Mark k lecture 11 Flashcards
Normal fetal heart rate
120 to 160 beats per minutes
Low Fetal HR (heart rate)—HR <110
- This is BAD
- You do “LION”
o Left side (place mother on the left side)
o IV
o Oxygen
o Notify HCP - Stop Pitocin (pit) if it was running
o Implement before “LION”
High Fetal HR—HR >160
- Document acceleration of fetal HR
- Take the mother’s temp
- Not a high priority … Baby is WNL
Low Baseline Variability
- This is BAD
- Fetal HR stays the same—it doesn’t change
- You do “LION”
o Left side
o IV
o Oxygen
o Notify HCP - Stop pit if it is running (first)
High Baseline Variability
- Fetal heart rate is always changing—This is GOOD
- Document finding
Early Deceleration
- This is normal … No big deal
- Document finding
Variable (VERY) Decelerations
- This is very BAD
- This indicates prolapsed cord
- What is the nursing intervention?
o PUSH and POSITION
Late Decelerations
- This is BAD
- You do “LION”
o Left side
o IV
o Oxygen
o Notify HCP - Stop pit if it is running
VEAL CHOP
Variable declatrions —- Cord compression/prolapse
Early decelations—– Head compression
Accelerations—okay
Late decel—– plemtal insuifferncy
The second stage of L&D (labour and delivery) to do’s
- Deliver head … The mother needs to stop pushing
- Suction the mouth then the nose … ABC order
3.Check for nuchal (around the neck) cord - Deliver the shoulders, next, the body
- Make sure baby has ID band on before it leaves the delivery area
Third stage of L&D to do’s
- Delivery of the placenta
- What do you check for with the delivery of the placenta?
o Make sure the placenta is complete and intact
o Check for 3-vessel cord—2 arteries and 1 vein, AVA
Fourth Stage of L&D to do’s
- Recovery
- There are 4 things you do in the 4th stage, 4 times an hour (every 15 minutes)
- Vital signs: Assessing for shock … Blood pressure goes down, HR goes up … Pt looks
pale, cold, and clammy - Fundus: If it is boggy, massage it … If displaced, catheterize it
3.Check perineal pads … If there is excessive bleeding, the pad will saturate in 15
minutes or less
4.Roll pt over and check for bleeding underneath her
Post partum Assessment times
Assess every 4 to 8 hours
Post partum Assessment
- Assess for “BUBBLE HEAD”
- Make sure you focus on the 3 designated steps stated as important from BUBBLE HEAD
- Breasts
- Uterine fundus should be firm … Important
o Massage if fundus is boggy and midline
o Catheterize pt if fundus is boggy and not midline - Bladder
- Bowel
- Lochia is vaginal drainage postpartum (Know
the order) … Important
o Rubra—red
o Serosa (if your cheeks are rosy)—pink
o Alba (albino)—white
o Moderate amount: 4 to 6 inches on pad in an
hour
o Excessive: saturate a pad in 15 minutes - Episiotomy
- Hemoglobin/hematocrit
- Extremities—Looking for thrombophlebitis … Important
o What is the best way to determine if a pt has thrombophlebitis?
The best way is to measure Bilateral calf circumference (Best answer)
Homan sign is not the best answer - Affect—emotional
- Discomforts
What should the postpartum uterine tone, height, and
location normally be?
- The tone of the fundus should be firm, not boggy
- The height of the fundus after delivery should be at
the umbilicus (or navel)
o Fundus involutes about 2 cm every day PP
(postpartum) - The location of the uterus should be midline
o If not midline, the bladder is distended
Milia
Milia—White, pinhead-size, distended sebaceous glands on the nose, cheek, chin, and
occasionally on the trunk. Usually disappear after a few week of bathing not a issue
Epstein pearls
pearls—Palatal cysts of the newborn, which are small white or yellow cystic
vesicles not a issue
Mongolian spot—Bluish
Bluish discoloration in the sacral region of newborn usually seen in
African Americans … Carefully document its presence as such action may prevent child
abuse charges against parents or caregiver not a issue
Erythema toxicum neoratorum
Described as flee-bitten lesion … pink rash with firm,
yellow-white papules or pustule on the face, chest, abdomen, back and buttocks of some
newborns. Usually appears 24 to 48 hours after birth and disappear in a few days not a issue
Hemangioma
An abnormal accumulation of blood vessels in the skin of the newborn. It is
one of the most common birthmarks associated with childhood and affect 10% of all children not a issue
Cephalohematoma
Cephalohematoma—A collection of blood between the periosteum of a skull bone and the
bone itself
o Occurs in one or both sides of the head
o Occasionally forms over the occipital bone
o Develops within the first 24 to 48 hours after birth
Caput succedaneum
An edema of the scalp of the neonate during birth from mechanical
trauma of the initial portion of scalp pushing through a narrowed cervix
o The edema crosses the suture lines
o May involve wide areas of the head or it may just be a size of a large egg
o Caput Succedaneum (CS)—Crosses Suture line, and Caput Symmetrical
Hyperbilirubinemia in the Newborn
- Physiologic jaundice is normal and appears after 24 hours after birth … Disappears in about
one week - Pathologic jaundice is seen in the 1st 24 hours after birth
Nevi (Telangiectatic nevi)
Nevi or telangiectatic nevi, a.k.a. “stork bites,” are pink and easily blanched skin lesion that
appear on upper eyelid, nose, upper lip, lower occipital area, and nape of the neck
* No clinical significance
* Disappears by 2 years of age
Port wine stain
Port-wine stain or nevus flammeus is seen at birth and is composed of a plexus of newly
formed capillaries in the papillary layer of the corium
* Commonly found on the face and neck
* Red to purple, varies in size, shape and location
* Does not blanch on pressure
6 main ob medications
- Terbutaline (Brethine)
- Mag sulfate
- Pitocin
- Methergine
- Bexamethasone
- Surfactant
Tocolytics (Stop contractions, stop labor)
- Tocolytics are given to women in premature labor that must be stopped
- Terbutaline (Brethine)
o S/E: maternal tachycardia (don’t give with cardiac disease) - Mag sulfate
o Treatment with Mag sulfate will induce hypermagnesemia, which will cause everything to
go down
o HR will go down, BP go down, Reflexes go down, RR go down, LOC go down
So, what is the nursing intervention for hypermagnesemia due to mag sulfate treatment?
- Monitor respiration
o If RR <12, decrease dose of Mag sulfate - Assess for reflexes
o Normal reflex is 2+
o If reflexes are 0 or 1+ … Decrease dose of mag sulfate
o If reflexes are 3+ or 4+ … Increase dose of mag sulfate
Oxytocics (Stimulate and strengthen labor)
Pitocin (Oxytocin)
o S/Es: Uterine hyperstimulation (defined as longer than 90 seconds, closer than 2 minutes)
The nursing intervention is to lower the dose of pitocin in case of uterine
hyperstimulation
* Methergine
o Causes HTN—if it contracts blood vessels it makes sense that this increases BP
Fetal/Neonatal Lung Meds
- Betamethasone (steroid)
o Given to mother IM
o Can repeat as long baby is in utero
o S/E: increase glucose (steroid) - Surfactant (Survanta)
o Given to baby via transtracheal route
o Given After birth
