Exam 1 Flashcards
What are the 5 Ps of labor?
Passageway, Passenger, Powers, Position, Psychological Response
what is the most common and favorable pelvic type?
gynecoid
what is fetal attitude and what leopold maneuver confirms it?
relationship of fetal body parts to one another, determined by 4th maneuver
what fetal attitude presents with the smallest diameter?
flexed, suboccipitobregmatic
what is fetal lie and which leopolds confirms it?
relationship of maternal spine to fetal spine, confirmed with leopold’s 1-3
what are the 3 types of fetal lie?
longitudinal, transverse, oblique
what is fetal presentation?
body part of fetus entering the pelvis
what are the 3 types of fetal presentation?
breech, shoulder, cephalic
what is fetal position?
relationship of fetal presenting part to one of the four quadrants of the mother’s pelvis
- right or left
- occiput, sacrum, mentum or scapula
- anterior, posterior or transverse
what are powers?
uterine contractions, intra-abdominal pressure
how do you measure frequency?
timed in minutes, beginning of one UC to the beginning of the next
how do you measure duration?
timed in seconds, beginning of UC to the end of the UC
why is it important for a mother to have frequent position changes?
increases comfort, relieves fatigue, promotes circulation, assists in fetal descent, duration of labor decreases, perineal outcomes improve, maternal satisfaction increases
what stages make up intrapartum?
3 phases of stage 1 & stage 2
normal frequency of contractions
5 or less contractions in 10 minutes, averaged over 30 minute period
abnormal frequency of contractions (tachysystole)
more than 5 contractions in 10 minutes, averaged over a 30 minute period
normal FHR
111-160
what is FHR baseline?
average FHR during a 10 minute period excludes periodic (associated with UC) and episodic changes
what is FHR tachycardia and what could it be signs of?
> 160 bpm for ten minutes
-early fetal hypoxia, maternal fever, betasympathomimetic drugs, maternal hyperthyroidism, fetal anemia dehydration
what is FHR bradycardia?
<110 bpm for 10 minutes
-profound asphyxia, maternal hypotension, prolonged umbilical cord compression, fetal arrhythmia
FHR variability: absent
undetected variability - flat line
FHR variability: minimal
0-5 bpm - don’t like to see
FHR variability: moderate
6-25 bpm
FHR variability: marked
> 25 bpm
what are accelerations?
increase in baseline FHR, associated with fetal movement and adequate oxygenation - indicates baby is healthy
- over 32 weeks: 15 beats above baseline that last for at least 15 seconds
- less than 32 weeks: 10 beats above baseline that lasts for 10 seconds
what are decelerations in FHR?
decrease in baseline FHR, can be periodic or episodic, recurrent or intermittent
what are early decels?
normal, d/t contraction
could be due to head compression during pushing
always periodic!
what are variable decels?
abnormal, abrupt, sign of cord compression
- decrease in baseline 15 or more bpm and lasts for 15 or longer seconds
- V or U shpaed
what are late decels?
abnormal, occurs after peak of UC, may be due to uteroplacental insufficiency (decrease in O2 to fetus)
always periodic
what are prolonged decels?
abnormal
decrease in FHR of at least 15 bpm lasting more than 2 minutes but less than 10
cause: sudden and profound change in fetal environment
what is reassuring FHR?
baseline = 110-160
- moderate variability
- periodic patterns consist of accels with fetal movement
- early decels may be present
what is non-reassuring FHR?
severe bradycardia/tachycardia
- severe variable decels
- late decels or prolonged decls
- absence of variabilty
VEAL CHOP
Variable –> cord Compression
Early –> head compression
Acceleration –> oxygenated
Late –> placental insufficiency
LOCK method
L - left lateral position - reposition first!
O - oxygen via face mask
C- correct contributing factors (IV fluid bolus, maternal position change, hypotension)
K - keep monitoring FHR and uterine activity
If variability is absent, how can you stimulate the baby?
- scalp stimulation via vaginal exam or FSE
- vibroacoustic
what is the first stage of labor?
three phases (latent, active, transition) from 1cm-10 cm dilation
what is stage two of labor?
from 10cm until birth of baby
what is the 3rd stage of labor?
after birth of baby until delivery of placenta
what is the 4th stage of labor?
delivery of placenta until 4 hours after birth
*assess every 15 minutes for 1 hour, every 30 minutes for 1 hour, hourly for 2 hours
what are the seven cardinal movements?
Engagement (station 0) Descent Flexion Internal Rotation Extension: crowning External Rotation/Restitution Expulsion
what are signs of placental separation?
lengthening of the umbilical cord
sudden gush of dark blood
uterine fundus rises up
change in shape of uterus
Shiny Schultze
placenta separates from inside to the other margins, limited bleeding
Dirty Duncan
separates from outer margins inward - more bleeding
what should a nurse do after delivery of placenta?
- make sure all cotyledons are present
- inspect for lacerations
- promote baby friendly activities
- fundal palpation –> should be firm
- cleanse perineum
- oxytocics
Oxytocics
- Pitocin - 10-20 units IV, 10 units IM, never push
- Methergine - .2mg IM
- hemabate - 250 mcg/mL IM
- cytotec - inserted into rectum
what cardiovascular changes happen during second stage of labor?
BP, pulse and CO increase
blood flow to uterine arteries becomes blocked with contractions
Valsalva maneuver
*want mom on their side
what cardiovascular changes happen during the third stage of labor?
CO peaks and then decreases
elevated output for 24 hours post birth
where does water loss come from?
- diaphoresis
- hyperventilation
- increased body temp from muscular activity
- increased RR, increased evaporative volume
what respiratory changes happen during birth?
- increased demand for O2
- RR increases
what renal changes occur during birth?
- increased GFR can lead to proteinuria
- increase in maternal renin
- increase in urinary output
what GI changes happen during birth?
- gastric motility and absorption decrease
- gastric emptying time increases
- increased gastric acidity
- glucose infusions –> can lead to fetal hyperglycemia and newborn hypoglycemia
what does the 4th stage of labor include?
after birth of placenta to 4 hours after birth
how often are mothers assessed during the 4th stage of labor?
every 15 minutes for 1 hour, every 30 minutes for 1 hour, hourly after 2 hourse
what is assessed during the nursing assessments in the 4th stage of labor?
vital signs, fundus, bladder blood flow
puerperium
period during which the body adjusts and returns to near pregnancy state
usually lasts 6 weeks
how long can it take deep vein diameters to return to normal?
6 weeks
how long does it take to return to prepregnancy CO?
3 months
what is the typical blood loss for a vaginal birth?
200-500 mL
why are postpartum women at risk for hypotension?
- natural hypovolemic state
- risk for DVT with increase diameter of veins
what is the decrease in hematocrit that would require investigation?
10%
three common occurrences after birth
postpartum chills
afterpain
diaphoresis
if bladder is full, where will the uterus be displaced to?
the right side
when does normal bowel eliminiation return?
2-3 days
how long is the immune system response to infection delayed for?
2-3 months
WBC levels after birth
increased without presence of infection
BUBBLE-HE
breast, uterus, bladder, bowel, lochia, episiotomy, homan’s, emotional status
2 common abdominal impacts PP
diastasis recti abdominis
striae
what would a temp of over 100.4 after the first 24 hours indicate?
puerperal sepsis, UTI, endometritis
Reva Rubin’s stage 1: taking in
passive, wants to be taken care of
Reva rubin’s stage 2: taking hold
initiates action, more interest in caring for self and child
reva rubin’s stage 3: letting go
more settled
happens more at home
PP depression
occurs after 14 days, but doesn’t have to begin immediately (can be within 1st year of life)
psychological disorder
PP Blues
affects 50-80% of all PP women
usually peaks at 5th day and goes away
characterized by mood swings, weepiness and let down
what would floaters in peripheral vision indicate?
increased BP
how often should breasts be examined?
every 8 hours for nipple soreness, tenderness, colostrum, pain and plugged ducts, engorgement
when does the fundus move to the umbilicus line?
6-12 hours after birth
involution of umbilicus per day
1 fingerbreadth per day
occurs faster in breastfeeding mothers
rubra lochia
red; first 3 days
serosa lochia
pink; day 3-10
alba
white; day 11-14
how long should you rest the pelvis post partum?
6 weeks
when should menstruation appear if not breastfeeding?
within 6 - 8 weeks
lochia: scant amount
less than 1 inch stain on peri pad within 1 hour
lochia: light amount
less than 4 inch stain on peri pad within 1 hour
lochia: moderate amount
less than 6 inch stain on peri pad within 1 hour
lochia: heavy amount
saturated peri pad within 1 hour
*needs to be evaluated
REEDA: perineum check
redness edema ecchymosis discharge from laceration or episiotomy approximation
what does clonus indicate?
neurological sign of increased BP
complications: when to call 911
P: pain in the chest
O: obstructed breathing or SOB
S: seizures
T: thoughts of hurting yourself or baby
complications: when to call healthcare provider
B: bleeding, soaking through one pad/hour, blood clots bigger than the size of an egg
I: incision that is not healing
R: red or swollen leg, that is painful or warm to touch
T: temperature of 100.4 or greater
H: headache that does not get better, even after medicine or bad headache with vision changes
what can increased stress during labor lead to?
increased O2 consumption for mom –> decreases O2 consumption to fetus
psychoprophylactic techniques
- relaxation techniques
- massage/effleurage
- therapeutic touch
- position change
- music
- hypnobirthing - breathing techniques
- acupressure, ice massage
- breathing techniques
- hydrotherapy
systemic analgesia
IV narcotics, affects mother systematically
when is systemic analgesia preferred?
stage 1, phase 1
why do babies need to be reactive?
need them active in birthing process, need them to realize if their O2 is cut off
what does systemic analgesia do?
provides pain relief without numbing or LOC
who cannot receive Nitrous Oxide?
B12 deficient patients
how long does systemic analgesia last?
2-4 hours
how to manage a wet tap (puncture of dura mater)?
hydrate
prepare client for headache
prepare for blood patch (several ccs of mother’s blood to alleviate headache)
how to combine epidural/spinal?
advance in place epidural catheter into the subarachnoid space
paracervical/pudendal analgesia
1% lidocaine used
placed in pudendal nerve through vaginal wall bilaterally
good relief for delivery and post delivery vaginal repairs
paracervical block
inject near cervix
pudendal block
inject in the outer inguinal area
general anesthesia - uses and side effects
used in emergency situations or if regional anesthesia is contraindicated
side effects: fetal depression, complete uterine relaxation, stops GI tract
nursing care during general anesthesia
- antacids
- NPO
- position in left lateral tilt
- patent IV
- neonatal team
- cricoid pressure
- preoxygenate
what is cricoid pressure?
pressure on cricoid cartilage so it is easer to intubate
when is a fetus considered full term?
38 weeks gestation
how does a nurse prepare the newborn room?
- warmer and room temp
- resuscitation equipment and team (correct mask size is imp, blood sugar test is diabetic, meconium, does mom have a fever?)
- warm blankets for mom and baby
- birth plan
what is included in the birth plan?
- skin to skin
- baby cleaned first?
- who is cutting cord?
- who is announcing sex?
When should the umbilical cord be clamped?
When it’s done pulsing, provides extra oxygenation to newborn
Palmar grasp
When placing a finger or stroking the inside of the infant’s palm the hand will close around it
Disappears around 4-6 months
Plantar grasp
When a finger is placed under the toes, toes will curl
Disappears 9 monhts - 1 year
Moro reflex
Startle reflex
When infant hears a sudden lound noise or unexpected movement, infant will extend arms palm up and move the arms back
Disappears 6 mons
Rooting reflex
Head will turn towards the side of the mouth you stroke
Disaappears around 4 months of age
Sucking reflex
When something touches the top of the infants mouth the infant wil begin to suck
Disappears around 4 months
Babinski reflex
When bottom of foot is stroke, heel upward, the big toe dorsiflexes and other toes fan out (opposite of correct adult response
Disappers around 1 year
Step reflex
Whe holding the infant upright with legs and feet touching a surface, the infant will move the legs like taking steps or walking
Disappears around 3-4 months of age
Tonic neck (fencing) reflex
When infants head is turned to a particular side, the leg and arm on that side will extend
Arm and leg on the opposite side will flex
Disappears around 4 months
what is another name for false labor?
prodromal
characteristics of false labor contractions
false and intermittent, no change in intensity, will lessen with activity, and be alleviated by comfort measures
where will you feel contractions during false labor
abdomen
“feels like baby is balling up”
do not radiate!
true or false labor: mucus plug
false labor
true or false labor: cervix is titled posterior towards the spine
false labor
contractions during true labor
regular intervals, become more frequent w/ time, varying intensity, worse with movement, and can’t be alleviated with distraction or comfort
where do you feel contractions in true labor?
discomfort in uterus/cervix/lower back area
they radiate!
true or false labor: bloody show
true labor
true or false labor: cervix is tilted anteriorly
true labor
what does 80/3/-3 mean?
80% effaced, 3cm dilated, -3 station
what position should the mother be in for a vaginal exam?
soles of feet together and knees apart
effacement
thinning and shortening of the cervix
0-100%
dilation
how the cervix is opening
what dilation does the woman have to reach to push?
10cm
station
the relationship of the fetal presenting part to the mom’s ischial spine
-3cm to 3cm
what does a + station indicate?
the more + the number, the closer to birth
what does 0 station mean?
fetus is engaged and committed
what does antepartum mean?
before birth
what makes up an initial labor assessment?
vaginal bleeding leaking of fluid fetal assessment contractions prenatal record vaginal exam vital signs pain assessment
after a water breaks, when should a mom go into labor?
within 24 hours
TACO
time, amount, color, and odor
assessment of water breaking
what color should the nitrazine paper turn if woman has broken her water?
green-blue because it is basic
*if pink- it is urine!
fern test
swab of discharge –> put on slide –> amniotic fluid will make a fern pattern
leopold’s maneuver: 1st maneuver
sides of palms at top of fundus
if it’s mushy - baby’s bottom
if firm and moving - baby’s head
If you don’t feel anything - baby is lying across
leopold’s maneuver: 2nd maneuver
sides of hands, push on one side and then the other
smooth and rounded = back
bumps = arms and legs
leopold’s maneuver: 3rd maneuver
Use one hand at bottom part, confirms the 1st maneuver
can determine if head is in cervix
leopolds maneuver: 4
face mom’s legs and feel to see if the chin is tucked in, out or straight ahead
used to determine fetal attitude
How do you evaluate intensity?
Palpate while she is having a UC or IUPC
Group beta strep status
A lot of women have strep in vaginal canal, no s/s, but can be transferred to fetus
Test done at 36 weeks
What makes up an initial labor assessment?
Vaginal bleeding - observe Leaking of luid Fetal assessment Contractions Prenatal record Vaginal exam Vital signs Pain assessment
Characteristics of latent phase
0-3cm dilated
5-9 hours
UCs every 15-30 minutes, for 15-30 seconds
UCs are typically irregular
Characteristics of active phase
4-7cm dilated
2-5 hours in duration
UCs every 2-5 minutes for 40-60 minutes, UCs are regular
Characterisitcs of transition phase
8-10cm dilated
UCs every 2-3 minutes, for 45-90 seconds, are regular
May have urge to bear down (feeling of a bowel mvmt), emesis, shaking legs, rectal pressure, bloody show
What is included in intrapartum maternal assessment?
- IPV assessment
- pregnancy history
- any high risk factors?
- physical assessment
- labor and fetal status (ongoing)
- lab tests (Rh factor)
- cultural and psychosocial assessments
what are signs of respiratory distress?
persistent cyanosis grunting respirations flaring nostrils retractions respiratory rate blow 30 or above 60 HR below 110 or above 160
why use the APGAR scoring?
objective way to determine if baby transitioned appropriately after birth
when do you do the APGAR scoring?
1 and 5 minutes
APGAR acronym
appearance, pulse, grimace, activity, respirations
what are the priorities in the first hour?
CV and respiratory assessment thermoregulation assessment and support of blood glucose weight and newborn meds identification and security observing urinary/meconium passage observing for major anomalies
Lechitin-spingomeylin ratio and when does it form?
has to deal with surfactant, should be 2:1 - indication baby is ready for outside world
38-42 weeks
what is the transition period?
6 hours after birth
what helps initiate breathing?
mechanical, chemical, thermal stimulation
what is the role of surfactant?
prevents alveoli collapse
acrocyanosis
blue-ish hands and feet
normal immediately after birth
breathing characteristics of newborns
diaphragmatic, shallow and irregular
periodic/episodic breathing (cessations should not last more than 20 secs!)
nose breathers
why does heat loss occur rapidly?
large skin surface area
little subq fat/thin skin
increased skin permeability to water
neutral thermal environment
temp range in which heat production is at the min. Needed to maintain normal body temperature
Normal newborn requires higher environmental temps to maintain a neutral thermal environment
normal newborn skin temp
36.5 - 37.2 (97.8-99)
conduction
touching something - heat will move from baby to surface that is colder
important to place them on something warm (mom’s chest, warmer)
convection
drafts - don’t have open windows, AC, doors
evaporation
water vapor - dry babies with blankets and give them new dry blankets
radiation
baby’s lose heat to cooler air
need to increase temperature in room, hats
fontanelles
where suture lines meet
placental previas
often end up in C-sections
complete or partial - placenta is blocking the cervix
CV assessment of newborn
HR should be between 110 and 160 bpm
listen to apical pulses for 1 minute
brachial and femoral pulses
listen for murmurs
caput succedaneum
swelling due to fluid accumulation
crosses suture lines b/w scalp and bone
not concerning unless it gets larger
cephalohematoma
does not cross suture lines
blood accumulation
could increase risk for jaundice
not normal!
if fontanelles are depressed, what does that indicate?
dehydration
when does the anterior fontanelle close?
12-18 months
when does the posterior fontanelle close?
by end of 2nd month
musculoskeletal assessment of newborn
- symmetry of eyes and ears
- five fingers and five toes
- clavicles
- movement of arms
- hips for hip dysplasia
- lower legs/feet for club foot
- check back for curvatures or dimples
epstein’s pearls
- small, white glistening specks (keratin)
- feel hard to touch
- usually disappear within a few weeks
erythema toxicum
- eruption of lesions in the area surrounding a hair follicle that are firm - 1-3mm
- white or pale yellow papule or pustule with a erythematous base
- aka newborn rash or flea bite dermatitis
- no lesions on hands or soles of feet
- rarely presents after 5 days
- unknown cause, no treatment
harlequin color
characterized by momentary red color changes of half the child, sharply demarcated at the body’s midline
stork bites
pale pink or red spots are are found on eyelids, nose, lower occipital bone and nape of neck - usually fade by second birthday
nevus vasulosis (strawberry mark)
capillary hemangioma - raised, clearly delineated, dark red rough surfaced, commonly found in head region, begin to grow during second or third week or life and may not reach full size until 6 months → then shrink and resolve spontaneously
average weight of newborn
2500-4000 grams (5.8 lbs to 8.13 lbs)
what’s the normal weight loss for a newborn in the first 3-4 days?
5-10%
average length of newborn
48-52 cm long (18-22 in)
average head circumference
32-37 cm (12.6-14.6 in)
2cm greater than chest circumference!
what factors influence blood volume?
placental transfusion (delayed cord clamping)
gestational age
prenatal hemorrhage
true or false: babies have an elevated RBC levels at birth
true
first period of reactivity
30 minutes after birth, good time to initiate breastfeeding
rapid RR and HR
sleep phase
few minutes to 4 hours
RR and HR stabilize
second period of reactivity
4-6 hours
mucus production increases –> need to maintain clear airway!
gastric activity
awake and alert
deep/quiet sleep
closed eyes, no movements, regular, even breathing, jerky motions or staples at regular intervals
100-120 bpm when startled
active or light sleep
REM sleep
irregular respirations, eyes closed, irregular sucking motions, minimal activity, irregular but smooth movements of extremities
alert states
drowsy or semi dozing
quiet alert
active alert
crying (hunger, pain, boredom, temperature)
what can lead to jaundice?
- immature liver might not be able to bind up bilirubin effectively
- Yellowish coloration of the skin and sclera
what % of fetal glucose levels are mother’s glucose levels?
80%
signs and symptoms of newborn hypoglycemia
jittery, weak cry, feeding issues, diuresis, resp. issues, poor muscle tone
what can newborns not digest?
complex starches
lacking pancreatic amylase
what will breastfeed stool look like?
yellow, soft, sweet odor
what will formula stool look like?
pale yellow, light brown, firm, ordorous
when should newborns void by?
within 48 hours after birth
when are newborns able to concentrate urine?
3 months
what happens to the GFR within first two weeks of life?
it doubles
how often should a newborn urinate?
2-6x day first 2 days and increase after that
uric acid crystals
can appear red and is normal
*not the same as red discharge in females
what antibodies do newborns receive from mother?
IgG - transfer across placenta
passive immunity!
what antibodies do they receive via colostrum?
IgA
medications for newborns
erythromycin eye ointment - prophylaxis for gonorrhea
aquamephyton (vit K)
first hep B vaccine
HBIG if mother is Hep B surface anitgen positive
newborn care
- keep warm, skin to skin
- keep cord dry
- gently wash eyes from inner to outer
- do not retract foreskin
- gently clean labia
- gently clean scalp
bathing baby steps
start with legs and trunk –> do head last!
mild soap
do not cut nails for 1st week
keep parts not actively bathing covered!
when do you start tub baths?
once cord has fallen off - usually 2 weeks
how to avoid SIDS
- place baby on back when sleeping
- firm sleep surface
- do not use bumpers
- do not share beds
- avoid overheating
- parents should avoid alcohol and drugs
when to call healthcare provider for newborn?
- temp above 38 (100.4 F)
- more than 1 forceful vomit or frequent vomit
- refusal to feed for 2 feedings
- lethargy
- cyanosis or jaundice
- absence of breathing for more than 20 s
- inconsolable
- no wet diapers for 18-24 hours, fewer than 6-8 diapers per day
- drainage from circumcision, cord or eyes
what happens to CO after birth?
transient increase for 48 hours
what happens to GI after birth?
mother is hungry b/c of energy expended after labor
when does acid base levels return to pregnancy levels?
within 24 hours
what oxytocic is contraindicated in asthmatics?
hemabate
what oxytocic would you not give to preeclamptic or high BP
methergine
when is brown fat developed
26 weeks
systemic analgesics
NO morphine stadol nubain phenergen benadryl fentanyl
what are stool softeners?
colace, simethicone
when does normal bowel elim return?
2-3 days
lidocaine
for repairs
injection or topical
which pain relievers can you take PO?
acetaminophen and morphine
sedatives
benadryl, stadol, fentanyl, dermerol, nubain, NO, phenergen
reassuring (reactive) fetus
accels, moderate variability, early decels are okay, HR 110-160
when does placenta exchange start
10 weeks
when does brown fat develop
26-30 wks
how much does CO increase in response to labor
30%
average number of peri pads per day
6
