serum bilirubin (TSB) - visually apparent jaundice=TSB of 4-6 mg/dl
Transcutaneous bilirubin level

137
Q

Can RhoGAM be used to help treat hyperbilirubinemia?

A

YES

138
Q

What is kernicterus? Is it preventable?

A

Preventable

Chronic and permanent sequelae of untreated hyperbili

139
Q

What are the early s/s of kernicterus?

A

Extreme jaundice
Absent startle/moror reflex
Poor feeding or sucking
Extreme sleepiness (lethargy)

140
Q

What are the mid s/s of kernicterus?

A

High-pitched cry
Arched back with neck hyperextended backward
Bulging fontanel (soft spot)
Seizures

141
Q

What are the late s/s of kernicterus?

A

High-frequency hearing loss
Mental retardation
Muscle rigidity
Speech difficulties
Seizures
Movement disorder

142
Q

What does type O blood contain? What is the concern with this?

A

Type O blood contains anti-A & anti-B antibodies (IgM)

If enter fetal circulation of blood types A or B cause clumping of RBCs

143
Q

What are the consqueces of HDN? Is it preventable?

A

Rapid destruction of fetal RBCs –> Hyperbilirubinemia, Anemia and Death

No available prevention

144
Q

What is the difference between Rh positive and Rh negative blood?

A

Positive: D antigen

Negative: No D antigen and with exposure to Rh positive blood anti-D antibodies are produced (IgG antibodies)

145
Q

What occurs when anti-D antibodies cross placenta and attach to fetal RBCs?

A

Cause hemolysis of fetal RBCs
Erythroblastosis fetalis
Hydrops fetalis

146
Q

What is hydrops fetalis? S/S?

A

most severe form

Severe anemia
Multiple organ system failure
Cardiac decompensation
Generalized massive edema
Death

147
Q

What is erythroblastosis fetalis? S/S?

A

Anemia
Jaundice
Increased immature RBCs
Death

148
Q

How should Rh sensitization be prevented? What is the MOA? How long does it protect for? When is it not effective

A

RhoGAM - Made from plasma

Prevents production of anti-D antibodies –> decreases risk of hemolytic disease in fetuses in subsequent pregnancies

Provides protection for approximately 12-14 weeks

Once antibodies form RhoGAM is no longer effective

149
Q

When should RhoGAM because give to a Rh negative mom?

A

At 28 weeks in every pregnancy
Miscarriage/abortion
Other—amniocentesis, abdominal trauma, ECV, when mixing suspected
After delivery if fetus is Rh Positive

150
Q

What is late preterm? What are the complications of being late preterm? How long do they need close monitoring for?

A

34-36 6/7 weeks gestation

Inadequate or delayed transition
Up to 20% of NICU admissions
Morbidity rate doubles for every week below 38 weeks

Close monitoring for at least first 24 hours

151
Q

What a patient is late preterm what occurs in their lungs?

A

Lungs immature
Decreased surfactant
Immature respiratory control
Decreased muscle tone

152
Q

How is thermal control altered in late preterm newborns?

A

Decreased brown fat for thermogenesis
Decreased white fat for insulation

153
Q

What causes feeding difficulties in late preterm infants?

A

Immature coordination
Inadequate milk transfer
Sleepier
Low milk supply

154
Q

Are late preterm infants at increased risk for hyperbilirubinemia? why?

A

2X greater risk for significantly high levels
More susceptible to bilirubin toxicity

Delay in metabolism and excretion

155
Q

Does a late preterm infant have any differences in their brain? Any changes this causes?

A

Cortical volume increases 50% in volume between 34-40 weeks, great increase in surface area

Needs more sleep to conserve energy

156
Q

Why do late preterm infants have hypoglycemia?

A

Low glycogen stores
Immature pathways to make glucose

157
Q

Why do late preterm infants have an increased risk for sepsis?

A

Immature immune system

158
Q

What special care should a late preterm infant have?

A

Close monitoring for at least 24 hours
More frequent vital signs
Feeding - lactation consultation and encourage frequent feedings and assess adequacy
Unlimited skin-to-skin contact

159
Q

What should be prevented in a late preterm infant?

A

Hypoglycemia
Hyperbilirubinemia
Prevent infections
Hypothermia

160
Q

What needs to be completed prior to discharge of a late preterm infant?

A

Car seat challenge prior to discharge

161
Q

What are the risk factors of a fractures clavicle in birth?

A

Macrosomia
Shoulder dystocia
Forceps and vacuum
Unpredictable

162
Q

If a baby has cephalohematoma what should they be monitored closely for?

A

Monitor closely for jaundice

163
Q

What is the cause of neurological injuries at birth?

A

Excessive or improper traction on head during birth

164
Q

What are two locations for a branchial plexus injury?

A

Erb’s palsy-damage to network of nerves for arm, hand and shoulder (C5-8 and T1)

Klumpke’s- nerves of forearm and hand (C8 and T1)

165
Q

What are risk factors for hypoglycemia in a newborn? (10)

A

Neonate of diabetic mother
SGA
Preterm
Hypothermia
Birth trauma
RDS
Resuscitation
Macrosomia/LGA
Postdates
Maternal chorioamniotis

166
Q

What is considered hypoglycemia in a newborn?

A

Blood sugar <40-45

167
Q

What are s/s of hypoglycemia in a newborn?

A

Jitteriness
Poor tone
Lethargy
Temperature instability
Apnea
Irritability

168
Q

What is the leading cause of morbidity and mortality in a newborn?

A

Neonatal sepsis

169
Q

What are ways that neonatal sepsis is transmitted?

A

Vertical:
1. Transplacentally-TORCH infections
2. Ascending- R/T prolonged rupture of membranes
3. Delivery exposure-herpes, GBS

Horizontal

170
Q

What are the two types of sepsis? Causes of each?

A

Early onset- within first 7 days—GBS #1 culprit
Higher incidence with low birth weight

Late onset- 8 days to 3 months- Staph, pseudomonas, e-coli

171
Q

What can be used to predict the risk of sepsis in a neonate?

A

Neonatal early onset sepsis calculator

172
Q

What are the s/s of neonatal sepsis?

A

Respiratory-Apnea, grunting, tachypnea, cyanosis
Thermoregulation-Temperature instability, hypothermia
Neurological- Lethargy
Poor feeding, glucose instability
Cardiovascular-brady/tachy, hypotension, poor perfusion

173
Q

What tests should be ordered r/t neonatal sepsis?

A

CBC:
1. WBCs-high or low
2. Neutrophils-low
3. Bands (immature WBC)-high
Blood cultures
Spinal tap
Others: c-reactive protein, urine culture, chest x-ray

174
Q

Can neonatal sepsis be prenatally prevented? Intrapartum? Postnatal?

A

Prenatally: screen/treat infections, education

Intrapartum: GBS, limit # of VE, avoid AROM too early, avoid PTD

Postnatal: education and good hand hygiene

175
Q

What is the treatment for neonatal sepsis?

A

Antibiotics- start prior to blood culture results
Nutrition-may be NPO
Assessment- symptoms, weight, I&Os, hypoglycemia, electrolyte imbalances
Respiratory & cardiovascular support
Support bonding & parental education

176
Q

If fetus has apnea what else should be assessed? (7)

A

Hypoglycemia
Infection
Hypoxia
Fluid imbalances
CNS abnormalities
Cyanosis
Bradycardia

177
Q

What is the cause of transient tachypnea of the newborn (TTN)? What dies is resemble?

A

Failure to clear fluid in pulmonary system

Resembles classic RDS

178
Q

What are the risk factors for TTN?

A

C-section
Maternal diabetes and asthma
Male infants
LGA, macrosomia
Late preterm

179
Q

What are the s/s of TTN?

A

Rapid rate
Grunting, retractions, nasal flaring
Cyanosis

180
Q

What is the nursing care for TTN? (3)

A

Oxygen
Prevent cold stress
Provide calories—oral feedings contraindicated

181
Q

What is asphyxia?

A

Inability to transition to extrauterine circulation

No lung expansion and respirations –> hypoxemia –> metabolic acidosis & hypercapnia

Change from aerobic to anaerobic metabolism

182
Q

What are the antepartum risk factors for asphyxia? Intrapartum? Neonatal?

A

Antepartum factors: anything affecting placental perfusion

Intrapartum factors: prolonged labor, cord issues, assisted delivery, malposition

Neonatal factors: prematurity, male gender, infant of diabetic mother, SGA/macrosomia

183
Q

What are the protective factors for asphyxia?

A

Brain is immature
Lower resting metabolic rate
More efficient energy use
Able to redistribute lactate and hydrogen ions

184
Q

What is the morbidity associated with asphyxia?

A

Mild- no long term sequela
Moderate to severe- depends on extent of insult
~58% CP
~48% other abnormal outcome

185
Q

What are the intrapartum s/s for asphyxia? What are the neonatal s/s for asphyxia?

A

Intrapartum:
Non-reassuring FHR in labor (category 3)
Cord blood gas pH <7

Neonatal:
No respiratory effort @ 5 min or APGAR score < 5 @ 10 min
Need for prolonged resuscitation
Stunned look or lethargic
Seizures & CNS irritability
Hypertonic or hypotonic
Poor feeding

186
Q

What is the treatment for asphyxia?

A

Rapid identification
Appropriate resuscitation
Support oxygenation & ventilation
Therapeutic hypothermia
Decreased mortality and neurodevelopmental disability rates
Provide nutrition

187
Q

When can therapeutic hypothermia be used? What does this include?

A

For 36 or more weeks gestation

Cool to 33.5-34.5 C
Initiated within 6 hours

188
Q

What is the cause of respiratory distress syndrome? (RDS)

A

Absence, deficiency or alteration in pulmonary surfactant

189
Q

What is the role of surfactant? What if there is not surfactant?

A

Lowers surface tension –> reduces pressure required to keep alveoli open with inspiration
Prevents total alveolar collapse on exhalation –> maintains alveolar stability
Decreased surface tension –> increased lung compliance
Helps to establish functional residual capacity of lungs

Without surfactant –> more pressure must be generated for inspiration –> can tire or exhaust preterm or sick infants

190
Q

When does surfactant start to develop? When should babies have naturally occurring surfactant?

A

develop around 24-28 weeks

By 35 weeks most babies have enough naturally occurring surfactant to keep the alveoli from collapsing

191
Q

What are the risk factors for RDS?

A

Prematurity
~50% Preterm newborns < 30 weeks
Asphyxia
Infant of a mother with diabetes
Surfactant deficiency syndrome

192
Q

What do corticosteroids do for RDS? When are they recommended?

A

Promote fetal lung development and surfactant production

IM injection when in preterm labor and repeated in 24 hours

Recommended to give Corticosteroids if the woman is expected to deliver within the next 7 days:
24 0/7-33 6/7 weeks
34 0/7-36 6/7 weeks for women who have not previously received corticosteroids
23 0/7-23 6/7 weeks based on parents desires for resuscitation
A single repeat series can be given if < 34 weeks

193
Q

What assessment finding would be expected for RDS?

A

Progressive respiratory difficulty
Grunting, tachypnea, nasal flaring, retractions
Lethargy
Hypotonia
Cyanosis
Hypoxemia and acidosis
CXR-reticulograndular pattern
Increased O2 requirements

194
Q

What is the management of RDS?

A

Preterm birth prevention
Maintain neutral thermal environment
Respiratory support & oxygenation to maintain pulse ox @ 90%
Nutrition via IV
Maintain BP
Surfactant administration

195
Q

When is surfactant administered? How? Benefits?

A

Prophylaxis- within 15 minutes of birth
Rescue treatment- within 8 hours of birth

Administered via ET tube

Benefits- reduces risk of RDS, pneumothorax, IVH, bronchopulmonary dysplasia, pulmonary interstitial emphysema

196
Q

With use of illicit drugs, alcohol & tobacco increased risks for issues?

A

Poor or no prenatal care
Poor weight gain
STIs
OB complications

197
Q

What factors affect neonatal abstinence syndrome? What is the timing of s/s for alcohol? Narcotics? Barbituates?

A

Last exposure, half-life, type

Alcohol-3-12 hours

Narcotics-2-3 days

Barbiturates-1-14 days

198
Q

What effects does fetal alcohol syndrome have on the neonate?

A

Facial- small eyes, thin upper lip, short nose
Heart, joint, limb, finger deformities
IUGR and poor growth after birth
Cognitive impairment—COMPLETELY PREVENTABLE!!!
Vision and hearing problems, behavior problems

199
Q

What is affected with alcohol related birth defects?

A

Congenital anomalies-heart, skeleton, kidneys, eyes, ears

200
Q

What is alcohol related neurodevelopment disorder?

A

Small head size, brain abnormalities, neuro, cognitive, behavioral problems

201
Q

When reviewing the records, what are you looking for?

A

look for potential exposure
Assess for withdrawal and anomalies

202
Q

What would urine vs cord vs stool tell you about exposure?

A

Meconium – shows longer exposure
Urine – more recent exposure
Cord – long exposure

203
Q

What is different about the nutrition of a baby exposure to substances?

A

Poor feeders
Small, frequent feedings
Higher calorie formula?

204
Q

If baby is hypoglycemic, what should be done?

A

Provide calories
Reassess glucose in hours

205
Q

Nursing care of the neonate with exposure?

A

Review records
Obtain toxicology –meconium and urine screening, cord tissue sampling
Control environment - Dim, quiet, group care activities
Nutrition
Promote self-soothing/regulation with swaddling, gentle rocking, non-nutritive sucking
Promote bonding

OB (16 decks)

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