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OB > Exam Two: class 5- normal newborn > Flashcards

Exam Two: class 5- normal newborn Flashcards

1
Q

nursing care of the neonate in the first four hours

A
  • Universal precautions
  • D-A-B-C
  • Temperature Regulation
    -Support respirations
    -Apgar score
    -Vital signs
    -Identification
    -Measurements/Classification
    -Neonatal assessment
    -Gestational age assessment
    -Administer medications
    1.Vitamin K
    2.E-mycin opthalmic ointment
    3.Hepatitis B
    -Labs
    -Bath
    -Establish feeding
    -Promote parent – infant attachment
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2
Q

nursing care at delivery- dry and stimulate the newborn

A

-If stable may be done on maternal abdomen
-Head first then body
-Promotes warmth and respirations
-Remove wet linens
-Cover with warm dry blankets and hat

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3
Q

nursing care at delivery- skin to skin

A

-Newborn placed directly on maternal abdomen after delivery
-Kangaroo reflex- mom increases her temp until newborn’s temp normalizes
-Olfactory stimulation so newborn can find nipple

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4
Q

nursing care at delivery- oral care

A

-Suction Airway if needed
-Bulb syringe- to help clear oro/naso pharynx
-MOUTH 1st / NARES 2nd
-DeLee Mucus Trap Suction:
Use if bulb ineffective
Avoid injury to mucus membranes and stimulation of vagus nerve (bradycardia)

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5
Q

APGARS

A

-Appearance
-pulse
-grimace
-activity
-respirations

*all assessed to determine need for resuscitation

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6
Q

what is a good apgar score

A

Score of 7 or above=good

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7
Q

When is the APGAR score done

A

-Done at 1 and 5 minutes after birth
-Repeated q 5 min if score <7

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8
Q

Cold Stress Prevention/Treatment

A

-Keep newborn warm or rewarm newborn
-Keep newborn dry
-avoid exposure to cold surfaces

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9
Q

how to keep newborn warm or rewarm them

A

-Skin-to-skin contact
-Radiant warmer
-Warm blankets
-Increase room temperature

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10
Q

how to help avoid cold surfaces with the newboarn to keep them warm

A

warm hands
pre warm surfaces

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11
Q

identification

A

-Foot prints are done
-ID bands with identical numbers applied
-Newborn- 2 bands
-Mom- 1 band
-Person of mom’s choice- 1 band
-Electronic security bands applied

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12
Q

measurements- weight

A

-Water comprises 70-75% of the body weight
-What are factors that may affect birth weight?
-Usually weighed each day

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13
Q

average weight of a baby at birth

A

2500-4000g (5 lbs. 8 oz.- 8 lbs. 13 oz.)

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14
Q

how much might a baby loose in weight in the first 3-4 days of life

A
  • 10% of birth weight
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15
Q

measurements- length

A
  • difficult to measure accurately
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16
Q

average term newborn height

A

-18-22 inches (48-52 cm)
-Grow about 1 inch a month for first six months of life

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17
Q

measurement- head

A

-¼ size of body size
-Measure the occipital frontal head circumference (OFC)

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18
Q

average term newborn head size

A

13-14 inches (33-35 cm)

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19
Q

measurement- chest

A

2 cm smaller than the head

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20
Q

Average chest size for term newborn

A

12-14 inches (30-35 cm)

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21
Q

temperature

A

-Axillary
-36.5-37.2 C (97.7-99 F)
-Skin temperature sensor-best placed over liver
-Prevention of cold stress is critical

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22
Q

respirations

A

-30-60 normal
-Respiratory distress results in grunting, retractions, nasal flaring
-`Clear airway if needed with bulb syringe

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23
Q

pulse

A

-110-160
-Irregular rate
-Regular, soft “come & go” murmur

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24
Q

blood pressure

A

-70-50/45-40 mmHG at birth
-May not be routinely measured on healthy newborns

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25
Q

Ilotycin eye ointment (erythromycin)

A

-Legally required for prevention of gonorrhea and chlamydia ophthalmic infections
-At least ¼ inch strand
-Within first hour of life- allow for period of bonding first

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26
Q

Vitamin K (Phytonadione)

A

-Prevention of hemorrhage: Lacks gut bacterial flora necessary for synthesizing vitamin K
-One time injection:
0.5-1 mg IM in vastus lateralis
Neonatal concentration 1 mg/0.5 ml

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27
Q

Hepatitis B vaccine

A

Series of 3 shots to prevent Hep B infection
Some providers will begin series in the hospital
Given IM in vastus lateralis
Ensure pediatric/adolescent preparation

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28
Q

Hepatitis B Immuglobulin

A

Given to newborn if mother is Hepatitis B positive
In addition to Hepatitis B vaccine

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29
Q

Cord Blood Gas Collection

A

-Non-reassuring FHR or depressed neonate
-Extra section of cord is obtained
-Arterial and venous blood samples obtained for cord blood gas assessment
-pH >7
-Base excess < -12

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30
Q

glucose levels

A

-May be done routinely for all newborns
-Risk factors- SGA, LGA, infant of diabetic mother
->40% and <300%
-Use heel warmer

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31
Q

Cord blood

A
  • usually drawn by provider
  • Blood type/Rh: All Rh negative moms, O+ moms
    -Direct Coombs
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32
Q

bath

A

-Until first bath is completed use gloves when handling newborn
-Use gloves when changing diapers, for procedures, and assessing genitals
-Given when temperature stable
-In Nursery or at bedside; usually only one given during hospital stay

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33
Q

immersion bath

A

-Evidence base- less temperature drop (0.1 vs. 0.3), tolerated better by newborn, no increased risk of cord infection, and does not increase length of time for cord drying
-With males that are circumcised do sponge bath until site healed

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34
Q

LGA

A

> 90th percentile on chart

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35
Q

AGA

A

Between 10th and 90th percentile

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36
Q

SGA

A

Less than 10th percentile

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37
Q

LBW

A

-<2500 grams
-Depending on gestational age may also be SGA

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38
Q

gestational age assessment is done when

A

Done in the first four hours of birth to confirm or establish gestational age

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39
Q

what tools do you use to do the gestational age assessment

A
  • Ballard or Dubowitz
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40
Q

gestational age assessment

A
  1. Numerical Scores are given for:
    -Physical maturity
    -Neuromuscular maturity
  2. Neurological system is unstable for 24 hours so may need to repeat
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41
Q

physical maturity

A

Skin
Lanugo
Sole (plantar) creases
Areola and breast bud tissue
Ear form and cartilage distribution
Genitalia

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42
Q

skin

A

Assessment includes texture, cracking, visualization of vessels, lanugo

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43
Q

plantar surface

A

Sole of the foot is assessed for how much of it is covered with creases

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44
Q

breast

A

Assessment of the areolar development and measurement of the breast bud

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45
Q

eye/ear cartilage

A

Assessment of how well formed the pinna is and how quickly it recoils

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46
Q

Male Genitalia

A

Assessment consists of size of scrotal sac, descent of the testes, and amount of wrinkles on the scrotum

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47
Q

Female Genitalia

A

Size of labia majora, labia minora and clitoris is assessed

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48
Q

Neuromuscular Maturity

A

Posture
Square Window (wrist)
Arm recoil
Popliteal Angle
Scarf Sign
Heel to ear

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49
Q

Resting Posture

A

Extension vs. flexion

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50
Q

Square Window

A

The newborn’s hand is flexed toward the forearm and the angle between the hand and wrist is noted

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51
Q

Arm Recoil

A

-Arms are held extended at the baby’s sides for 5 sec then released
-Once released the elbows should be flexed rapidly in a term newborn
-Angle of flexion at the elbow is measured

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52
Q

Scarf Sign

A

-Pull hand across chest towards opposite shoulder until resistance is met

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53
Q

Heel to Ear

A

-May be affected by position in utero
-Foot is gently drawn toward ear until resistance is felt or bottom begins to lift off the bed

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54
Q

Popliteal Angle

A

-Thigh flexed on the abdomen and the toes are grasped to attempt to straighten the leg
-Once resistance is met the angle behind the knee is estimated

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55
Q

Nursing Care of the Neonate: 4 Hours to Discharge

A

-Vital signs
-Temperature regulation
-Neonatal assessment
-Promote parent – infant attachment
-Promote sibling attachment
-Prevent infant abduction
-Assist with feedings
-Education: Safety, Newborn care
-Labs
-Procedures
-Provide information on newborn characteristics

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56
Q

Neonatal Assessment- general

A

-NIPS pain scale
-Posture
-Cry
-Behavioral state

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57
Q

Neonatal Assessment- skin

A

-Rashes
-Birthmarks
-Jaundice
-Color

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58
Q

NIPS pain scale

A
  1. Facial expression: Grimace vs. relaxed
  2. Cry: Vigorous, none, whimpering
  3. Breathing: Relaxed vs. different than baseline
  4. Alertness- Sleeping, active alert
  5. Arms/Legs: Relaxed vs. flexed
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59
Q

Neonatal Assessment- head

A

-Symmetry
-Fontanels: Anterior, Posterior
-Suture lines
-Caput/cephalohemtoma
-Bruising, lacerations

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60
Q

Neonatal Assessment- Face

A

-Eyes- clearness/redness/discharge
-Nose
-Mouth/gums/palate/tongue
-Ears-canals present, pinna, normal position

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61
Q

Neonatal Assessment- Neck

A

Short, stubby
Clavicles-check for intactness

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62
Q

neonatal assessment- chest

A

-Auscultate heart
-Lungs
-Assess for shape, use of accessory muscles
-Breast buds
-Normal to have abdominal breathing

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63
Q

neonatal assessment - abdomen

A

-Assess bowel sounds
-Palpate for masses
-Cord site: Redness, discharge, Number of vessels

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64
Q

Neonatal Assessment- hands

A

Number of digits
Creases
Grip reflex
Band number/correct information

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65
Q

neonatal assessment- arms

A

Check brachial pulses
Moro reflex
Moving appropriately

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66
Q

Neonatal Assessment- legs

A

Femoral pulses
Congenital hip dislocation- also called hip click
Gluteal folds symmetric
Hernias

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67
Q

neonatal assessment- feet

A

Band number, electronic monitoring system
Number of toes, webbing (syndactyly)
Grasp reflex
Babinski reflex
Assessment for club foot

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68
Q

neonatal assessment- back

A

Straight spine, intact
Sacral dimples
Nevus pilosus-tuft of hair

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69
Q

neonatal assessment- Truncal incurvation or Galant reflex

A
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70
Q

neonatal assessment- anus

A

Check for patency
Stools

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71
Q

neonatal assessment- male

A
  1. Urinary meatus correctly positioned
  2. Scrotum
    -Hydrocele
    -Swollen
  3. Testes descended
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72
Q

neonatal assessment- female

A

-Labia-note how well majora covers minora and clitoris
-Psuedomenstruation
-Vaginal skin tags?

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73
Q

Facial Palsy

A

-Asymmetry of the face due to injury of the facial nerve
-Most noticeable when infant cries and the affected side is immobile
-Usually disappears in a few weeks but may be permanent

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74
Q

Cleft Lip/Palate

A

-A incomplete closure of lip and/or palate
-May be unilateral or bilateral
-May only affect soft palate

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75
Q

Checking Femoral Pulses

A

Assess for equality
Absence may be sign of coarctation of aorta or hypovolemia

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76
Q

Club Foot Assessment

A

To assess for club foot the newborn’s foot is moved to midline—resistance indicates talipes equinovarus

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77
Q

moro reflex

A

Disappears by 6 months

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78
Q

rooting

A

Disappears by 4-7 months

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79
Q

sucking

A

Disappears by 12 months

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80
Q

palmar grasp

A

Lessens by 3-4 months

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81
Q

stepping

A

Disappears by 4-8 weeks

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82
Q

tonic neck

A

Disappears by 3-4 months

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83
Q

galant reflex

A
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84
Q

babinski

A

Disappears by 12 months

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85
Q

plantar grasp

A

Lessens by 8 months

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86
Q

caloric intake

A

105-108 kcal/ kg/ day

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87
Q

water requirements

A

140-160 ml/ kg/ day

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88
Q

formula

A

-20 kcal/ 30 ml (1 ounce)
-Max: 32 oz./ day
-Per feeding: 2-4 oz./ feed q 3-5 hrs.

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89
Q

breast milk

A

-20 kcal/ oz. (1 ounce)
-Less protein than formulas, easier on renal system
-Newborns “feed on demand” q 1.5 – 3 hrs.
-Documented number of minutes fed on each side
-Assess LATCH score at least once a day and if the score is 5 or less then assess each feeding

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90
Q

voids

A

Note all voids
First void may not occur for first 24-48 hours

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91
Q

stools

A
  1. Meconium-thick, tarry, black, very sticky
  2. Transitional-strange colors from green to yellow to brown
  3. Breast milk stools
    -Breast fed babies poop more often, not as “stinky”
    -Yellow with curds
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92
Q

breastfeeding and To be certain they are getting enough nutrition/volume the newborn should (after milk begins to come in):

A

Poop: 1+ a day
Pee: at least 6-8 wet diapers a day

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93
Q

Nursing Care of the Newborn

A

-Procedures:
1. CCHD screening
2. Hearing screen
3. Circumcision
4. Car seat challenge

-labs
-safety
-education

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94
Q

Critical Congenital Heart Defect (CCHD) screening

A

-Done on all newborns between 24-48 hours
-Pulse oximetry to look for hypoxemia
1. Right wrist– pre-ductal: same 02 as vital organs
2. One lower extremity– post-ductal: after the blood crosses ductus arteriosis (low oxygenated)
*compare the two

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95
Q

testing for CCHD: FAILED

A
  • <90% in right hand or foot
  • go to diagnostic test
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96
Q

Testing fro CCHD: repeat testing needed

A
  • 90%-<95% in right hand and foot or >3% difference between right foot and hand
  • repeat 3 times till get failed or passed
  • repeat in one hour
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97
Q

Testing for CCHD: passed

A
  • > /= 95% in right hand or foot and </= 3% difference between right foot and hand
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98
Q

Hearing Screen

A

-Done prior to discharge
- put ear buds or muphs and sensors on baby
-Assesses brain wave activity related to transmission of sounds
-Retained amniotic fluid in ears may prevent passing the hearing screen

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99
Q

what is circumcision

A

Removal of the penile glans prepuce (foreskin)

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100
Q

reasons for circumcisions

A

Culture/religious
Social- “look like daddy”
Medical benefits- decreased STIs and UTIs

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101
Q

types of circumcision

A

-Gomco clamp
-Mogan Clamp
-Plastibell

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102
Q

2012 AAP Policy statement about uncircumcised penis

A

Benefits may outweigh risks- but not enough to recommend it
Final decision still up to parents

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103
Q

pain management for circumcision

A

Dorsal penile nerve block
Acetaminophen
Emla cream
SweetEase

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104
Q

Dorsal penile nerve block for circumcision

A
  • Usually Lidocaine is injected at base of penis
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105
Q

acetaminophen for circumcision

A

Before the procedure and prn for first 24 hours
Dose based on weight

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106
Q

emla cream for circucision

A

Topical cream applied to penis about 1 hr. prior to procedure
Cover with occlusive dressing

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107
Q

SweetEase for circumcision

A

24% sucrose solution- dripped into mouth during procedure and suck on pacifier or gloved finger
May be beneficial in promoting endorphin release and decrease discomfort

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108
Q

Nursing Responsibilities for circumcision

A

-Patient Identification
-Ensure provider has obtained parental consent and the form is signed
-After procedure is completed
1.Vaseline applied to circumcisions done with Gomco and Mogan clamps
2.Plastibell- no creams or ointments applied
3.Wash off any betadine
4.Check site for bleeding q 30 min x 2 hours

-Apply direct pressure for active bleeding and notify provider if it doesn’t resolve
-Monitor for signs of infection and bleeding throughout hospital stay
-Document first void after circumcision
-Analgesics for pain- use NIPS pain score

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109
Q

parental education for circumscised babies

A

Signs of infection
Circumcision care
Encouraged to comfort newborn after procedure is completed

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110
Q

Car seat challenge

A

-Done on preterm or late preterm infants
-Monitor pulse oxymetry while sitting in car seat for at least the length to drive home

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111
Q

spot oxygenation checks

A

If family lives at higher altitude may need to set up a spot pulse oxymetry at the altitude of home

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112
Q

Lab- Metabolic Screening for Inborn Errors of Metabolism (IEM)

A

-Sometimes referred to as “PKU test”
-Phenylketonuria (PKU), hypothyroidism, cystic fibrosis, galactosemia, homocystinuria, maple syrup disease, Sickle cell
-1st check at 24 hours of age & then in 2 weeks

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113
Q

Lab- total bilirubin

A

-Usually done prior to discharge and prn
-Plotted on graph based on age to determine risk

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114
Q

Labs- CBC

A

WBC: 10-30
Hgb: > 14, < 20
Hct: > 43 %, < 63%
I/T ratio < 2 (> 2 indicates infection)
# bands divided by # neutrophils

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115
Q

urine/meconium lab

A

for toxicology

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116
Q

Cord Care

A
  • Assess for signs of infection/bleeding
  • keep dry- fold diaper away from stump
  • Clamp usually removed 24-72 hours after birth once cord begins to dry
    -Many types of cord care are practiced from nothing to alcohol or triple dye:
    1. Know the facility/pediatrician’s recommendation
    2. Plain water and air drying promotes quicker separation and drying than does alcohol
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117
Q

Safety- Infant Abduction Prevention

A

National Center for Missing & Exploited Children
55% of infant abductions occur in the mother’s room
Recent Story

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118
Q

safety- prevention measures in place to prevent abduction

A

Identification bands are placed on mother, baby and one other person of mother’s choice
All personnel wear a special badge for identification
Electronic security bands have radio alarm system
ALWAYS CHECK BANDS WITH MOTHER AND SIGNIFICANT OTHER!!!!

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119
Q

safety- SIDS

A

-AAP recommends “Back to Sleep”
-Place neonate in supine position for sleeping
-Avoid pillows, loose blankets, bumper pads
-Encourage smoking cessation for parents

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120
Q

saftey- car seats

A
  • CDC recommendations
    -Birth to age 2- rear facing car seat
    -2-4 years (or up to 40 lbs.)- forward facing car seat
    -4-8 years (or 4’9”)-booster seat
    -Best place-rear middle seat
    -Not near air bags
    -Must have prior to discharge
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121
Q

car seat and blankets

A

-Need to make sure the blankets and clothes allow for belt to be correctly positioned between legs
-Un-swaddle and then cover with blanke

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122
Q

Routines prior to Discharge

A

-Admission and Discharge physical by pediatric provider (MD or NNP)
-Follow-up appointment scheduled
-Hearing screen completed
-Metabolic Screening for Inborn Errors of Metabolism completed: Card given for repeat testing
-CCHD screening completed and passed
-Discharge instructions

123
Q

early discharge

A

Discharge within 48 hours
May miss medical, nursing, family, psychosocial, feeding problems, and educational needs

124
Q

AAP guidelines for early discharge

A

-Term infant with normal exam
-Stay of at least 12 hours
-Able to maintain homeostasis
-Feeding normally
-Exam by pediatric provider
-Follow-up appointment within 48 hours
-All state required screening tests completed
-Cord blood saved on O+ mothers
-Parents able to demonstrate correct usage of approved car seat

125
Q

Discharge Instructions

A
  1. Newborn appearance
  2. Newborn care
    -Bulb syringe
    -Umbilical cord care
    -Hygiene
    -Circumcision care
    -How to take an axillary temperature
    3.Feeding and elimination
  3. Safety
    -Car seats
    -“Back to sleep”
    -Never shake a baby
  4. Follow-up appointments
  5. Sibling rivalry
  6. Bonding
  7. Danger/Warning Signs
126
Q

Danger/Warning Signs

A

-Vomiting (more than 1 feeding)/ Refuses to feed
-Difficulty breathing
-Drastic behavior changes to irritable or overly sleepy
-Inability to void/ Diarrhea
-Axillary temperature of 99.6 F or higher
-Change in skin color- pale white, blue or yellow
-Rashes
-Umbilical stump infection signs- foul discharge, redness around site
-Drainage from eyes or ears

127
Q

Newborn Characteristics

A

-Name of characteristic
-Identify if it is normal, abnormal or a variation of normal
-Education to parents on the finding

128
Q

Polydactyly

A

-Extra digits on hands or feet.
-May be familial or associated with a syndrome—make sure to assess for other abnormal findings
-Usually tied off or removed

129
Q

Vernix

A

-White cheesy substance on skin:
1. Consists of sebum & desquamated epithial cells
2. Protects and lubricates skin in-utero
3. Decreases as fetus nears term

130
Q

Acrocyanosis

A

Hand and feet are blue due to poor circulation

131
Q

Telangiectatic Nevi

A

-AKA “Stork bites” (nape of neck) and “Angel’s kisses” (face)
-No clinical significance and usually fade by 2nd year
- this will blanch
-more common in fair skinned babies

132
Q

Erythema Toxicum

A

AKA “Newborn rash” or baby acne
-No known cause and no treatment
-Peak around 24-48 hrs.
-Eruption of lesions surrounding the hair follicle
-Moves around body and disappear spontaneously
- use gentle soap, leave alone, avoid lotion

133
Q

Slate Grey Spots

A

-AKA Mongolian spots
-Macular areas of blue/black pigmentation usually found on sacrum/buttocks
-Fade by 2nd year
-May be mistaken for bruises so very important to document them

134
Q

Nevus Flammeus

A

-AKA “Port Wine Stain”
- if on face and associated with seizures = not normal
-Capillary angioma
-Non elevated, does not blanch and does not fade
-Commonly on the face

135
Q

Milia

A

Exposed sebaceous glands
No clinical significance
Clear up spontaneously by 1 month
-dont squeeze- leave alone

136
Q

over riding sutures

A

-Normal finding related to pressure exerted on head
-Usually diminishes within a few days after birth
-Head measurements may be affected
- to explain to paretn: bones overlapping to help fit through the pelvis

137
Q

Cephalohematoma

A

-Collection of blood between skull bone and periosteal membrane
-Does not cross suture lines
- can be normal especially with vacuum assisted
- could increase jaundice

138
Q

“Caput” Succedaneum

A

-Collection of fluid under the scalp
-Crosses suture line
-should go away within 24 hours
- cone head

139
Q

Natal Teeth

A

-AKA “Milk teeth”
-Not the primary teeth and are usually removed because they are a chocking hazard since not well seeded in the gum

140
Q

Epstein Pearls

A

-Keratin containing cysts often found on gums and palate
-No clinical significance
-will go away

141
Q

Syndactyly

A

Webbing of fingers or toes
- normal if not seeing anything else
- if completely fused= surgery or affect ability to seperate to use hands or feet

142
Q

Sacral Dimple

A
  • May also be called a Pilonidal dimple
    -May be associated with spina bifida
    -May need ultrasound to determine if there is a connection to spinal column
    -If able to see the base of the dimple there is low risk of spina bifida
143
Q

Sucking Blister

A

-Normal finding from vigorous fetal sucking
-May be found on hands, feet, lips
-May be intact or ruptured
-No treatment needed
- dont pop it, keep dry and clean, watch for signs of infection

144
Q

Eyelid Edema

A

-Normal puffiness noted
-May be caused by a chemical conjunctivitis from ophthalmic ointments
-Resolves in a few days after birth

145
Q

Lanugo

A

-Protective hair that is present inutero
-As fetus matures lanugo disappears

146
Q

Pseudomenstruation

A

-Withdrawal bleeding as estrogen and progesterone levels drop noted in female infants
-Usually occurs day 3-4 after birth

147
Q

fetal circulation- lungs

A

-No need for oxygenated blood from lungs
-Blood shunted away from lungs
-High pressure system
-Pulmonary vessels are constricted
-PaO2 is low
-Fluid filled- 80-100 ml at birth
-Fetus practices breathing-allows development of chest wall muscles & diaphragm and lungs to grow

148
Q

fetal circulation- foramen ovale

A

-Shunts blood from right atrium to left atrium
-Shunts blood from pulmonary artery and lungs by never letting it get to the right ventricle

149
Q

fetal circulation- ductus arteriosis

A

-Shunts blood away from pulmonary artery and lungs into the descending aorta
-Shunts blood away from the left side of the heart

150
Q

fetal circulation ductus venosus

A

Branches of umbilical vein that carries blood away from the fetal liver, directly into vena cava

151
Q

fetal circulation- umbilical arteries

A

Carries un-oxygenated blood from fetus to placenta

152
Q

fetal circulation- umbilical vein

A

Carries oxygenated blood from placenta to fetus

153
Q

when is the neonatal period

A
  • from birth to 28 days old
154
Q

Systems that have to change from fetal to neonatal include

A

-Respiratory
-Cardiovascular
-Thermal regulation
-Hematological
-Hepatic
-GI/GU
-Immunological
-Neurological/Sensory perception

155
Q

Cord Clamping

A
  1. With first breath blood flows to lungs
    -Umbilical arteries immediately constrict
    -Pulmonary bed moves from high resistance bed to low resistance bed
  2. Umbilical vein continues to receive blood from intervillous space
    -Delayed vs. immediate cord clamping
156
Q

Respiratory adaptation

A

-Must move fluid out of lungs
-Establish blood flow to lungs
-Ensure blood circulating through lungs becomes oxygenated: Establish functional residual capacity—air remaining in the lungs at the end of exhalation

157
Q

Fetal to Neonatal Pulmonary & CV Function

A
  1. first breath
  2. increased Pa02
  3. increased pulmonary blood flow
  4. decreased pulmonary vascular resistance
  5. –Increased blood return to left heart
    –Mechanical closure of ducti
    –Blood pumped from lungs to body
    –Blood returned to right side of heart
    –Placental system, UA/UV shut down
  6. blood is oxygenated on neonatal lungs and sent to the body
158
Q

mechanical

A
  • Respirations are stimulated by changes in intrathoracic pressure resulting from compression of the chest during vaginal birth (as they pass through the birth canal—the chest is compressed and 1/3 of fluid is squeezed OUT of the lungs)
    *Fluid is reabsorbed—w/ each breath the lungs expand and fluid passes into the blood and lymphatics (Most fluid is reabsorbed w/in 2 hours and completely absorbed by 12-24 hours after birth!)
    *When born, pressure on chest is relieved allowing air to enter the lungs and when the neonate cries, this allows air to spread throughout the lungs causing the alveoli to expand—chest recoil causes passive air entry into the alveoli
159
Q

first breath to be initiated is a combination of

A

mechanical
chemical
sensory
thermal

160
Q

chemical

A
  1. Transitory asphyxia
    -Rise in PCO2
    -Decreased pH
    -Decreased O2
    *This stimulates the Aortic and Carotid chemoreceptors and triggers the respiratory center in the medulla
  2. Chemoreceptors stimulated & triggers respiratory center
  3. Prostaglandin levels fall increasing respiratory drive When the cord is clamped which increases the respiratory drive
161
Q

thermal

A
  • The temperature of the environment drops from 98.6 to about 70F (temp in the extrauterine environment is MUCH lower)
  • The profound change in temperature (from the womb to outside) causes the stimulation of receptors in the skin.
  • Results in rhythmic respirations d/t the stimulation of the respiratory center in the medulla.
162
Q

sensory

A
  • Auditory, visual, touch/pain, proprioceptor stimulation (baby scares itself)–> help maintain respirations
163
Q

Closure of Foramen Ovale

A
  1. With first breath
    -PaO2 rises
    -Pulmonary arteries dilate
  2. Increased blood returns to left atrium
    -Foramen ovale closes due to increased pressure gradient in left side of heart
  3. Functionally closed at 1-2 hours
    -Crying, acidosis, cold stress or hypoxia may cause reopening
    -Permanently closes by 6 months
164
Q

Closure of Ductus Arteriosus

A
  1. Constriction of ductus arteriosus caused by:
    -Increased PaO2
    -Drop in prostaglandins E2 from placenta
  2. Pressure from left heart causes mechanical closure of ductus arteriosus
  3. Functional closure 10-15 hrs. after birth
  4. Fibrosis of ductus arteriosus is complete within 4 weeks- becomes known as ligamentum venosum
165
Q

Closure of Ductus Venosus

A

-Exact causes for closure is unknown
-Redistribution of blood through newborn liver
1. Flows through hepatic vein into the inferior vena cava
2. Increases blood return to right side of heart
-Mechanical closure with umbilical cord clamping/cutting
-Fibrosis occurs within 2 months—becomes ligamentum venosus

166
Q

Newborn Oxygen Saturation- normal transition

A

-Normal oxygen saturation inutero-60%
-Takes up to 10 minutes to be >90%

167
Q

Newborn Oxygen Saturation- pulse oximeter

A
  1. On right wrist- same oxygen saturation as vital organs
    - Pre-ductal- blood prior to reaching ductus arteriosus before mixing with blood with low O2 levels coming from the pulmonary artery across the ductus
168
Q

02: 1 min after birth

A

60-65%

169
Q

02 2 min after birth

A

65-70%

170
Q

02 3 minutes after birth

A

70-75%

171
Q

02 4 minutes after birth

A

75-80%

172
Q

02 5 min after birth

A

80-85%

173
Q

02 10 minutes after birth

A

85-95%

174
Q

Temperature Regulation

A
  1. Neutral Thermal Environment
    -Perfect balance between heat lost and heat produced
    -Minimizes rate of oxygen consumption and consumption of calories
  2. Newborns require higher ambient temperature than adults
    89.6-93.2 F ideal
175
Q

Characteristics of Newborn

A

-Large body surface in relation to mass
-Thin epidermis
-Limited subcutaneous fat
-Blood vessels nearer to skin
-Posture
1. Flexed promotes heat retention
2. Extended increases heat loss

176
Q

Newborn Heat Production

A
  1. Increased basal metabolic rate
    - Result of increased glucose conversion to energy
  2. Muscular activity
    -Doesn’t produce enough heat
  3. Non-shivering thermogenesis- major source of heat production
    -Stimulation of sympathetic nervous system by the cold on skin receptors causes newborn to use brown fat stores to produce heat
    -Unique to newborn
    -Facilitates metabolism of triglycerides for heat production
177
Q

Brown Fat

A

-Appears around 26-30 weeks gestation
-Comprises 2%-7% of infant’s body weight
Once depleted, brown fat is not replenished

178
Q

Heat Loss

A
  1. Lose about 4 x as much heat as adult
  2. Inability to maintain normal temperature is usually related to excessive heat loss not impaired heat production
  3. Four methods of heat loss
    -Convection
    -Radiation
    -Evaporation
    -Conduction

-Once newborn is dried most common methods of heat loss are convection & radiation

179
Q

Convection

A

Heat lost to cooler ambient air

180
Q

radiation

A

Heat lost to cooler surfaces in close proximity

181
Q

evaporation

A

Heat lost as skin moisture is vaporized

182
Q

conduction

A

Heat lost to cooler surface area in direct contact with body

183
Q

cold stress

A
  1. Increased heat production and metabolism in response to cold
    -Leads to hypoglycemia
    -Increased O2 consumption
    -Increased anaerobic metabolism
  2. Metabolic acidosis occurs
    -pH decreases, PaO2 drops, PaCO2 rises
    -Ductus arteriosus reopens
    -Pulmonary vasoconstriction occurs
    -Blood shunted away from lungs
    -Increased pulmonary vascular resistance
    -REVERTS BACK TO FETAL CIRCULATION but there is no placenta to supply O2
184
Q

Hematological Adaptation

A
  1. Blood volume in term newborn ~80-85 ml/kg
  2. Contributing factors:
    -Antenatal hemorrhage
    -Rh alloimmunization
    -Time of cord clamping/ level of baby R/T placenta
  3. Fetal RBC have short half life
    -Contributes to physiological jaundice
  4. Physiological anemia & abnormal clotting studies
185
Q

Hepatic Adaptation

A
  1. Neonatal liver is immature
    -Lack glucuronyl transferase- more difficult to conjugate bilirubin and excrete it
    -Higher levels of unconjugated bilirubin leads to physiological jaundice
  2. Neonatal gut is sterile
    -No bacteria to synthesize vitamin K-
    -Liver does not produce vitamin K dependent clotting factors– factors I, VII, IX & X
  3. Liver frequently palpable—about 40% of abdominal cavity
  4. iron stores from maternal intake sufficient for ~ 5 months
186
Q

Bilirubin Conjugation

A

-Breakdown of heme-containing proteins
1. Conjugation
-Conversion of fat soluble to water soluble
-Total serum bilirubin= conjugated (direct) + unconjugated (indirect) bilirubin
2. After birth liver must conjugate bilirubin
-Early feedings & getting gut moving to pass stools assists liver in removal of conjugated bilirubin

187
Q

Physiologic Jaundice

A

Appears after 24 hours and is no longer apparent by 14 days
Peaks around 3-4 days
Not pathological but a normal adaptation after birth

188
Q

causes of Physiologic Jaundice

A

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

189
Q

Metabolic Adaptation

A

-Carbohydrate reserves low
-Glucose main source of energy 4–6 h after birth
-Fuel source consumed quickly: Stress of delivery rapidly uses up hepatic glycogen
- Changes from carbohydrate metabolism to fat metabolism

190
Q

Genitourinary Adaptation

A
  1. Glomerular filtration rate low
    -Limited capacity to concentrate urine
    -Urine may be cloudy
  2. Bladder holds 6-44 ml
  3. Voids within 48 hours
    -In first 2 days of life produce about 15 ml/kg/day = 2 to 6 wet diapers/day
    -Day 3 produce 25 ml/kg/day = 5-25 wet diapers/day
  4. Pseudo menstruation- from maternal hormone withdrawal
191
Q

GI Adaptation

A
  1. Adequate intestinal and pancreatic enzymes
    -Proteins require more digestion
    -Absorbs and digests fats less efficiently
  2. Experienced at swallowing/sucking
  3. Stomach capacity 50–60 ml (1-2 oz.) capacity
    -Requires 105-108 kcal/kg/day
    -Air enters stomach immediately after birth
  4. Cardiac sphincter immature
  5. 5–10% shift of intracellular fluid
192
Q

Immunological Adaptation

A
  1. Immune system not fully activated
  2. Fever not a reliable indicator of infection
  3. Immunoglobulins:
    -IgG: Only type small enough to cross placenta; passive acquired immunity from mother usually in 3rd trimester
    -IgM: begin to produce on own by 15 weeks of age
    -IgA: receive from breast milk especially colostrum
193
Q

Neurological & Sensory/Perceptual Adaptation

A
  1. Brain one-quarter size of adult brain
    -Myelination of nerve fibers incomplete
  2. Responses to different stresses vary
  3. Perinatal factors
    -Antenatal maternal substance abuse
    -Antenatal CNS abnormalities
    -Congenital CNS abnormalities
  4. Maturity of neurological system progresses in cephalocaudal direction
194
Q

Neurological & Sensory/Perceptual Adaptation- important factors

A
  1. Examine newborn at the right time of “sleep cycles”
    -In deep sleep some reflexes are diminished
  2. Establish breast feeding at the right time
    -Crying vigorously & inconsolable will not feed well
    -Deep sleep won’t be able to wake to feed
  3. Promote bonding and attachment at the right time
    -Quiet alert is optimal time
195
Q

Periods of Reactivity- first period

A

Birth to about 30 minutes after birth
Bonding, initiate breastfeeding
Respirations and heart rate rapid

196
Q

Period of inactivity to sleep

A

Heart rate, respirations decrease
Sleep phase will last from minutes to 2–4 hours
Deep sleep

197
Q

periods or reactivity- second period

A

Awake and alert
Lasts 2 to 5 hours
Physiologic responses vary
GI tract more active
Good time for bonding

198
Q

Deep or quiet sleep

A

-Closed eyes with no eye movements
-Regular, even breathing
-Jerky movements or startles easily

199
Q

REM sleep

A

-Eyes closed with eye movements noted
-Irregular breathing
-Irregular sucking motions
-Minimal activity
-External stimuli will initiate a startle reaction

200
Q

Behavioral States:Alert- drowsy alert

A

-Open or closed eyes
-Semi-dozing appearance
-Slow regular movements
-Mild startles may be noted

201
Q

wide awake

A

-Alert and focuses on objects
-Minimal motor activity
-Good time to feed

202
Q

active alert

A

-Eyes open
-Intense motor activity with thrusting movements of the extremities
-Startles easily and increased movement from stimuli

203
Q

crying

A

-Intense crying
-Jerky movements
-Attention getting
-Very hard to feed in this state

204
Q

Behavioral Capacities

A
  1. Able to self sooth
    -Sucking on hand, toes, fingers, lip
    -Hand to mouth
  2. Habituation
    -Eventually blocks out annoying stimuli
  3. Orientation
    -Follows faces, shiny objects, lights
  4. Swaddling can help provide comfort
205
Q

visual Sensory Capacities

A

Prefers the human face and eyes
High contrast items
8-15 inches ideal distance for focusing

206
Q

auditory Sensory Capacities

A

Responds to auditory stimuli with organized behavior

207
Q

tactile sensory capabilities

A

Very sensitive to touch
May be most important

208
Q

olfactory sensory capabilities

A

Can differentiate mother’s smell by 1 week of age

209
Q

taste and suck capabilities

A
  1. Able to taste sweet and sour
    -Taste buds not fully developed until age 4 yrs.
  2. Suck occurs in bursts
  3. Rooting reflex when hungry
210
Q

what are the benefits of delayed cord clamping

A
  • Protected transition
  • Prevents anemia
211
Q

what are disadvantages to delayed cord clamping

A
  • Increased risk of hyperbilirubinemia
  • not enough to out weigh the benefits
212
Q

what is physiological cord clamping

A
  • a form of delayed cord clamping when the cord is clamped/cut based on the onset of respirations and cessation of cord pulsations (3-5 minutes after birth) rather than at a fixed time point.
213
Q

WHAT IS DELAYED CORD clamping

A
  • waiting 30-60 seconds to clamp the cord
  • recommend waiting at least 30-60 seconds after birth to clamp the cord in vigorous term and preterm infants
214
Q

what is cord milking

A
  • physically pushing the blood through the cord to the baby
215
Q

Are there any situations where delayed cord clamping is contraindicated?

A
  • When the newborn-placental circulation is not intact (abruption, previa, cord avulsion)
  • May not be appropriate in a fetus with growth restriction and abnormal doppler flow studies (may already have polycythemia and hyperviscosity)
216
Q

what should you do before you place the ID band and security tag on baby

A
  • Correct information and numbers match
  • Provide education to parents about the bands
217
Q

why is right after birth a good time to breastfeed

A
  • First period of reactivity
  • Will move into a period of inactivity or sleep at about 1 hour of age.
218
Q

what is the moro reflex

A

Hold infant in semi sitting position, allow head and trunk to fall backward to angle of at least 30 degrees (with support); symmetric abduction and extension of arms, fingers fan out, thumb and forefinger form a C; arms are then adducted into an embracing motion and return to relaxed flexion and movement.

219
Q

what is the palmar grasp reflex

A

Place finger in the palm of the hand; infant’s fingers curl around examiner’s finger

220
Q

what is the plantar grasp reflex

A

Place finger at the base of the toes; infant’s toes curl downward

221
Q

what is the truncal incurvation reflex

A

Place infant prone on a flat surface or suspended in the palm of the examiner’s hand, run finger down side of back first on one side and then down the other side approximately 4-5 cm lateral to spine; trunk flexes and pelvis swings toward stimulated side.

222
Q

what is the babinski reflex

A

Use finger to stroke sole of foot beginning at heel, upward along lateral aspect of sole, then across ball of foot; all toes hyperextend, with dorsiflexion of big toe

223
Q

what is the rooting reflex

A

Touch infant’s lip, cheek, or corner of mouth with nipple or finger; turns head toward stimulus and opens mouth ready to take hold and suck.

224
Q

what is the tonic neck reflex

A

Place sleepy infant in a supine position, then turn head quickly to one side; arm and leg on side to which head is turned extend while opposite arm and leg flex.

225
Q

what is the step reflex

A

Hold infant vertically, allowing one foot to touch table surface; infant alternates flexion and extension of feet.

226
Q

According to this policy what are the health benefits of newborn male circumcision?

A
  • Prevention of UTI in male infants <1 year old
  • Reduced risk of penile cancer
  • Reduced risk for heterosexual acquisition of STI’s, especially HIV
227
Q

pharmacological measures for circumcision

A

Local anesthesia with a penile block, topical preparations (EMLA), oral sucrose, liquid acetaminophen 10-15 mg/kg after the procedure q 4-6 hours as needed (max of 30-45 mg/kg/24 hrs)

228
Q

non-pharmacological measures for circumcision

A

swaddling, nonnutritive sucking, skin-to-skin with parents, distraction (visual, oral, auditory, or tactile), Vaseline ointment, change diaper promptly, avoid pressure on site when holding or positioning

229
Q

care for all types of circumcisions

A

o Wash off betadine
o Assess for bleeding q 15-30 mins x 1 hour, then q 1 hour for 4-5 hrs
o Monitor for first void after procedure

230
Q

care for gomco/mogen circumcision

A

o Apply Vaseline gauze to the penis for the first 24 hours, then apply petrolatum (Vaseline) until healed to prevent the diaper from sticking

231
Q

care for plastibell circumcision

A

Do not use Vaseline or Vaseline gauze as it causes the string to degrade prematurely

232
Q

when and how is testing for congenital heart defects done

A
  • Between 24-48 hours of life or just prior to discharge from the hospital the newborn is screened for critical congenital heart defects using a pulse oximeter to measure the oxygen saturation.
  • Oxygen saturation is measured in the right hand and one foot and is considered normal if O2 sat is >95% in either extremity and there is <3% absolute difference between the upper and lower extremities.
233
Q

what findings from the congenital heart defect test need more testing

A
  • Positive screens are
    1. O2 sat < 90% in right hand or foot
    2. 90-95% in right hand or foot OR >3% difference between the two extremities
  • Retest in 1 hour up to 2 times
  • If parameters remain unchanged after third time considered positive screen

*Additional testing needed for any positive screening—i.e. echocardiogram

234
Q

signs she is coping with the pain in labor

A
  • using breathing and relaxation techniques
  • moaning and chanting
  • inward focus
  • says i am coping
  • rocking and swaing
235
Q

signs she is not coping with labor

A
  • i cant do this
  • crying screaming
  • tremulous voice
  • unable to focus
  • panicky during contractions
  • thrashing
  • scratching, biting, writhing
  • sweaty shaky
236
Q

causes of pain in 1st stage of labor

A
  • Cervical effacement & dilatation
  • Hypoxia of uterine muscle cells
  • Stretching of lower uterine segment
  • Pressure on adjacent structures: Referred pain-low back, thighs, buttocks, groin, iliac crest
  • Pain impulses enter spinal cord at L1, T10-12
237
Q

Causes of Pain in 2nd Stage

A

-Uterine hypoxia
-Stretching of vagina, pelvic floor: Pain impulses enter spinal cord through S2-4
-Distention of lower uterine segment
-Pressure on adjacent structures

238
Q

Implications of Pain in Labor

A
  1. Physiologic response
    -Tachycardia
    -Increased O2 consumption
    -Lactic acid
    -Hyperventilation (risk of resp alkalosis)
  2. Psychological implications
    -Unrelieved pain may prolong labor
    -Post traumatic stress disorder
239
Q

mom assessment of well being before giving pain meds

A

-Vital signs and initial assessment and history
-Allergies

240
Q

fetus assessment of well being fetus before giving pain meds

A
  • Baseline fetal heart rate
  • Decelerations, accelerations, baseline variability
  • Presentation
241
Q

labor assessment of well being before giving pain meds

A

-Dilation, effacement, station
-Contraction frequency
-Ruptured membranes?

242
Q

timing of interventions

A
  • Offered too soon will stop/slow labor
  • Offered too late risk un-medicated delivery when she really wanted an epidural
  • Sometimes delivery happens too quickly to allow pharmacological interventions
    *Very rapid labors/deliveries are more difficult to cope with the intensity and rapidity of the pain
243
Q

analgesic effects in latent stage of labor

A
  • May slow contractions and labor progress
244
Q

analgesic effects in active phase of labor

A

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

245
Q

Analgesic effects in the second stage of labor

A

not much help, too close to birth

246
Q

important principles related to pain

A
  • uterus functioning effectively when well hydrated and 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
  • more tense the other body muscles are the less work the uterus can do and the more painful the contractions feel
  • support touch and hydrotherapy can be just as good as narcotics
247
Q

non pharm methods

A

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

248
Q

non pharm methods

A

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

249
Q

relaxation

A
  1. Visualization/Guided Imagery
    -Visualize sights, sounds, feelings of a pleasant place
    -Visualize cervix opening up
  2. Progressive relaxation
    -Tighten and relax muscle groups through body
  3. Assist woman to find areas of tension in her body and help them become dead weight/relaxed
    -Stroke/place hand on tense muscle and encourage release of tension
  4. Music, dim lights
    -Best music is instrumental or classical
250
Q

importance of relaxation

A
  • The more tense other body muscles are, the less work the uterus can do AND the more painful the contractions feel
251
Q

Hydrotherapy

A

Showers
Jacuzzi tubs

252
Q

Massage

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

253
Q

benefits of Movement, ambulation and position changes

A

-Shorten labor
-Lessens pain
-Promotes fetal descent
-Birthing balls- increase the diameter of pelvis, assists with fetal rotation and descen

254
Q

Aromatherapy

A

-Make sure it doesn’t set off fire alarms
-Lavender, sage, peppermint, citrus

255
Q

Sterile water papules

A

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

256
Q

TENS unit

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

257
Q

Breathing technique

A

-Don’t start any technique too early- she will exhaust herself
-Benefits: Increases pain threshold, encourages relaxation, provides distraction, enhanced coping ability, and more efficient uterine functioning by keeping it oxygenated
-Best if learned and practiced prior to labor
-Bradley breathing technique: Slow and focused throughout labor

258
Q

Lamaze Breathing

A
  1. Cleansing breath before and after
    -Deep breath in through nose out through mouth
  2. Slow chest breathing
    -Usually used in latent and active labor
    -decreases insensible water loss from lungs and delays exhaustion
    -Count of one one thousand, two one thousand, three one thousand, four one thousand and then exhale to the same rate
  3. Modified paced
    -Usually used in active labor and 2nd stage
    -Short shallow breaths and the rate matches the intensity of contraction
  4. Pattern paced- “Hee, hee, hee, hoo”
    -Usually used active labor and 2nd stage
    -Breaths are all in and out through mouth
    -Inhalations occur after the hoo sound and before the next hee
  5. Quick method
    -Pant-pant-blow
    -If hasn’t learned a breathing technique can use this one
    -Two short blows from mouth followed by a longer blow
    -All exhalations are a blowing motion
  6. Puffing
    -Used when urge to push prior to complete dilation
    -Head dropped back, checks loose and floppy
    -Think about keeping feather off nose
259
Q

Pharmacological Pain Management in pregnancy and labor

A
  • All systemic analgesics cross placental barrier by simple diffusion some more readily than others
  • All consent forms signed before medications
260
Q

timing of pain medications

A

-IV pain medication and nitrous will not slow down labor if given in latent labor. Epidurals may.
-Only too late to given an epidural if patient unable to sit still for procedure or pushing the baby out

261
Q

Analgesic:

A

Affects perception of pain, does not take pain away

262
Q

Anesthetic:

A

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

263
Q

sedation is used for

A

maternal exhaustion in prodromal labor

264
Q

analgesia is used for

A

For moderate - severe pain

265
Q

Anesthesia is used for

A

-For moderate - severe pain
-When prolonged effect desired or analgesia is ineffective

266
Q

endorphins

A

Endogenous opiates secreted by pituitary in response to pain
- Often epidurals or anesthesia blocks the body’s natural response to produce endorphins

267
Q

sedative types

A

Ambien 5-10 mg PO
*preferable to other sedatives because it has a shorter half life

268
Q

benefits/ risks of sedatives

A

-Decreases anxiety
-Allows for rest

-Inhibit uterine contractions (good for prodromal labor)
-Neonatal CNS depression
-have a minimal analgesic effect and can increase response to painful stimuli
-Make you groggy
-Maternal response

269
Q

Antihistamines types

A

Benadryl 25-50 mg PO

270
Q

benefits/risks of antihistamines

A

Induces relaxation and sleepiness

271
Q

H1-Receptor Antagonists (anti-emetics) type

A

Promethazine HCL (Phenergan) 12.5 25 mg IM or PO

272
Q

Benefits/ Risks of Anti-emetics

A

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

273
Q

true narcotics type

A

-Fentanyl 50-100 mcg IVP Q10-15 minutes x 5 doses: 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

-Morphine Sulfate:2 mg IV + 10 mg IM with PO Phenergan for prodromal labor

274
Q

partial opioid agonist type

A
  • Nalbuphine (Nubain): 5-10 mg IVP
275
Q

Benefits/Risks to opioids/synthetics- true narcotics, partial opioid agonists

A

-Pain blunting effect –> increased relaxation btw UCs
-Neonatal CNS depression

276
Q

why are oral forms of opioids/synthetics not used

A

they are poorly absorbed and due to prolonged gastric emptying of stomach in laboring women

277
Q

Nitrous Oxide MOA

A

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

278
Q

onset for nitrous oxide

A

Within 30-60 seconds of inhalation

279
Q

clearance of nitrous oxide

A

Maternal: within 30-60 seconds of discontinuation

280
Q

administration of nitrous oxide

A

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

281
Q

nitrous oxide advantages and uses

A
  1. During all stages of labor
  2. Can be used with ambulation, hydrotherapy, etc.
  3. Does not require IV catheter or continuous fetal monitoring (but this may be dependent on institution)
  4. Useful for other painful procedures
    -Forceps or vacuum assisted deliveries
    -Manual removal of placenta or uterine exploration
    -Laceration or episiotomy repairs
282
Q

side effects of nitrous oxide

A

Nausea & vomiting
Vertigo

283
Q

contraindications of nitrous oxide

A

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

284
Q

Effects on fetus/newborn of nitrous oxide

A
  1. Crosses placenta-80% of maternal serum levels
  2. Evidence shows:
    -No increase in CNS or respiratory depression
    -APGARS unaffected
    -No FHR changes
  3. Cleared rapidly with initiation of effective respirations
285
Q

Nitrous Oxide: Nursing Care and Implications: Patient safety and education

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)

286
Q

Obstetrical Anesthesia:Regional

A
  1. epidural
  2. spinal
  3. combined spinal epidural
  4. pudendal
  5. para cervical block
287
Q

epidural

A

-Continuous dose throughout labor. Takes longer to take affect
-Walking epidural is without the lidocaine or “caine”

288
Q

spinal

A

-Faster onset
-Lasts 1-3 hours
-Used for cesareans

289
Q

Combined spinal epidural

A

Patient gets benefit of spinal then maintenance of epidural

290
Q

Pudendal

A

-Used in second stage and repair of the perineum
-Injection of local anesthesia into pudendal nerve
-Produces anesthesia to lower vagina, vulva, and perineum
-Only produces pain relief at end of labor
-Has no effect on fetus or progress of labor

291
Q

Para cervical Block

A

Blocks cervical pain

292
Q

Epidural Anesthesia administration

A

-Injection of Anesthetic into epidural space:
1. L-2 to L-4 vertebrae with a T-8 to S-5 block
2. Variety of “caine” drugs + narcotics

293
Q

contraindications of epidurals

A

-Allergy to the agent
-Clotting disorders or hemorrhage
-Hx of spinal injury or abnormality
-Uncorrected hypovolemia
-Increased intracranial pressure (ICP)
-Platelet count less than 100,000/mm3
-sepsis
-hypertension

294
Q

where is the epidural space

A

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

295
Q

Epidural Advantages

A

-Provides good pain relief and assists with coping
-Allows woman to be fully awake
-Continuous epidurals: Allows for different blocking during each stage of labor, Dose can be adjusted
-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

296
Q

Spinal Block Advantages

A

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

297
Q

Regional Anesthesia Complications

A
  1. Inadequate block
    -“Hot spot”
    -One sided: prevented/treated by changing positions from side to side. Lie on unblocked side to allow gravity to permit anesthetic to bathe the nerves.
    -Block Failure
  2. Breakthrough pain
    -Full bladder, complete dilation, uterine rupture
  3. Procedure-Related Events
    -Nerve Root Injury
    -Accidental Dura (spinal) Puncture
    -Intravascular Injection
  4. Sympathetic Nerve Blockade
    -Maternal Hypotension –> late decelerations: Treat with Ephedrine 5-10 mg IV and fluid bolus, Oxygen via facemask, side-lying position
    -Urinary Retention : Foley
    -Fever
    -Itching: Nubain or Benadryl
  • shorter acting than epidural
298
Q

Regional Anesthesia Complications- postpartum findings

A

-Localized tenderness
-Backache
-Migraine Headache: Spinal headache with inadvertent spinal-treated with blood patch
-Transient Neurological Deficits
-Elevation in temperature

299
Q

Nursing Responsibilities: Regional Anesthesia

A
  1. Informed Consent
  2. Void prior to administration
  3. IV Access
  4. Preload with 500-1000ml IV fluids (dependent on hospital)
  5. Monitor vital signs, PO2, and fetal heart rate
  6. Assist with positioning
  7. Explain and reassure
300
Q

Ethical Issues with Epidural

A
  1. Informed consent: Question: Can a woman in severe pain give informed consent?
  2. Epidurals lead to other interventions
    -Continuous fetal monitoring
    -? Increased risk of C-section or assisted vaginal delivery (forceps or vacuum)
301
Q

complications of Pudendal Anesthesia

A

Hematoma, perforation of rectum, and trauma to sciatic nerve

302
Q

Local Anesthesia

A

-Injection of anesthetic into soft tissues of perineum
-Prior to episiotomy
-Prior to de-infibulation
-Repair of lacerations
-Does not affect fetus or labor progression
-Effect is only locally- not effective for pain prior to crowning

303
Q

General Anesthesia

A

-Used rarely
-For emergent C-sections with no or ineffective regional anesthesia
-Requires intubation
-High rate of neonatal depression
-Beware of aspiration pneumonia: A laboring woman’s stomach is never empty

304
Q

Nursing Responsibilities: General Anesthesia

A

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

OB (12 decks)

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