Postpartum Assessment and Nursing Care of the Newborn Flashcards
History terms of pregnant women
- Gravida and para
- Prenatal care
- Blood type
- Rubella Status
- Last Tdap
- Labor type
- Medication use
- Alcohol or drug use
Involution of the uterus
- uterus moves down one finger each day
- three processes> contradiction, catabolic processes, regeneration
Descent of the uterine fundus
- At end of 3rd stage is 2cm below the umbilicus, then returns to umbilicus or 1 above within 12 hrs of delivery
- decrease 1cm per day
- 14 days after childbirth the fundus should no longer be palpable
- afterpains/ uterine contractions may cause discomfort
Uterine Contradictions
- necessary to achieve hemostasis at the placental site
- Stimulated by release of oxytocin
- Administration of exogenous oxytocin
- Breastfeeding
The more kids you have the worse cramps you get T or F
True
Lochia
Vaginal Discharge
Lochia Rubra
- 1-3 days
- bloody, red/brown
Lochia serosa
- 4-10 days
- pink/ brown
Lochia alba
- 11-21 days
- white/ cream/ light yellow
Soaking up a pad in an hour or less is good T or F
FALSE, it is BAD
Lacerations of the Birth Canal
- perineum, 1st, 2nd, 3rd, 4th degree
- periurethral area
- vaginal wall
- cervix
Perinueum tears
Perineal lacerations are classified in degrees to describe the amount of tissue involved
Periurethral area tear
- A laceration in the area of the urethra may cause women difficulty urinating after birth
- An indwelling catheter may be necessary for a day or two
Vaginal Wall tear
A laceration involving the mucosa of the vaginal wall
Cervix tear
Tears may be a source of significant bleeding after birth
1st degree tear
involves the superficial vaginal mucosa or perineal skin
2nd degree tear
-involves the vaginal mucosa, perineal skin, and deeper tissues, which may include fascia and muscles of the perineum
- MOST COMMON
3rd degree tear
Same as second-degree lacerations but involves the anal sphincter
4th degree tear
Extends through the anal sphincter into the rectal mucosa
Additional system changes
- resumption of ovulation/ menstruation
- Lactation
- Urine output
- Coagulation> blood clots(DVT)
- Loss of hair
BUBBLEEE
-Breasts & nipples
- Uterus
- Bladder
- Bowel
-Lochia
- Episiotomy/ perineum/ epidural site
- Extremities
- Emotional Status
Breast and Nipples
-Delivery of placenta causes a surge in prolactin levels and stimulates milk production
- the condition of breasts
- comfort
- assessment of latch-on if breastfeeding
- good fitting bra
Uterus
- uterus/ fundal assessment
- height, midline, firm
- encourage patient to void before assessment
- Assess uterine pain and other comfort measures
- Uterus should be at the umbilicus after delivery and decrease about a centimeter everyday
Bladder
- ensure empty bladder
- look for infections
- increased diuresis
- look for signs of a distended bladder
- bladder discomfort/ bulge
- excessive lochia
- frequent voiding may be a sign of urinary retention and overflow
Bowel
- Potential constipation
- hemorrhoids
- dehydration
- laceration
- immobility
- fear of pain
Lochia
- volume of lochia flow according to the amount of flow on a perineal pad after 1-3 hours
- scant: <2-5cm
- light: 2.5-10cm
- Moderate: 10-15cm
- Heavy: saturated within 1 hr
Extremities
- Thrombophlebitis
- most likely lower extremities
- dependent edema
- prevent with early ambulation
Emotional State
- baby blues
- Attachment difficulties
Episiotomy/ perineum/ epidural site
- Perineum> inspect with the woman lying on her side
- assess and evaluate episiotomy/ laceration
- Assess anal area as well for hemorrhoids
- Check incision
- assess for healing, approximation, discharge, and swelling
- provide comfort measures
- teach proper care of incisions
comfort measures
- ice packs
- baths
- peri care
- topical medication
- sitting measures
- analgesics
- hot pack
- massage/ touch
- guided imagery
- relaxation
Postpartum Warning Sign
- fever > 100.4
- foul-smelling lochia or unexpected change in color
- large blood clots
- severe headaches, blurred vision
- calf pain> could be DVT
- swelling, redness, or discharge at sites
- depression and or mood swings
-shortness of breath
Cesarean Birth
- purpose: to preserve the well-being of the mother and the fetus
- can be planned/ scheduled
- same assessments for C-birth patients except some postoperative care
- percentage is higher in the US
Postpartum Psychological Adjustment: Bonding
- skin to skin> up for an hour after birth
- Fatigue/ feeling overwhelmed
- infant bonding
- first period of reactivity
Postpartum Psychological adjustment: Attachment
- process by which an enduring bond to a child is developing through pleasurable, satisfying parent-child interactions
- begins in pregnancy
- Signs of reciprocal attachment behavior> eye contract, tracking parent, grasp/ hold fingers, entrainment
- rooting/ latching
Becoming Acquainted
- maternal touch
- en face, fingertipping, enfolding
- verbal behaviors
- call infant by name, mothers speak in high pitches
Puerperal Phases
- taking- in phase
- taking-hold phase
- letting-go phase
Taking-in phase
- first couple days
- mother is focused on her own need for food and sleep
- passive dependent behaviors
- Making the birth a reality
Taking-hold phase
- Taking care of newborn
- become more independent and concerned for her self-care
- shifts attn to the newborn
- great timing for treaching
Letting-go phase
- New role phase
- relinquishes her previous roles
- adjusting to disappointments
- parents let go of ideals and fantasies
Factors that affect adaptation
- discomfort or pain
- chronic fatigue
- knowledge of infant needs
- expectations of newborns
- previous experience with newborns
- maternal temperment
postpartum blues
- mild depression
- affects 70-80% of new mothers
- begins in the first week postpartum
- should not last more than 2 weeks
- must be distinguished from post partum depression or psychosis
Initial newborn assessment
APGAR Score
A- Appearance(color)
P- Pulse(Heart Rate)
G- Grimace(irritability)
A- Activity(muscle tone)
R- Respiration
- 0,1,2 score
- closer to ten the better and less distress
When is APGAR Score assessed?
- 1 minute after birth and 5 minutes after birth
Why do nurses administer vitamin K
- newborns have no intestinal flora needed to produce vitamin K
- Helps with clotting
Prevention of eye infections
- prophylactic eye ointment erythromycin
- prevents ophthalmia neonatorum
- required by law in most states
Initiation of first feeding
- encourage the mother to breastfeed within the first hour of life, during first period of reactivity
- Bottle-fed babies may wait 4-5 hours before the first formula is given, during second period of reactivity
Facilitation of parent-infant attachment
- eye to eye contact during the first hour
- unlimited contact in first few hours
- skin to skin
- mother and father involved in first interaction
- do all cares in room
Behavioral patterns of newborns
- first period of reactivity
- period of decreased responsivness
- second period of reactivity
First period of reactivity
- birth/30 minutes to 2hrs after birth
- newborn is alert, moving, may appear hungry
period of decreased responsivness
- 30-120 minutes old
- period of sleep or decreased activity
second period of reactivity
- 2 to 8 hours
- newborn awakens and shows an interest in stimuli
Respiratory Adaptations for Newborns
- expansion of lungs, surfactant
- resp. are shallow and irregular
- 30-60 breaths/ minute
- periodic breathing
Routine Shift assessment
- check head/ fontanels
- Activity/ muscle tone
- voiding/ stooling
- bowel sounds
- color, temp, integrity of skin
- vitals
- genitalia/ extremities
- pain score
- hygiene
- length/ weight
Methods of heat loss in infants
- convections
- radiation
- evaportation
- conduction
Convection
loss of heat to the cooler air currents(fan)
Radiation
transfer of body heat to a cooler solid object nearby(cold window)
Evaporation
Loss of heat through conversion of a liquid to a vapor(bath)
Conduction
Loss of heat to a cooler surface by direct skin contact(unwarmed blanket)
Rooting Reflex
Infant opens mouth and turns head toward anything that touches its cheek
Moro Reflex
Startle reflex
Grasp Reflex
-any object placed in its hands will be grasped and then let go
Tonic Neck reflex
the infant assumes a fencing position, while on the back it rotates the head to one side and extends the arm and leg it faces
Walking reflex
tries to walk, step by step when held up right with legs hanging down
Babinski reflex
infant hyperextends and fans toes when foot is stroked
Plantar reflex
causes toes to curl inward and downward
Newborn screening after 24 hours
- bilirubin testing
- newborn metabolic screen
- hearing and screening
- CCHD screening-critical congenital heart disease
Metabolic screening
- Have to wait 24 hrs after birth
- identifies babies who may have certain inborn errors of metabolism
- drop of blood obtained from baby’s heel 24-48 hrs of life
- if diagnosed and treated early, development delays, sever illness, and death can be prevented
hearing screening
- # 1 birth defect
- 90% of deaf/impaired newborns are born to hearing parents
- early detection facilitates early treatment
- infants who fail screening need to be further check by doctor
CCHD Screening
- pulse/ ox symmetry
- R hand & 1 foot> fetal circulation
- normal range is 95% +/- 3%
- can decrease morbidity
Hep B vaccine
- received in the hospital soon after birth
- the first dose can also be given up to 2 months
- usually received before going home or at first dr visit
Hypoglycemia in the newborn
- Physiologic signs
- Behavioral signs
- Other signs
< or equal to 45
Physiologic signs of hypoglycemia in newborn
- jitteriness
- poor muscle tone
- sweating
- resp difficulty
- low temperature
- tachycardia
- tachypnea
Behavioral signs of hypoglycemia in newborn
-high-pitched cry
- lethargy
- irribility
- poor sucking
- grunting
Other signs of hypoglycemia in newborn
- Seizures
- Coma
- Cyanosis
- Apnea
- low temperature
Jaundice
- yellowing of skin
- occurs in 60% of babies
