Exam 2 Blueprint Flashcards
Postpartum at risk: Postpartum hemorrhage risk factors
- Past History of PPH (doubles risk)
- Overdistention of uterus (polyhydramnios, macrosomia, twins)
- Prolonged/dysfunctional labor
- Grand multiparity (5+ kids -> trouble maintaining tone)
- Preeclampsia (low platelets, HELLP)
- Medications that relax smooth muscle
- Obesity
- Asian or Latina heritage
- Birth procedures - oxytocin, operative vaginal delivery, cesarean section
anemia or low platelets makes the hemorhage worse
Teaching for Self-Care of the Postpartum Patient: When to call the doctor/911- post-birth warning signs
Call 911: POST
- P: pain in chest
- O: obstructed breathing or shortness of breath
- S: seizures
- T: thoughts of hurting yourself or your baby
Call provider: BIRTH
- B: bleeding, soaking through one pad/hour, or blood clots the size of an egg or bigger
- I: incision that is not healing
- R: red or swollen leg, that is painful or warm to touch
- T: temperature of 100.4F or higher
- H: headache that does not get better, even after taking medicine or bad headache with vision changes
Apgar scoring
A- appearance
P-Pulse (heart rate)
G-Grimmace (reflex/irritability)
A- Activity (tone)
R- Respiratory Effort
If less than 7 min- repeat the assessment every 5 min until stable
Gestational age estimation
A term baby has:
* Flexed tone, resistance to extension, well-developed creases and folds, thicker skin, little vernix, firmer
cartilage
A preterm baby has:
* More flaccid tone, more flexibility, thinner skin, visible veins, few creases, lots of vernix, softer cartilage
A post-term baby has:
* Lots of cracking, leathery skin, possibly meconium staining, no vernix
Unexpected outcomes of childbearing: Perinatal Loss
Nursing interventions, what to say, what to do
Miscarriage
Stillbirth
Neonatal Death
Allow family to see and hold baby
- If possible, provide a room away from main maternity traffic
- Post a symbol on the door to alert housekeeping, dietary and other staff
- Pastoral Care or family pastor/priest
- Blessing or Emergency Baptism
- Mementos - photos, blankets, footprints, lock of hair.
- Refer to perinatal bereavement
- say you’re sorry for their loss
The nurse is caring for a client who is 3 days post-cesarean section. The patient complains of left calf pain and inspection of the lower extremities shows the finding in the image below. The left extremity is warm to the touch. What should the nurse do next?
Contact the provider and anticipate doppler studies and laboratory evaluation for coagulopathy studies (PT, PTT, CBC, INR, and d-Dimer) while monitoring respiratory status.
Newborn assessment/care: Common findings - milia, stork bites, mongolian spots, caput, etc.
May want to add in photos because I think she said she’s putting up photos of these and we have to identify
Safe sleeping
Always on the back!
Firm mattress
No extra bedding
No recliners, adult beds
Discourage bed-sharing
Newborn assessment/care:
Signs of respiratory distress
Nasal Flaring
* Grunting
* Tachypnea
* Substernal Retractions
* SeeSaw Respirations
Interprofessional communication during a postpartum hemorrhage - SBAR, Chain of command, CUS words, etc.
CUS: Concerned, Uncomfortable, Safety Issue
- I am concerned about
- I feel uncomfortable with
- This is a safety issue because
Preterm infants (Airway management): Complications of prematurity
Retinopathy of prematurity
NEC
BPD
Newborn Jaundice: Phototherapy- reasons for using it/Nursing care
Pathologic - hemolysis
- Coombs positive babies (Or Rh+ babies)
- Levels climb high and fast
- Increased risk (esp for brain damage)
Physiologic - immature liver
Ineffective breastfeeding= higher risk
- Low intake
- Less stooling (less excretion of bili)
- Higher levels
Treatment:
- Supplementation
- Phototherapy
- Overhead or blanket
- Eye protection
- Temp probe if in isolette
- Monitor bilirubin levels
Restorative Period: Letting Go
- incorporating old self into new role as a mom
- acquiring role of motherhood
- taking care of kid
- independent
- knows resources
this phase happens after several weeks of adjustment. The mother reestablishes her previous relationships, functions in her new role with confidence, and builds a lifestyle that includes the infant. She relinquishes the “fantasy infant” and her idealized concepts about parenting and motherhood and accepts her role.
Necrotizing enterocolitis - know nursing assessments, signs and symptoms, prevention of NEC
Signs and symptoms
- Lack of bowel movements
- Abdominal distention
- Increase in abdominal circumference of 1 to 2 cm since last feed
- Irritability
- Lethargy
- Can lead to respiratory difficulties
Diagnosis:
X-ray will show free air in abdominal cavity, distended loops of bowel
Prevention of NEC:
- Human milk feeding for infants <32 weeks - mom’s or donor
- Measure and record abdominal circumferences
- Auscultate bowel sounds before every feeding and observe for abdominal distention
- Before any gastric tube feeding, check for aspirates of undigested formula or breast milk
- Record all bowel movements for amount, consistency, and frequency
If you suspect a problem: HOLD FEEDINGS AND SBAR THE NEONATOLOGIST!
The nurse is preparing to administer Vitamin K to a newborn. What is the purpose of this medication?
To promote normal blood clotting
Vitamin K is produced by bacteria in the gut and promotes normal blood clotting. The gut of a newborn infant is sterile, and incapable of producing Vitamin K. A one-time injection of phytonadione (Vitamin K) will prevent abnormal bleeding in newborn infants.
Post partum mental health: Postpartum Psychosis: Signs and symptoms
Rare; women with history of bipolar disorder have 100 times the incidence; risk for suicide/infanticide is high
S/S:
- delusions/hallucinations
- depersonalization
- bizarre and disorganized behavior
- neglect of self/infant
A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman’s breasts are swollen, hard, and tender to the touch. The nurse documents this finding as:
engorgement
Engorgement is the process of swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36 hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Involution refers to the process of the uterus returning to its prepregnant state. Mastitis refers to an infection of the breasts. Engrossment refers to the bond that develops between the father and the newborn.
Why do you need NICU team at delivery especially with meconium aspiration syndrome?
If it is a vigorous infant: just bulb suction mouth and nose
But if non-vigorous infant: require interventions from NICU team so need to have them already present incase
- tracheal suctioning (below cords)
- may require supplemental oxygen
Management of PPH: Uterine atony (if least invasive methods fail)
- if medication/least invasive methods fail: prepare for OR
- exploration of uterus
- placement of balloon for tamponade
- suture
- ligation of arteries
- hysterectomy
Post partum mental health: Postpartum Depression: Preventing Suicide
- knowledge is power
- highest risk is early in treatment
- low energy = desire without energy
- increased energy = ability to carry out plan
- assess suicide risk
Cesarean- managing incisional pain (3)
Splinting of incision
Ambulation to prevent gas
Binders
Newborn state screening
Online: Many conditions screened for, such as cystic fibrosis, sickle cell disease, and endocrine diseases, do not have obvious symptoms at birth, making early detection crucial for preventing long-term health problems or even death.
The nurse is caring for a patient experiencing postpartum hemorrhage related to uterine atony. Fundal massage and an oxytocin bolus have been ineffective in stopping the bleeding. The provider orders methylergonovine (Methergine) 0.2 mg IM stat. In which situation should the nurse question this order?
The patient has preeclampsia with severe features
Promoting normal bowel/bladder function
Promoting Peristalsis
Early ambulation
Dulcolax, milk of magnesia
The nurse is preparing discharge teaching for a client who is 2 days postpartum. Which instruction should the nurse give to the patient to help her prevent constipation?
Encourage fiber-rich foods.
Encouraging fiber-rich foods will help with prevention of constipation. The client needs plenty of water, needs to ambulate, and should take stool softeners (not a stimulant laxative) if ordered by the health care provider. Increasing the coffee intake will not assist with preventing constipation. The client should get plenty of rest but it should be balanced with activity to help stimulate peristalsis of the GI tract.
The nurse is caring for a woman who gave birth by cesarean section two days ago. The woman is complaining of pain, is not passing flatus, has abdominal distention, and has hypoactive bowel sounds. Which instruction is most appropriate to relieve this patient’s discomfort?
“You should ambulate around the unit several times a day to promote passing gas.”
A visiting nurse is assessing a client on the fifth postpartum day. She reports that she has been crying on and off and sometimes gets irritable with her husband for leaving dishes in the sink. She denies difficulty with eating or sleeping and tells you that she feels “okay most of the time.” What is an appropriate response by the nurse?
“This sounds like the baby blues. They are common and usually go away in 10-14 days. Let’s review the signs of postpartum depression in case things change.”
Promoting normal bowel and bladder function
Bladder:
- if fundus is 3cm above umbilicus and displace: ask patient when last voiding, if only small amounts or not voiding help them empty
- run water
- run water over perineum
- have her lean over
- if can’t relieve: straight cath
Bowel:
- can get very constipated postdelivery; have some sluggish peristalsis
- encourage fluids, ambulation, fiber, and stool softener (Colace)
The nurse is preparing to administer the DTaP vaccine to a 2 month infant. Which site should the nurse select for this immunization?
In a 2 month infant, the only safe site for intramuscular injection is the vastus lateralis. This site avoids blood vessels and nerves that may be injured during IM injection.
Breastfeeding:
Latching
Positioning
How often
How to know if the baby is getting enough
When to do it:
8 or more in 24.
May need to wake a sleepy baby, BUT
Watch the baby, not the clock
Growth spurts -
baby needs more frequent feedings
Exclusivity advised unless medically needed
How to know if the baby is getting enough:
number of diapers increasing per day; 1st day: 1 wet 1 dirty; 2nd day: 2 wet 2 dirty and so on then 6-8 by 6th day
The nurse is teaching a postpartum client about perineal care during toileting using the teach-back method. Which action, performed by the patient, requires further intervention?
The patient uses toilet paper to vigorously wipe the perineum from front to back
The patient who uses toilet paper to vigorously cleanse the area is going to experience pain and is less likely to void frequently to prevent uterine bleeding and urinary tract infection. Additionally, fragments of soiled toilet paper may be left behind and contribute to the risk for infection. The patient should be educated to use a peri-bottle filled with warm water to gently rinse the area and pat dry with a soft disposable cloth.
Hand hygiene should be performed before and after any contact with the perineum to prevent infection. The woman should also shower daily (no tub baths).
The perineal pad should be changed approximately every 2-3 hours or every time the patient uses the bathroom to prevent infection. The nurse should ensure that the patient has an adequate supply of these products to take home as the cost may be an issue for low-income mothers and there may be a tendency to change pads less frequently to avoid running out.
Infections: Wound infections
- S/S
- Contributory factors
- When to call the DR
S/S:
- Redness at incision
- Foul-smelling discharge
- Edema
- Induration (hardness) at incision
- Pain
Most likely culprit: Staph Aureus (can be MRSA)
Contributory/Risk factors:
- obesity
- presence of staples (two portals w each staple)
- compromised health status, lower SES
- poor hygiene
Tx:
- culture, sensitivity, antiobiotics
- may need opening and packing
- wound vac may be needed; pain relief
Preventing complications from C-sections (Preventing DVT, respiratory complications, wound infection, and promoting peristalsis)
DVT prevention:
* Lovenox/heparin
* Sequential Compression Device
* Ambulation ASAP
Prevention of respiratory complications:
* Incentive Spirometry
* Cough and Deep Breathe
* Ambulation ASAP
Prevention of wound infection
- Hand hygiene before touching incision
- Shower daily, use clean towels
- Patient teaching - wound care, inspect daily
- REEDA - it’s not just for episiotomies!
Promoting Peristalsis
- Early ambulation
- Dulcolax, milk of magnesia
The nurse is caring for a woman who has just delivered a baby two hours ago. What is appropriate teaching for this patient regarding lochia? Select all that apply.
Your lochia should slow down and become pinkish or brownish in a day or two
“You should wash your hands before and after changing your pad.”
“You should call me immediately if you soak a pad in less than an hour or have a clot bigger than an egg.”
The nurse is caring for a child who is on neutropenic precautions. Which statement, made by the parents, would indicate the need for further teaching?
“I will encourage my child to eat lots of raw, fresh fruits and vegetables
Fresh fruits and vegetables may harbor food-borne pathogens. A child with an immune deficiency should eat fruits and vegetables that have been thoroughly washed and cooked.
Fresh flowers may also harbor pathogens that are harmful to patients on neutropenic precautions.
If the child’s grandparents are healthy and observe hand hygiene, there is no reason not to allow a visit. Social support can be important both for the child and the family.
Parents of this child should be vaccinated against influenza, which can be lethal to an immunocompromised patient.
Vaginal delivery- perineal pain, cramping, constipation
Ice for 24-48 hours
Warmth - sitz baths, peri-bottle, warm pack to abdomen for cramping
Constipation:
Common after vaginal and C-section births
Offer Colace (docusate sodium)
Ambulation
Fluids
Fiber
Bring it up before they ask-
Embarassment + fear factor = needless suffering
Pharmacological and nonpharmacological methods of managing discomfort
Pharmacological:
Vaginal:
- Ibuprofen/acetaminophen
- Topical agents for perineal discomfort, sore nipples
Cesarean:
- Narcotic analgesia
- Ketorolac/ibuprofen
- Acetaminophen - IV or PO
- Simethicone
Non-pharmacological:
Vaginal:
- Ice for 24-48 hours
- Warmth - sitz baths, peri-bottle, warm pack to abdomen for cramping
Cesarean:
- Splinting of incision
- Ambulation to prevent gas
- Binders
Non-pharmacological:
Breastfeeding mothers - sore or cracked nipples:
- Proper latch
- Topical lanolin
- Gel discs
Non-breastfeeding mothers - engorgement:
- Supportive bra
- Ice
- Cabbage leaves in the bra
The visiting nurse is assessing a postpartum client who has given birth vaginally 6 days ago. Which findings are expected at this time?
Presence of mature milk with hand expression
Fundus firm, 6 fingerbreadths below the umbilicus
Scant lochia serosa (pinkish or brownish)
Postpartum hemorrhage and intervention: Trauma
Repair of lacerations
The nurse is assessing a patient 25 minutes after delivery and finds that the patient’s underpad is saturated with bright red blood. There are two clots about the size of an orange on the pad. What should the nurse do first
Assess the fundal height and consistency and perform fundal massage.
The patient’s bleeding is excessive. The nurse should first address the root cause of the bleeding. Most (80%) cases of postpartum hemorrhage are due to uterine atony, or lack of tone. The first thing that the nurse should do is to assess fundal tone and massage the fundus to get the uterus to contract.
After this is done, the nurse should weigh the pad and contact the provider, increase the rate of fluids (lactated ringer’s or 0.9% NSS), and ensure that oxytocin is running. The bladder may need to be emptied, particularly if the fundus is boggy and deviated from the midline. The nurse should be recording vital signs every 5-15 minutes to assess hemodynamic stability, but these actions do not take priority over fundal massage.
The nurse should anticipate orders for uterotonic medications, including oxytocin, methylergonovine, misoprostol, and carboprost.
The nurse should measure quantitative blood loss by weighing pads, but this should only be done after the nurse has assessed the fundus and performed fundal massage.
The nurse is caring for a woman who has delivered a baby 45 minutes ago. Which aspect of the patient’s history would alert the nurse to assess more frequently for signs of postpartum hemorrhage?
The newborn weighed 4300 g (9 lb, 5 oz)
Teaching new patients: Bathing/dressing
First bath- Best Practice - delay up to 24 hr
Unless -
Maternal HIV, HSV, HBV
Use mild soap and washcloths
Test water temperature
Sponge baths until the cord stump falls off!
● Warm room, gather supplies ahead
● Dress baby in one more layer than adults
- only have what is needed to be cleaned open to air: work head to toe, diaper area last
Diapering:
● Demonstrate/return demonstration
● Work quickly or do laundry
● Girls -front to back
Cord Care - nothing special, just keep it dry
Fingernails - mittens or emory board
Postpartum hemorrhage and intervention: Tissue
Removal of placental fragments
Preterm infants (Airway management): Reason for weaning off ventilators
so they don’t develop BPD or ROP, and are able to breathe without the ventilation rather than becoming dependent on it
The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest?
promoting skin-to-skin contact (kangaroo care) on the chest
This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breastfeeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care.
Newborn hearing screening
Online: a vital test that helps identify hearing loss in infants early in their lives. It is recommended for all newborns, regardless of family history or risk factors.
Bubble tea: Lochia
Lochia signifies endometrial healing/exfoliation
Rubra: bright red bleeding
- usually in moderate amounts
Need to find out when pad last changed: keep an eye if heavy
- alert if clot passed that is larger than egg
Lochia serosa is pinkish or brownish - starts on the 3rd or 4h day postpartum lasting up to ten days.
Lochia alba is a creamy vaginal discharge
- can persist for the remainder of the postpartum period (6 weeks).
there is a risk for infection; no sex for 6 weeks
The nurse is assessing a patient 4 days postpartum during a home visit. The client’s breasts are firm, heavy, and red. The patient complains of breast pain 6/10 on a numeric pain scale. She is breastfeeding. What comfort measures can the nurse recommend to deal with breast engorgement?
Massage the breasts prior to nursing or pumping
Breast engorgement can happen in both breastfeeding and non-breastfeeding mothers. It is a result of increased blood supply to the breasts under the influence of prolactin, a hormone that stimulates milk production, and can be exacerbated by ineffective or infrequent emptying of the breasts.
In engorgement, the breasts will be tender bilaterally and will feel warm and firm to palpation. They will appear tight because they are edematous, and the mother will complain that they are heavy. There may be redness. This can be differentiated from mastitis because it is generalized to the entire breast area bilaterally, whereas mastitis is usually a localized area on only one breast.
Frequent feedings help relieve discomfort by emptying the breast. Ice between feedings will reduce edema and pain. Massaging the breast or applying warmth just prior to feeding will help soften them and facilitate milk flow.
Cabbage leaves and tight binding applications or sports bras suppress lactation. They can be used in mothers who are not breastfeeding but are not indicated for this patient.
The patient should shower with her back to the warm water, not her chest, between feedings. Warmth brings blood to the surface and can exacerbate this problem, unless the woman is planning to empty the breast immediately.
Post partum mental health: Postpartum Depression - Risk factors
Affects 10-20% of women after giving birth; stigma prevents women from getting help; can interference with bonding and infant development
Risk factors:
- history of mood disorder
- stressful life events
- unplanned pregnancy
- lack of social support!
- complications during pregnancy or delivery
- body image issues
Perineal hematoma - recognize signs and symptoms
- Pt. will complain of sudden, excruciating pain
- Swelling at the site - discoloration, fluctuant mass
- Can fill with 250-500 mL blood
Finding the root cause of PPH
- If tone: uterus will be boggy; “high” above U because not contracting
– try straight cath first b/c suspect urinary retention - If tissue: may have “trailing membranes”
- If trauma: continuous trickle with firm fundus at umbilicus OR s/s perineal hematoma
- If thrombins:
– lab values (platelets) abnormal
– history of PPH, heavy periods, etc
– coagulopathy may be secondary to primary cause
A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. The nurse employs standard interventions to promote voiding and they are ineffective. What intervention would the nurse perform next? (Assume that you have standing orders to address common problems of the postpartum period.)
Perform urinary catheterization.
Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The health care provider would be notified if no other interventions help the client.
Standard interventions are less invasive than urinary catheterization and include having the woman lean forward while sitting on the toilet, running tap water to provide “the power of suggestion”, pouring warm water over the perineum with a peri-bottle, placing the patient’s hand in warm water, having the patient blow bubbles through a straw, and having the patient inhale a few drops of peppermint oil on a piece of gauze or diluted in a cup of warm water.
When these are not effective, it’s important to empty the patient’s bladder to prevent uterine atony.
The nurse is preparing to discharge a patient from the mother-baby unit. The woman’s partner appears impatient for discharge because he has nobody to care for his three other children and needs to go to work. When the partner leaves the room, the patient tells the nurse that sometimes she thinks that her family would be better off without her. The patient displays flat affect and will not give eye contact. What is the appropriate nursing action at this time?
Contact the provider and recommend canceling the discharge until further assessment for suicide risk can be performed.
A visiting nurse assesses a patient who is at home 5 days after having a C-section. Which finding would prompt a phone call to the provider?
Painful, frequent urination accompanied by fever.
The nurse is performing a postpartum assessment on a client. Why is the nurse concerned with assessment of the lower extremities?
Postpartum women are at risk for deep vein thrombosis (DVT) and may have residual weakness from epidural or spinal anesthesia
Pregnancy and postpartum are hypercoaguable states that place postpartum women at risk for DVT. Prolonged time spent in bed will increase this risk. Additionally, residual weakness or numbness of the lower extremities after epidural anesthesia puts the patient at risk for falls in the early postpartum client.
Bubble Tea
B: Breast: soft nontender, nipples intact
U: uterus: 1 cm lower every day; should be midline; massage if boggy
B: bladder: output in sufficient quantities
B: bowel: gas should be passed
L: lochia - rubra, serosa, alba: shouldn’t expect to smell bad, should be decreasing in color and amount
E: episiotomy: REEDA, don’t want perineal hematoma
T: thromboembolic events: check extremities
EA: emotional adaptations: taking in, taking hold, letting go; bonding with baby; flat affect?
Newborn meds: Vitamin K
K for Klotting factors
Prioritization of care on mother baby unit
Who would you see first? Based on acute needs (see exercise from class)
Restorative Period: Taking In
- first day
- mother focusing on her self and the birth experience
- not in a great teaching space - they are hard to teach; need to assist them and give info in chunks
from delivery to approximately 24-48 hours after: the mother is preoccupied with her birth experience and recounts the story of her delivery repeatedly. Her focus is on physical recovery, getting rest, and having her needs met by supportive people and nursing staff.
What are afterpains/ how to treat them?
Afterpains are contractions of the uterus in the postpartum period as the uterus tries to contract to control bleeding. They are influenced by uterine tone (multiparous women experience worse pain than primiparous ones; in hemorrhage situations, they can be severe.) and the release of endogenous (natural) prostaglandin. Ibuprofen is a prostaglandin inhibitor. It should not be given if the patient is bleeding excessively, but if lochia is scant or moderate, it is often used to relieve pain.
Postpartum hemorrhage: Medications (Oxytocin, methergine, prostaglandins)
Medications that control PPH from uterine atony:
- Oxytocin (Pitocin)- first line agent
- Methylergonovine (Methergine) - CHECK BP FIRST
- Misoprostol (Cytotec)
– SL, PO, rectal route of administration
- Tranexamic Acid (TXA) - for any cause of PPH
– Inhibits fibrinolysis - allows normal clotting
- Carboprost (Hemabate)- promotes strong contractions - used after oxytocics fail
Causes of postpartum hemorrhage: 4 T’s
4 T’s
- TONE: Uterine atony (failure of the uterus to contract adequately following delivery; #1 cause, 50% of all hemorrhages)
- Tissue: Retained placental fragments (increased blood flow b/s body thinks there is still a baby)
- Trauma: Unrepaired lacerations or hematoma
- Thrombins: Thrombocytopenia or coagulopathy
Bubble tea: Breast
should be soft and non tender
- milk around day 3-5
- colostrum first
want intact nipples; no lumps or swelling
watch for
- cracked nipples
- inverted nipples
- engorgement
Preeclampsia in the postpartum period- how long can it last, what discharge teaching is important?
can last up to 6 weeks after birth. Teach mom S/S of hypertension
Bubble tea: Episiotomy (REEDA)
Redness, edema, ecchymosis, drainage, approximation
- can be used for any incision
- if any in REEDA seen, alert
Infant of diabetic mother:
Which babies are at risk and what interventions for hypoglycemia
Usually large (esp. If maternal glucose poorly controlled)
- “Ruddy” - extra RBC’s - increased risk for jaundice
- Increased abdominal circumference, fatty tissue
- Thick umbilical cord, large placenta
- Lungs may be slow to mature - RDS and PDA more common
- Congenital birth defects (Pre-gestational diabetes)
- Maternal glucose leads to hypersecretion of fetal insulin
HYPOGLYCEMIA!
Signs of hypoglycemia:
- Jittery
- Low temp
- Disorganized, poor feeders
- Glucose via heelstick < 40
Treatment for hypoglycemia:
- Feed the baby!
- Glucose Gel
- Dextrose IV
- Monitor until stable
The nurse is assessing a postpartum client in the home at 4 days post-delivery. Where does the nurse expect to find the fundus?
4 cm (fingerbreadths) below the umbilicus
Classifications of prematurity
Term infants - 37 weeks/0 days to 41 weeks/6 days
Pre-term:
Extremely preterm: <25 weeks
Very preterm: 26 - 31 6/7 weeks
Moderately preterm: 32-33 6/7 weeks
Late preterm: 34-36 6/7 weeks
Post-term: 42 weeks and over
Teaching for Self-Care of the Postpartum Patient: Incisional care
Hand hygiene before touching incision
Shower daily, use clean towels
Patient teaching - wound care, inspect daily
REEDA - it’s not just for episiotomies!
Medication that will effectively treat postpartum condition: Decreased Hemoglobin
Iron sucrose (venofer)
Postpartum hemorrhage: Nursing management (goals, first thing to do, preventing complications)
1st goal: Stop the bleeding at its root cause!
2nd goal: Replace fluid volume
- Support hemodynamic stability
FIRST THING to do IS FUNDAL MASSAGE
Prevention of complications from PPH:
- identify patients at risk; notify blood bank
- frequent assessment of pt
- active management of third stage labor
- administration of oxytocin immediately after delivery
- early intervention when bleeding is heavy
Medication that will effectively treat postpartum condition: Risk for constipation
Colace (docusate sodium)
A nurse tests a newborn’s nervous functioning by stroking the sole of the baby’s foot in an inverted “J” curve from the heel upward. The baby responds by fanning his toes. Which reflex has just been demonstrated?
The Babinski reflex is demonstrated when the sole of a newborn’s foot is stroked in an inverted “J” curve from the heel upward and the newborn fans the toes in response (positive Babinski sign).
The nurse is ccaring from a client who is experiencing a postpartum hemorrhage. Her heart rate is 139 bpm and her blood pressure is 80/50 mm Hg. Which actions address the nursing diagnosis: Fluid Volume deficit r/t excessive blood loss after delivery
-Administration of crystalloid IV fluids.
- Initiation of a second IV site with a large bore IV catheter
Fall risk for postpartum patient
Post-epidural precautions:
* * Assess motor strength and sensory function of legs
* Stay nearby when toileting patient
(most common) Fainting -
* “Dangle” at the bedside before standing
* Make sure vitals, bleeding are stable before ambulating
* Ammonia inhalant
Restorative Period: Taking Hold
- mother realizing she needs to care for infant and for herself
- coming to terms with birth; full of questions
- great time to teach
- usually discharged at this time
- usually the 2nd day
this phase lasts for several weeks and is concerned with learning how to function in the role of mother. At this time, the postpartum patient frequently asks questions and is eager to learn the tasks of self and newborn care.
The nurse assesses a postpartum woman’s perineum and notices that her vaginal discharge is moderate in amount and bright red. The nurse would record this as what type of lochia?
lochia rubra
Lochia rubra is red; it lasts for the first few days of the postpartum period. Lochia serosa is pinkish or brownish and starts on the 3rd or 4h day postpartum lasting up to ten days. Lochia alba is a creamy vaginal discharge that can persist for the remainder of the postpartum period (6 weeks).
Bright red bleeding is fresh - so the take home here is that once it stops, it shouldn’t return during the postpartum period.
The nurse prepares to administer the measles, mumps and rubella (MMR) vaccine to a child. What statement by the child’s parent would alert the nurse to avoid giving the vaccine?
“My child had gelatin at day care and broke out in hives afterwards.”
Anaphylactic reactions are believed to be associated with the neomycin or gelatin component of the vaccine. A child having hives after eating gelatin would alert the nurse to hold the vaccine and discuss with the health care provider. Allergies to eggs and pregnancy in child’s parent are not contraindications for receiving the vaccine. The MMR and other live attenuated virus vaccines (such as varicella) can be given on the same day but, if not given on the same day, 28 days should separate the immunizations.
Formula feeding
Risks?
What to feed
When to discard?
Risks of formula feeding:
Allergies
Alteration in gut flora
Overfeeding
Increased risk of:
● Ear infections/respiratory infections
● Asthma
● Later obesity
● Eczema
What to feed:
○ Usually milk-based
○ Lactose-free, soy, pre-digested
○ Defer to pediatrician
● When to feed:
○ 6-8 times in 24 hours (8 or more in 24)
● How to feed:
○ Mix per instructions for specific type
○ Fill nipple of bottle with formula
○ Hold infant “en face”
○ Burp halfway through feeding and at the end
○ No microwaves, no stovetops
○ Discard uneaten formula after 1 hour
○ If mixing with powder, 24 hours only
A nurse is assessing a postpartum patient on the day after delivery and locates the fundus 3 fingerbreadths above the umbilicus and displaced to the right. Which action is most appropriate at this time?
Assist the patient to empty her bladder
Mechanisms of heat loss
Nursing interventions that promote thermal stability
Delivery room - polystyrene bag, warm chemical mattress,
In NICU or ICN: isolette or warmer with temp probe
Wean slowly to open crib
Evaporation
* Dry the baby!
Conduction
* Skin to skin
* Warmed blankets
** Radiation:*
* Hat
* Cover with blankets, clothing
* Radiant warmer
Convection:
* Keep out of drafts
* Warmer away from door
* Low temp = low glucose and Risk for respiratory distress
A 4 year-old child is receiving chemotherapy with an agent that causes immunosuppression. Which of the following vaccines should the nurse avoid administering?
Measles, Mumps, and Rubella (MMR)
The MMR vaccine is a live, attenuated virus. Although it is weakened and will not cause disease in healthy children, it should not be given to immunocompromised patients.
Quadrivalent influenza vaccine, IPV (inactivated polio vaccine), and DTaP are killed vaccines and are safe and effective for immunocompromised patients. They are all offered to children aged 4-6 years of age.
Infections: Endometritis
- S/S
- Contributory factors
- When to call the DR
S/S:
- Foul Smelling Lochia
- Temperature 100.4 or greater (usu. 101.0 to 104.0 F)
- Tachycardia
- Chills, aching
- Lower abdominal pain, uterine tenderness
Most common post C/S; especially if not treated prophylactically; other risks:
- PROM
- multiple vaginal exams in labor
- compromised health status; low SES
- instrumental deliveries
Management: (idk when to call dr, prob w/ sign of foul smelling lochia if that appears first)
- cephalosporins/penicillin
- aggressive infection: broad spectrums (vanco, gentamicin, clindamycin)
The nurse is caring for a patient one hour after delivery and notes that the pad underneath her has been saturated in 15 minutes. There are two clots on the pad approximately the size of an orange. The fundus is boggy. What does the nurse do first?
Massages the fundus to stimulate the uterus to contract
Which actions can a nurse take to encourage a postpartum patient to void? Select all that apply
-Assist the woman to lean forward on the toilet or commode
Leaning forward will help apply gentle pressure to the bladder and facilitate normal voiding.
Blowing bubbles through a straw may help the woman relax the muscles of the perineum.
Running the faucet uses the power of suggestion to facilitate voiding.
Applying ice to the perineum reduces pain and swelling of the perineal area but does not stimulate voiding. Warm water poured over the perineal area may relax the muscles to facilitate voiding.
Insertion of a straight catheter will empty the bladder but does not promote normal urination.
What are SGA babies at risk for?
- asphyxiation
- meconium aspiration syndrome
- hypothermia
- polycythemia
Preterm infants (Airway management): Methods of supplemental oxygenation
least invasive to most invasive:
- room air, nasal cannula, mask, CPAP, mechanical ventilator, ECMO
Car seat safety
Must be correct size for newborn
Rear-facing in the back seat
Watch buckle!!! Level of armpit!!!
No more than 2 fingers between baby
And straps
No snowsuits, bulky jackets under straps
Make sure that it is level in car
Anchor with tether and use base
The nurse is caring for a postpartum patient whose labor was induced for preeclampsia. Which statement is true regarding preeclampsia in the postpartum period?
Preeclampsia can persist and cause complications in the postpartum period for up to 4 weeks; the patient should be taught to report headache, visual disturbance, epigastric pain immediately to her provider.
Preterm infants (Medications): Surfactant
what are they used for, how do we monitor for complications or adverse effects of antibiotics?
lowers surface tension prevents atelectasis
Post partum mental health: Postpartum Psychosis Management
- usually responsive to treatment
- woman fears “losing her mind”
- safety of woman and infant are most important
– hospitalization/separation from infant
– stabilization on anti-psychotics
– agents may be incompatible with breastfeeding - support groups for woman and family
Psychosocial changes in postpartum: attachment behaviors
- touch exploration
- “en face” positioning
- reciprocity: parents and infants respond to cues
- partner: engrossment; feeling of total preoccupation; infatuation
Circumsision care
Nurse’s role
● Restrain infant
● Provide pain relief
● Prevent infection
● Monitor for bleeding, voiding
● Educate parents
Mogen or Gomco:
Gauze square with vaseline
Report bleeding > quarter
Yellow crystals = normal healing
■ Call if:
■ Site looks more red, swollen
■ Baby can’t void
Plastibell will fall off on its own
The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartum blues?
a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding
They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta.
Postpartum hemorrhage and intervention: Thrombins
Administration of clotting flactors
Infections: Mastitis
- S/S
- Contributory factors
- When to call the DR
S/S:
- Red lump in the breast - superficial
- Mild fever, chills, feeling “unwell”
- Pain
- Yeast - ground glass in nipples sensation when feeding; will need to treat mom and baby
- Abscess - collection of pus, may be very discolored
Contributory/risk factors:
- cracked nipples
- compromised health status
- antibiotic therapy (candida/yeast) leads to yeast infection
- inconsistent nursing pumping: milk can crystallize and clog
Treatment:
- Don’t stop nursing!
- Pump if nursing is too painful
- Use heat and massage to encourage milk expression, every 2-3 hours
- For lump: try to massage from lump towards nipple and heat
- antibiotics
Teaching for Self-Care of the Postpartum Patient: Medications given postpartum for routine discomfort
Vaginal:
- ibuprofen/acetaminophen (tylenol)
- topical agents for perineal discomfort, sore nipples
Cesarean:
- ketorolac/ibuprofen
- acetaminophen IV or PO
- simethicone (GasX)
A woman who has delivered a healthy baby 6 hours ago appears preoccupied with her birth story and requests that the nurse perform all tasks related to the care of her newborn because she is tired and needs to rest. What is the significance of the mother’s behavior?
The woman is in the “taking in” phase of maternal adaptation and this is normal.
Retinopathy of prematurity - what causes it and how would we detect it?
detected by eye exam
- caused by high levels of oxygenation
Most common in infants born <31 weeks or <1250 g
Can cause retinal detachment, blindness
Eye exam at 4-9 weeks post-birth
May require surgical intervention
May be caused by unstable
oxygenation
Postpartum hemorrhage: Nursing assessment during postpartum hemorrhage (Replacing Fluid Volume and Supporting Hemodynamic Stability)
- Get a second IV site - pref. 18 gauge
- Crystalloid Fluids - LR or NSS
- Frequent monitoring of VS,
– Hypovolemic shock - tachycardia, hypotension, decreased O2 sat (late), - Administer Oxygen if needed
- Elevate legs 30 degrees - perfuse vital organs
- Foley catheter - monitor output
- Transfusion if indicated, massive transfusion protocol (MTP) may be needed
DVT- recognize S/S
- Redness, swelling, heat, pain
- Affects one leg - usually left
- Homan’s sign not a good indicator
- Low-grade fever, may progress to high temp
- “Palpable cord”
- “Milk Leg”: spasms distal to clot, gets white and cold
Diagnosed with doppler studies, elevated D-dimer
Ways to calm a fussy baby
5 S’s -
- Swaddling
- Stomach
- Shushing noises
- Swinging
- Sucking
It’s ok to put a fussy baby down if you’re losing your patience
AND NEVER SHAKE A BABY!!!!
Medication that will effectively treat postpartum condition: Afterpains or uterine cramping
ibuprofen (Motrin)
The nurse is caring for a patient several hours after a vaginal delivery on the mother-baby floor. The patient complains of severe pain “down there, like I tore something”. Inspection of the perineum reveals a large swollen area on the right side that is discolored and “fluctuant”. Based on these findings, what does the nurse suspect?
Perineal hematoma
The parents of a newborn have questions about the first immunization their baby will receive. Which statement is accurate and appropriate to give the parents at this time?
The first vaccine offered to infants is the Hepatitis B vaccine. The schedule includes a vaccine within 24 hours of birth, 1-2 months, and 6 months of age.
Passive immunity offers some protection against vaccine-preventable infants, but this is limited to about 2 months of age, and is not an excuse not to vaccinate children according to the schedule. Hep B vaccination is important to prevent severe liver disease in infants who may be exposed to the virus.
Teaching new parents: When to call the pediatrician
Call 911 if:
● Baby turns blue or stops
breathing
● Has a seizure
● Is unresponsive to stimuli
Call the doctor if:
● Baby is crying inconsolably
● Temperature 100.3 axillary
● Projectile vomiting
● Refuses to feed
● Is lethargic
● Has too few diapers
● Looks yellow
● Has problems with the circ
site
Red Flags
Postpartum assessment: Cardiovascular changes postpartum
- blood loss: 200-500; fluid shift from loss of amniotic fluid
- cardiac output: remains elevated for 24 hours
- VS: every 15 mins for 1-2 hrs, then per protocol
– BP, O2, temp - normal limits apply
– heart rate, respirations - decreased; 50-70 BPM common - postpartal chills: shaking after delivery; can give warm blanket
Medication that will effectively treat postpartum condition: Risk for uterine atony in the immediate postpartum preiod
Pitocin
The infant has Apgar scores of 8 at 1 minute and 9 at 5 minutes. What is the indication of this assessment finding?
Successful transition to extrauterine life
The infant is tolerating the adjustment to extrauterine life; the Apgar scores are within normal limits for appropriate transition. Severe distress and absolute need for resuscitation is an Apgar score of 0 to 3; moderate difficulty is indicated by a score of 4 to 6. An Apgar score of 7 to 10 at 5 minutes indicates a fair neurologic future outcome.
Teaching for Self-Care of the Postpartum Patient: Hygiene
- Hand hygiene!
- Front-to-back for perineal care
- Foley out ASAP, void frequently
- Shower daily, use clean towels
- Nothing in the vagina for 6 weeks
- Incisional Care
- Address cracked nipples
– Improve latch and position
– Creams, soaks, gel discs - Regular nursing to prevent plugged ducts
Psychosocial adaptation to postpartum: Baby blues and postpartum depression screening (Edinburgh)
Baby Blues:
- Normal - may occur at home or in hospital
- Weepiness, mood swings, irritability, disappointment
- “Comes and goes”
- Usually resolve in 10-14 days without treatment
Screening is a 13 question tool used for mothers. Under 10 is considered normal.
Bubble tea: Thromboemolism
DVT or thromboembolism because pregnancy is hypercoagulable state
- watch for complaints of calf pain on one side, swelling, redness, palpable cord - signs of DVT
What to do: contact provider; anticipate Doppler studies, D-Dimer, mom cannot get out of bed because risk of dislodging clot
Meconium aspiration syndrome
aspirates fecal mater and it causes inflammation
A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?
Apply ice.
Ice is applied to perineal edema within 24 hours after birth. Cold applications constrict blood vessels and reduce swelling. Use of ointments is not effective for perineal edema, although hydrocortisone may be used for hemorrhoids if that is the woman’s complaint. Warmth brings blood flow to the area, which can increase swelling. Moist heat and a sitz or tub bath are encouraged to promote healing to the area 24 hours after birth until no longer needed.
The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?
Sudden Infant Death Syndrome (SIDS)
Safe sleep includes placing the infant on a firm crib mattress on the back (supine position) without soft or loose bedding. There should be no extra objects in the crib. The infant should not sleep with siblings or adults and should not be exposed to secondhand or thirdhand smoke in the sleeping environment. The infant should not be overheated, and should be wearing only a sleeper and a swaddling blanket that is away from the face.
Infants who sleep in prone (on the stomach) or side-lying positions are at risk for SIDS because they rebreathe carbon dioxide. Suffocation from loose bedding, pillows, quilts, or bumper pads is associated with SIDS deaths.
Safe sleep environments as described above do not prevent GERD, colic, or plagiocephaly (flattening of the back of the head).
Newborn meds: Erythromycin
Erythromycin is an antibiotic that helps prevent bacterial eye infections, particularly those caused by Neisseria gonorrhoeae (gonorrhea)
The nurse is caring for a woman who delivered a baby vaginally with a mediolateral episiotomy 12 hours ago. She is complaining of soreness and has mild perineal edema. Which choice represents an appropriate method of pain relief for this patient?
Application of ice packs to the perineum for 24-48 hours.
A patient is 2 days postpartum and is eager to learn self-care and newborn care. In which phase of maternal adaptation is the patient in?
Taking In - from delivery to approximately 24-48 hours after: the mother is preoccupied with her birth experience and recounts the story of her delivery repeatedly. Her focus is on physical recovery, getting rest, and having her needs met by supportive people and nursing staff.
Taking Hold - this phase lasts for several weeks and is concerned with learning how to function in the role of mother. At this time, the postpartum patient frequently asks questions and is eager to learn the tasks of self and newborn care.
Letting Go - this phase happens after several weeks of adjustment. The mother reestablishes her previous relationships, functions in her new role with confidence, and builds a lifestyle that includes the infant. She relinquishes the “fantasy infant” and her idealized concepts about parenting and motherhood and accepts her role.
The parents of a 15 month old child come for a well visit at the pediatric office. The nurse reviews the chart and sees that the parents have declined all vaccines for this child since birth. What should the nurse do next?
Explore the parents’ reasons for declining the vaccine and offer accurate information.
Newborn meds: Heb B vaccine
The Centers for Disease Control and Prevention (CDC) recommends that all newborns receive the first dose of the hepatitis B vaccine within 24 hours of birth. This is especially important for babies born to mothers who are infected with HBV.
Infections: UTI
- S/S
- Contributory factors
- When to call the DR
Burning, urgency, frequency, Nocturia
If it progresses -
- Fever, chills, flank pain, nausea/vomiting
- CVA tenderness
Call dr with symptoms appearing
Contributory/Risk Factors:
- urinary cath
- urinary stasis
- trauma to urinary structures
- improper hygiene
Dx with “clean catch” specimen
Management:
- bactrim, Septra, augmentin
Delayed cord clamping
How long?
Effects?
Delaying cord clamping for at least
30 seconds up to 5 minutes:
● Increases Blood volume about 33%
● Increases Iron Stores for up to 6 months
● Increases oxygen to vital organs
May be contraindicated if neonate needs immediate
resuscitation.
The mother-baby nurse is caring for a client who is 2 days post-cesarean section. Assessment findings reveal redness, edema, warmth, and pain in the left calf. The nurse contacts the provider, gives SBAR and receives an order for doppler studies of the lower extremities and labs for coagulation studies.
What is the purpose for obtaining coagulation studies for this patient?
If the doppler studies diagnose a deep vein thrombosis (DVT), the lab values will be needed to initiate a heparin infusion
DVT- Nurses actions and priority assessments
- Strict Bedrest
- Do not massage the clot
- Anticoagulant therapy
- Heparin drip - monitor PTT
- Convert to warfarin (Coumadin) - PT/INR
- Pt. education re: anticoagulants
- Monitor for Pulmonary Embolism - assess respiratory status frequently
Neonatal abstinence: interventions for opioid withdrawal
- Comfort Care
– Whenever possible, involve mom
– Kangaroo care
– Breastfeeding unless polysubstance use - Swaddling, holding, swinging, rocking
- Decreased stimuli
- Volunteer “cuddlers”
- Pacifiers/non-nutritive sucking
- Cream to prevent diaper rash
- Administration of morphine or other agent
- Monitor growth
Postpartum hemorrhage and intervention: Tone
Administration of misoprostol/ Carboprost/tranexamic acid
Bronchopulmonary dysplasia
Lungs actually change shape
- can be due to mechanical ventilation and lungs adapting to the ventilation
- online: BPD is a chronic lung condition in premature infants that occurs when their lungs don’t develop properly and can be damaged by oxygen therapy or mechanical ventilation.
Preterm infants (Medications): Antibiotics
what are they used for, how do we monitor for complications or adverse effects of antibiotics?
Vanco- ototoxic, nephrotoxic, hearing screen - need to monitor BUN/Cr
Gentamycin? - i think also nephro and oto - monitor labs
Post partum mental health: Postpartum Depression - S/S and Treatment
Signs and Symptoms:
- persistent sadness or lack of joy
- disturbances in eating or sleeping
- may have significant anxiety component
- feelings of worthlessness; inadequacy as a mother
- thoughts of hurting self
- may have OCD component; unwanted thoughts
Treatment:
- Therapy (CBT, support groups)
- Antidepressants (SSRIs, Brexanolone, most compatible with breastfeeding)
- ECT
- alternative treatments for milder cases: exercise, exposure to light/sun
Perineal hematoma- nursing actions
For small hematoma- Ice/pressure
For Large- Incision/drainage and packing
MONITOR FOR HYPOVOLEMIC SHOCK
The nurse is giving discharge instructions to a postpartum patient 2 days after a vaginal delivery. The patient asks when she can resume sexual intercourse with her husband. What is the correct response to her question?
“Your body needs about 6 weeks to heal from childbirth. Until then, there should be nothing in the vagina, which includes douching, tampons, and intercourse. You should talk to your provider at your 6 week visit about contraception.”
Unexpected outcomes of childbearing: Promotion of attachment and bonding with unexpected outcomes
Kangaroo care and allowing them to help with care/involving in care. Being available for them
Newborn congenital cardiac screening
Online: CCHD refers to heart defects that typically require intervention in the first year of life and present with hypoxemia (low blood oxygen levels). Tested with a pulse-ox
A visiting nurse is caring for a breastfeeding mother who has been diagnosed with mastitis. Which statement indicates the need for further teaching?
“I should stop breastfeeding to avoid spreading the infection to my baby.”
A nurse is caring for a woman who is G5 P4 and complaining of 7/10 uterine cramping when she nurses the baby. Which nursing action is appropriate?
Administer ibuprofen (Motrin) 600 mg q 6 hours with food or milk.
Preterm infants (Medications): Caffeine citrate
what are they used for, how do we monitor for complications or adverse effects of antibiotics?
Online: Administering caffeine citrate is a safe, noninvasive way to treat premature infants with persistent apnea. This drug decreases the frequency of apneic episodes, thus reducing the need for mechanical ventilation. It is given once a day, either orally or intravenously.
Which nursing intervention helps prevent complications from postpartum hemorrhage?
Frequent assessment and quantifying blood loss by weighing pads
