Study Guide Test 3 Flashcards
At birth the stomach holds __ml/kg
6ml/kg
Peristalsis in newborns is _______
rapid - twice as fast
Initial feedings should be about ____ ml and then increase very slowly
20 - 25ml
What is the main defining factors between Physiologic Jaundice vs Nonphysiologic Jaundice?
Nonphysiologic (pathologic) jaundice may occur in the first 24 hours while physiologic Jaundice never occurs before 24 hours
Which jaundice is considered normal.
Physiologic jaundice, also called nonpathologic or developmental jaundice, is a transient hyperbilirubinemia (excess bilirubin in the blood) and is considered normal.
The most common cause of jaundice in breastfed infants is _____________.
Insufficient intake
What kind of bilirubin can move into the tissues and cross the blood-brain barrier.
unconjugated
Bilirubin needs to be _______ by the liver in order to be excreted
conjugated
Assess for jaundice by ….
- blanching the infant’s skin on the nose or sternum.
- Assessment should be done in natural light
- Assess for jaundice every 8 to 12 hours along with vital signs.
- Determine how far down the body the jaundice extends.
- obtain transcutaneous or serum bilirubin measurements in any jaundiced infant.
Instruct parents to contact their care provider if they see an increase in jaundice when they are at home or if the infant is not eating well, voiding at least __times daily by the __ day, and producing stools appropriately (at least one stool per day for formula-fed infants and at least four stools daily for breastfeeding infants).
- 6
- 4
Jaundice becomes visible when the bilirubin is greater than __mg/dL
5
How can elevated fatty acids in the blood from Metabolism of glucose in the presence of insufficient oxygen or the metabolism of brown fat increasing the risk of jaundice?
Elevated fatty acids in the blood can interfere with transport of bilirubin to the liver, increasing the risk of jaundice
What 4 things can lead to hemolysis of RBC’s thus increasing the risk of increased bilirubin (jaundice)
- Bruising
- Cephalhematoma
- Physiologic destruction of RBCs
- Pathologic destruction of RBCs
________ is a very rare type of brain damage that occurs in a newborn with severe jaundice
Kernicterus
Physiologic jaundice is caused by ________ _____________
transient hyperbilirubinemia (excess bilirubin in the blood)
Factors that increase risk for increased bilirubin?
- Excess production
- Red blood cell life
- Liver immaturity
- Intestinal factors
- Delayed feeding
- Trauma can result in increased hemolysis of
red blood cells. - Fatty acids are released when brown fat is used
Methods of heat loss
- Evaporation
- Conduction
- Convection -
- Radiation
_________ is air-drying of the skin that results in cooling.
Evaporation
How does CONDUCTION work in heat loss
Movement of heat away from the body occurs when newborns have direct contact with objects that are cooler than their skin.
What occurs in convection?
Transfer of heat from the infant to cooler surrounding air
- NO DRAFTS
__________ is the transfer of heat to cooler objects that are not in direct contact with the infant.
Radiation
Thermoneutral zone in healthy, unclothed, full-term newborns, an environmental temperature of ______________ provides a thermoneutral zone. When the infant is dressed, the thermoneutral range is ___________
- 89.6° to 92.3°F
- 75.2° to 80.6°F
Manifestations of hyperthermia?
- metabolic rate rises, causing an increased need for oxygen and glucose and possible metabolic acidosis.
- peripheral vasodilation leads to increased insensible fluid losses.
- Tachypnea
What is Non shivering thermogenesis?
Metabolism of brown fat to produce heat
What are the hazards of cold stress?
- Increased oxygen need
- Decreased surfactant production
- Respiratory distress
- Hypoglycemia
- Metabolic acidosis
- Jaundice
What can be the result of Metabolism of brown fat ?
- Releases fatty acids which can result in metabolic acidosis
- Elevated fatty acids in the blood can interfere with transport of bilirubin to the liver, increasing the risk of jaundice
How should an infant be dressed to maintain proper thermoregulation
Dressed in an outfit with one more layer
How do thermal factors support respiration of a newborn at birth?
The temperature change that occurs with birth also stimulates the initiation of respirations.
How do the sensory factors help stimulate the first breaths ?
The stimulation of the light, sound, smell, and pain at delivery may also aid in initiating respirations
What role do Chemical factors play in initial respiration’s of a newborn?
Chemoreceptors in the carotid arteries and the aorta respond to changes in blood chemistry caused by the hypoxia that occurs with normal birth.
- A decrease in the oxygen and pH and an increase in carbon dioxide (Pco2) in the blood cause impulses from these receptors to stimulate the respiratory center in the medulla.
What are the 3 shunts in the fetal cardiovascular system and what do they do?
- Ductus Venosus- Directs blood away from liver to inferior vena cava
- Foramen Ovale - a flap valve in the septum between the right and left atria of the fetal heart. As blood flows into the right atrium, 50% to 60% crosses the foramen ovale to the left atrium
- Ductus Arteriosus - Connects the pulmonary artery and the descending aorta
What changes in blood flow occurs after the umbilical cord is clamped and the newborn takes its first breath?
- increase blood flow to the liver and lungs
- Decrease blood flow through the shunts
Clamping of the umbilical cord closes which shunt?
- Ductus Venosus
When does the foramen ovale’s flap valve close?
- when the pressure in the left atrium is higher than that in the right atrium.
Heat is produced in newborns by increased activity, flexion, and metabolism, vasoconstriction, and nonshivering thermogenesis. These factors increase _______ and ________ consumption and may cause respiratory distress, hypoglycemia, acidosis, and jaundice.
- Oxygen
- Glucose
Newborns receive passive immunity when _____ crosses the placenta in utero. After birth, IgM and IgA are produced to protect against infection.
IgG
What immunoglobulin is present in colostrum and breast milk?
IgA
What 6 behavioral states do Newborns progress through
- quiet sleep
- active sleep
- drowsy
- quiet alert
- active alert
- crying.
During what behavioral state is it a good time to increase bonding and continue to work on breast feeding?
Quiet Alert State
When does the first period of reactivity occur and how long does it last?
- Right after birth for about 30 min but can last for 2 hrs
During what period of reactivity should the mother begin breast feeding?
1st period of reactivity
Observing for signs of hypoglycemia is necessary throughout routine assessment and care. Early signs include
- jitteriness and other central nervous system signs
- signs of respiratory difficulty
- decrease in temperature
- poor feeding
Signs of neonatal hypoglycemia (more extensive list)
• Jitteriness, tremors • Poor muscle tone • Diaphoresis (sweating) • Poor suck • Tachypnea • Tachycardia • Dyspnea • Grunting • Cyanosis • Apnea • Low temperature • High-pitched cry • Irritability • Lethargy • Seizures - coma
RISK FACTORS FOR NEONATAL HYPOGLYCEMIA
- Prematurity
- Postmaturity
- Late preterm infant
- Intrauterine growth restriction
- Large or small for gestational age
- Asphyxia
- Problems at birth
- Cold stress
- Maternal diabetes
- Maternal intake of terbutaline
what are the hormonal changes at birth in relation to breast milk production?
- prolactin is secreted after the delivery of the placenta and it activates milk production
- oxytocin increases in response to nipple stimulation
What 3 hormones inhibit breast response to prolactin during pregnancy milk production in a pregnant woman?
- Estrogen
- Progesterone
- hCS
When is prolactin secreted at the highest levels with suckling?
During the night
_______ increases in response to nipple stimulation and causes the milk ejection reflex or let-down reflex
Oxytoncin
How to care for a circumcision?
- Observe the circumcision site at each diaper change, and check the amount of bleeding. Call the physician if more than a few drops of blood are present with diaper changes on the first day or any bleeding thereafter.
- Continue to apply petroleum jelly to the penis with each diaper change for the first 4 to 7 days or as directed by your pediatrician.
- If a PlastiBell ring was used, do not use petroleum jelly because it might make the ring fall off too soon.
- Keeping the circumcision site clean is important for healing. Squeeze warm water from a clean washcloth over the penis to wash it. Pat gently to dry the area.
- Fasten the diaper loosely to prevent rubbing or pressure on the incision site.
- Expect a yellow crust or scab to form over the circumcision site. This is a normal part of healing and should not be removed.
- The scab will fall off within 7 to 10 days. If a PlastiBell ring was used, the plastic rim will fall off in 10 to 14 days (AAP, 2011). If it does not fall off by that time or falls off sooner, notify your physician.
- Watch for signs of infection such as fever or drainage that smells bad or has pus in it. Call your physician if you suspect any abnormalities. The circumcision site should be fully healed in approximately 10 days.
After a circumcision an infant should be observed for at least ___ hrs before being released
2
Nursing interventions for an infant with excessive bleeding post circumcision? And what would she anticipate the physician to do?
- Apply pressure
- NOTIFY PHYSICIAN
- Apply Gelfoam, epinephrine or may suture the small blood vessel
If the infant goes home before voiding, after being circumcised, the mother is instructed to call the physician if the baby does not urinate within __ to __hours.
6 - 8
Signs of complications of circumcision include the following:
- Bleeding more than a few drops with first diaper changes
- Failure to urinate
- Signs of infection: fever or low temperature, purulent or foul-smelling drainage
- Displacement of the PlastiBell ring
During the APGAR test, The nurse scores the infant at __ minute and __minutes in each of five areas.
- 1
- 5
Blood sugars are monitored for babies below the ___ percentile and above the ___ percentile.
- 10th
- 90th
During APGAR scoring, the infant is assigned a score of ___ to ___ in each of the five areas, and the scores are totaled.
0
2
What are the 5 areas of assessed during an APGAR SCORE?
- Heart Rate
- Respiratory effort
- Muscle tone
- Reflex response
- Color
What do you do for APGAR score of 0 - 2
Infant needs resuscitation
APGAR scores from ___ to ___ don’t require any interventions
7 - 10
What do you do for APGAR score of 3 - 6
- Gently stimulate by rubbing infant’s back while administering oxygen.
- Determine whether mother received narcotics, which may have depressed infant’s respirations.
- Have naloxone (Narcan) available for administration.
What blood tests are done to screen for metabolic, hematologic, or genetic disorders ?
When are the tests performed?
- phenylketonuria
- hypothyroidism
- galactosemia
- hemoglobinopathies
- congenital adrenal hyperplasia
24 to 48hrs
<p>When should the hearing test be performed?</p>
within the first month
<p>How do pain and anxiety affect a woman's already high metabolic rate.</p>
Increase
Excessive pain can heighten a woman’s fear and anxiety, which stimulates an increased secretion of
Catecholamines
Maternal catecholamines secreted in response to anxiety and fear can inhibit ________ &________________
- Reduced blood flow to and from the placenta,
* Reduced effectiveness of uterine contractions, slowing labor progress
What is dystocia of labor
difficult or prolonged labor
Physiologic effects of excessive pain?
- Fear & anxiety
- Increased maternal metabolic and respiratory rate
What is a major risk for an amniotomy? What are other risks?
MAJOR = prolapsed cord
- Infection
- Abruptio placenta
What type of aftercare is provided after an amniotomy?
<p>-FHR is assessed for at least one full minute
- quantity, color and odor of amniotic fluid are charted
- the woman's temp should be assess at least every 2-4 hours after the membranes rupture
- provide comfort</p>
what are some indications for an amniotomy?
<p>- induce labor
- augment labor
- allow internal fetal monitoring</p>
Induction and Augmentation of labor contraindications
- Placenta previa
- Vasa previa
- Umbilical cord prolapse
- Abnormal fetal presentation
- Fetal presenting part above the pelvic inlet
- Previous surgery in the upper uterus
<p>Induction and Augmentation of Labor: Risks</p>
- Hypertonic uterine activity
- Uterine rupture
- Maternal water intoxication
- Greater risk for chorioamnionitis
- Greater risk for cesarean birth
Advantages of Nonpharmacologic Pain Management:
- Non systemic
- Doesn’t affect fetus
- Doesn’t affect labor
- Does not slow labor
- No side effects or risk of allergy
- Some pharmacologic methods may not eliminate labor pain.
- May be the only realistic option in advanced, rapid labor
Disadvantages of pharmacological Interventions
- Side affects - itching, vomiting, pruritus, drowsiness, and neonatal depression
- Can slow labor
- Pain is not eliminated completely
- The fetus can be affected by medication
What are Common Breastfeeding Concerns: Infant Problems
- Sleepy
- Nipple confusion
- Suckling problems
- Infant complications
- Jaundice
- Prematurity
- Illness and congenital defects
Common Breastfeeding Concerns: Maternal Concerns
- Breast problems
- Illness in mother
- Medications
- Breast surgery
- Employment
- Milk expression
- Storing milk
- Multiple births
- Weaning
- Home care
How can the nurse help the mother who is breastfeeding and has engorged breasts?
Instruct and assist the mother to massage her breasts
- Massage of the breasts causes release of oxytocin and increases the speed of milk release
lactogenesis is defined as:
the composition of breast milk that changes in three phases
Lactogenesis ____ begins during pregnancy and continues after birth with the secretion of colostrum.
lactogenesis I
Lactogenesis ___ begins 2 to 3 days after birth when transitional milk appears.
lactogenesis II
Lactogenesis ___ is the time when mature milk replaces transitional milk.
Lactogenesis III
_____, also called “distraction method”, is a stimulation of large-diameter fibers in the skin that blocks conduction of pain through small-diameter fibers, thereby “closing the gate” and decreasing the amount of pain felt.
gate control theory
what are some examples of how nurses use gate control theory?
- massage
- thermal stimulation
- hydrotherapy
Name risk prevention tips to prevent SIDS
- always place baby on back for sleep
- infants sleep surface should be firm
- do not put any loose bedding, pillows, or toys in the baby bed.
- do not let the infant get overheated
- do not smoke during or after birth
- of possible breastfeed baby
name the period of reactivity in an infant:
- first period of reactivity
- period of sleep or decreased activity
- second period of reactivity
this type of reactivity begins at birth and lasts for 30 mins. their temp decreases, and respirations may be as high as 80.
first period of reactivity
after the first period of reactivity, infants become quieter or fall into a deep sleep during ____.
period of sleep or decreased activity
this period of reactivity lasts 4-6 hours, and it is the infants high alert period. infants become interested in feeding and may pass meconium.
second period of reactivity
Sedatives are given to …
- promote sedation and relaxation
Benefits of Sedatives
- promote sedation and relaxation
- Decrease release of catecholamines
Adverse effects of Epidural block
- Maternal hypotension
- Bladder distention
- Catheter migration
- Cesarean Birth
If you have a mom with a history of drug addiction, she is on heroin or she is on a drug treatment program such as methadone, what drugs should be avoided?
Stadol
Nubain
Disdvantages of pharmacological Interventions
- Side affects - itching, vomiting, pruritus, drowsiness, and neonatal depression
- Pain is not eliminated completely
- The fetus can be effected by medications
What is local anesthesia used for ?
- Anesthetizes the lower vagina and part of the perineum
- Provides anesthesia for an episiotomy and vaginal birth
- Mother feels pressure.
A spinal anesthesia is typically given for a ___________ birth
Cesarean
this type of opioid analgesics proved another option for pain management without sedation, the drug is injected into the subarachnoid space
intrathecal opioid analgesia
Pudendal Anesthesia
Provides pain relief for episiotomy and delivery
this type of medication is used in management of pregnancy-induced hypertension to prevent seizures
magnesium sulfate
____ is a calcium channel blocker that is usually give for problems such as hypertension.
nifedipine
Oxytocin Administration:
- dilute in isotonic solution
- secondary (piggyback) infusion
- insert oxytocin into the primary IV line
- start slowly, increase gradually
- monitor uterine activity, FHR, and fetal heart patterns frequently
What are techniques to induction and augmentation of labor?
- cervical ripening
- oxytocin administration
- serial induction of labor
What are some medical methods to cervical ripening?
- prostaglandin
- cervidal
- cytotec
because the major adverse effect of prostaglandins is ____________, the drug is administered in a setting in which fetal monitoring and emergency care, including section, are immediately available.
hyper stimulation of uterine contractions
How often do you monitor vital signs after an epidural is placed?
Every 3 Min
Because the medication given during an epidural/spinal causes vasodilation, a nurse must watch for
Hypotension
Medicine used to counteract hypotension
Ephedrine
A person with a spinal headache severe head pain in what position?
- Sitting up
Intervention for a spinal headache includes the use of __________ & Tylenol first and then a _______
- Alot Caffeine
- blood patch
What are the two types of versions?
- external
- internal
Contraindications for performing a Version
- Uterine malformations
- Previous cesarean
- Fetal size ≥4000 g
- Cephalopelvic disproportion
- Multifetal gestation
- Oligohydramnios
The goal of __ is to change the fetal position from a breech, shoulder (traverse lie), or oblique presentation
external cephalic version
___ change the position of a second twin a vaginal birth
internal version
nursing considerations for a women who is having an external version
- provide information (explains risks, informed consent)
- promote maternal and fetal health (NPO for 4 hours incase of section)
- reduce anxiety
what are some indications for an operative vaginal birth?
- shortened second stage of labor
- maternal indications (exhaustion, inability to push effectively, and cardiac and pulmonary disease)
- fetal indications (nonreassuring FHR)
Risks to operative vaginal birth:
- trauma to maternal and fetal tissues
- hematoma of the vagina
- fetus may have bruising, facial nerve injury, clavicular fractures, cephlahematoma
Technique to operative vaginal birth:
- preparation of woman (empty bladder, cervix completely dilated and membranes ruptured, adequate anesthesia)
- classification of techniques (outlet: fetal head on perineum, Low: leading edge of fetal skull at station +2, mid: leading edge of fetal skull between 0 and +2)
- forceps: locking blades applied to fetal head
- vacuum extraction: cup attached to fetal head and traction applied
what does the nurse during and after an operative vaginal birth?
- observe mother for trauma (bright red bleeding with firm fundus)
- observe neonate for trauma after birth (facial asymmetry)
What are some indications for an episiotomy?
- shoulder dystocia
- vacuum or forceps-assisted births
- face presentation
- preterm fetus
Risks for an episiotomy?
- infection
- perineal pain
What does the nurse do during and after an episiotomy?
- promote gradual stretching of perineum during second stage (perineum massage)
- delay pushing until the urge is felt
- push with an open glottis
- observe for hematoma and edema
What are the indications for a cesarean birth?
- dystocia
- cephalopelvic disproportion
- HTN
- maternal diseases
- active genital herpes
- fetal distress
- umbilical cord prolapse
- some previous uterine surgical procedures
- persistent non reassuring FHR pattersn
- prolapsed umbilical cord
- fetal malpresentations
- hemorrhagic conditions
What are contraindications to a C-section?
- fetal death
- immature fetus
- maternal coagulation defects
name maternal risks associated with a C-section?
- infection
- hemorrhage
- urinary tract infection or trauma
- thrombophlebits
- paralytic ileus
- atelectasis
- anesthesia complications
name fetal risk associated with a C-section?
- lung immaturity
- inadvertent preterm birth
- transient tachypnea
- persistent pulmonary HTN of the newborn
- traumatic injury
What is done in preparation for a c-section?
- anesthesia
- medication
- lab studies
- prophylactic antibiotics
- skin prep
- foley catheter
- IV insertion
- trim pubic hair
Nursing considerations for a c-section?
- provide emotional support
- teach
- promote safety
- provide post-op care (vitals, fundal checks, care of incision, monitor i/o, assessment of bowel sounds)
Name the type of incisions used for a c-section?
- low transverse (can have VBAC)
- low vertical
- classical (not likely to have VBAC)
When is the best time to give systemic pain meds for labor?
AFTER labor pattern well established to avoid slowing down labor
Contraindications for giving systemic pain meds during labor
- If patient taking certain herbals
- Allergies
- No Stadol given with opioids!
- Can’t give if the baby is having decreased accels or decreased variability
4 Types of Systemic Drugs
- Parenteral (IV) - demerol (not really used much); stadol and fentanyl (early labor); nalbuphine
- Adjunctive - zofran (nausea), Visteril (anxiety and also to potentiate stadol/fentanyl), Phenergan (anxiety or sleep or extreme early labor where contrax not tolerated)
- Sedatives
- Opioid antagonist - naloxone
Types of cord prolapse
- Complete - cord thru vagina and out vag canal
- Occult - can’t be felt with vag exam. Decels and decreased variability are signs
- Forelying - can’t see but can feel. FHR decel, no variability
What to do if cord prolapse
- Call for help
- Hold baby up off the cord all the way to OR
- Mom in knees to chest position once the baby is up off the cord
Causes of cord prolapse
PROM, polyhydramnios, LGA baby not well engaged when membranes rupture, ruptured membranes, shoulder or foot presentations
Signs of cord prolapse
Sustained bradycardia even with position changes; decreased variability; decreased FHR
Nurses Role for Amniotomy
Get baseline fetal HR! Pad mom with towels Hand hook to doc Note color, odor, amt of fluid Monitor fetal HR AFTER Procedure! Check vitals for infection Advise doc if nearing 24 hour post AROM Promote comfort and cleanliness
Nurses Role for Augmentation/Induction
Help assess ultrasound for amniotic fluid and cord
Prep IV
NPO
Draw labs in case of csection
Nurses Role in C-section
Prep mom: IV, NPO, scrubbed and shaved; consents signed; aware of risks
Do post-op vitals
Do bleeding and pain mgmt assessments
What is dystocia
difficult labor or birth- can be from any of the 4 Ps or from multiple Ps
4 Ps
- Power - not strong enough contrax- could be from fatigue, meds, overdistended uterus, hypotonic or hypertonic contrax. Use Freedman curve - tells how quickly labor should progress. If she falls off curve, it’s dystocia
- Passage - shape of pelvis or tissue of repro tract
Cephalopelvic disproportion, overly obese with panus, non-gynecoid pelvis - Passenger - LGA or large head, breech, not fully flexed, fetal anomalies, multifetal
- Psyche- fear and anxiety cause release of catecholamines and ineffective perfusion to fetus. Non relaxed mom inhibits contrax. Bad cycle.
What are causes of overdistention of uterus?
polyhydramnios twins grand multiparity post mature infants LGA +gestational diabetes
What are hypotonic contrax?
too weak and infrequent
What are hypertonic contrax?
So frequent that they become ineffective
Important newborn meds
Vitamin K
Erythromycin
Hep B vaccine
Details about vitamin K for newborn
Jumpstarts clotting case and prevents hemorrhagic disease
Given IM vastus lateralis within an hour of birth (oral ok but not as effective)
Details about erythromycin for newborn
Prophylactic opthmalic ointment given to prevent opthmalia neonatorum (not really for gonorrhea like people think)
Details about Hep B for newborns
Optional unless mom has Hep B, then we definitely give!
If mom has Hep B, we give the vaccine plus Hep B immune globulin within 12 hrs of birth
Amniotomy Indications
induction or augmentation of labor
To allow for internal monitoring
Amniotomy Risks
cord prolapse
infection
abruption if polyhydramnios present
Induction/Augmentation Indications
hostile intrauterine environment, SROM, post term, chorioamnionitis, HTN, abruption, worsening mom medical condition, fetal death.
Induction/Augmentation Contraindications
previa, prolapse, abnormal fetal presentation, prior upper uterine surgery, fetal presenting part above the pelvic inlet
Induction/Augmentation Risks
hypertonic uterine activity, rupture, maternal water intox, risk for csection, risk for chorioamnionitis.
Indications for Version
- to change fetal position to cephalic (external)
- to change position of second twin during vag birth (internal).
Risks with a Version
There are only a few.
cord entanglement, abruption, mixing of maternal and fetal blood
Contraindications to Version
ruptured membranes, nuchal cord, uteroplacental insufficiency, previa, fetal head engagement
Indications for Operative Vaginal Birth
short second stage of labor, maternal or fetal indications
Risks with Operative Vaginal Birth
trauma to tissues.
Contraindications of Operative Vaginal Birth
severe fetal compromise, high fetal station, cephalopelvic disproportion
Risks for Cesarean birth
Risks for mom: infxn, hemor, UTI, thromboemb, paralytic ileus, atelectasis, anesthesia complic.
Risks to baby: lung immaturity, inadvertent preterm birth, transient tachypnea, persistent pulmonary HTN, traumatic injury.
Contraindications to cesarean
fetal death, immature fetus, maternal coag defect
Indications for Cesarean
dystocia, cephalopelvic dispro, HTN, maternal disease, active herpes, some previous uterine surg, persistent non-reassuring FHR pattersn, fetal malpresentation, prolapse, hemorrhagic condition.
Indications for episiotomy
shoulder dystocia, vacuum or forceps birth, face presentation, preterm
Risks with episiotomy
infection, perineal pain
