Test 2 Flashcards
1
Q
what is the gate control theory
A
gate theory of pain asserts that non-painful input closes the “gates” to painful input, which prevents pain sensation from traveling to the CNS
2
Q
why do we prefer epidural anesthesia as opposed to general
A
general passes through to the baby, epidural does not
3
Q
what are the side effects of epidural anesthesia
A
maternal hypotension
fetal bradycardia
inability to feel the urge to void
loss of bearing down reflex
itching
cerebral spinal headache(biggest risk)
4
Q
what is the cause of a cerebral spinal headache
A
epidural fluid leaks into the back of your skull
5
Q
what are nursing interventions with epidural anesthesia
A
give iv fluids
encourage side lying
coach pt in pushing
monitor maternal bp & pulse
assess fetal hr
assess for orthostatic hypotension
assess bladder for distention; catheterize as needed
6
Q
benefits of nitric oxide
A
low intervention
no need for iv access or catheter
no need for continuous monitoring
continued ability to move
self administered medication
7
Q
what is included in the maternal assessment during labor and birth
A
vaginal exam to assess the amount of
-cervical dilation & effacement
-fetal descent and presenting part
-rupture of membranes
-amniotic fluid
-analysis of fetal hr
8
Q
what is stage one in labor
A
begins with onset of labor and ends when the cervix is 100% effaced and completely dilated to 10 cm
the average length for a first time mother is 10-14 hours
9
Q
what is stage 2 of labor
A
pushing stage
begins with complete effacement and dilation of the cervix and ends with delivery of baby
average length for first time mothers is 1-2 hours
10
Q
what is stage 3 of labor
A
begins with birth of baby and ends with delivery of placenta
average length is 5-15 minutes
11
Q
what are the three phases of stage 1 of labor
A
latent
active
transition
12
Q
what is the latent phase in first stage of labor
A
0-6 cm dilation
cervical effacement of 0-40%
contraction frequency every 5-10 min
13
Q
what is the active phase of stage 1 of labor
A
6-10cm dilation
cervical effacement of 40-100%
contractions stronger every 40-60 seconds and every 2-5 minutes
true discomfort
contraction intensity moderate to strong to palpation
14
Q
what happens in the third stage of labor
A
delivery of placenta
gush of blood
lengthening of the cord
uterus is globular and firm
check to be sure it is intact
should happen within 30 min of delivery
15
Q
why do we not want a contraction over 90 seconds
A
no relaxation for the baby
16
Q
what is crowning
A
when the head is in the perineum but not being retracted back in
17
Q
the fetal heart rate pattern is an indirect marker of what
A
fetal cardiac and central nervous system responses to change in bp, blood gases, and acid-base status
18
Q
when is the largest complication for the mother and what is it
A
during the 3rd stage of labor and due to postpartum hemorrhage
19
Q
in the fourth stage of labor the uterus should be
A
firm well contracted and located between umbilicus and pubic symphysis
20
Q
why is acid base status is important
A
they need to correct balance in order to start breathing out of the womb
21
Q
what is electronic fetal monitoring
A
used to establish a baseline of fetal hr
(most clearly heard through fetal back)
22
Q
what must happen for internal fetal monitoring to occur
A
the membranes must be ruptured
23
Q
what is IUPC
A
intrauterine pressure catheter placed inside the uterine cavity to monitor frequency, duration and intensity of contractions
24
Q
what is a normal fetal heart rate
A
110-160 bpm
25
what does veal chop stand for
Variable Cord compression
Early deceleration Head compression
Acceleration Okay
Late deceleration
Placental insufficiency
26
what is absent or undetectable variability
not reassuring
27
what is minimal variability
greater than undetectable but less than 5/min
28
what is moderate variability
6-25 /min
29
what is marked variability
greater than 25/ min
30
what is variability
increases and decreases from baseline fetal heart rate
31
what is a variable deceleration
abrupt slowing of 15 or more BPM for at least 15 seconds, has an unpredictable shape (u, v, w), associated with cord compression
32
nursing actions for variable decelerations
change moms position(knee to chest), may give O2, stop pitocin, increase fluids
33
what actions are taken for early deceleration
no action required as long as it turns back to base line
34
NADIR means
the lowest point that the fetal heart rate reaches
35
when do late decelerations of fetal heart rate occur
after the peak of the contraction
36
what can cause late decelerations of fetal heart rate
abruption, previa, gestational diabetes
37
what is involved in category I of the FHR interpretation system
Normal
baseline fhr 110-160
baseline fhr variability:moderate
accelerations: present or absent
early decelerations: present or absent
variable or late decelerations: absent
38
what are the signs that the body is preparing for labor
effacement&dilation
lightening (when presenting part begins to descend into the true pelvis)
increased energy level(nesting)
bloody show
braxton hicks contractions
spontaneous rupture of membranes
39
what is the bishop score used to determine
maternal readiness for labor by evaluating whether the cervix is favorable
( dilation, effacement, consistency, position, station of presenting part)
40
what does a bishop score of 0 entail
dilation(cm)-closed
position- posterior
effacement (%)- 0-30%
station- -3
consistency- firm
41
what does a bishop score of 1 entail
dilation(cm)- 1-2
position- mid position
effacement (%)- 40-50%
station- -2
consistency- medium
42
what does a bishop score of 2 entail
dilation (cm)- 3-4
position- anterior
effacement (%)- 60-70%
station- -1- 0
consistency- soft
43
what does a bishop score of 3 entail
dilation(cm)- 5-6
position------
effacement (%)- 80%
station- +1, +2
consistency-----------
44
what is nitrazine paper
used to check the pH of the fluid to determine if the fluid is amniotic fluid or urine after rupture of membranes (the paper will turn very dark blue when amniotic membranes are ruptured)
45
what is the vaginas pH vs the amniotic fluid pH
vagina- 4.5-5.5 (turns paper yellow)
Amniotic fluid- 7-7.5 (turns paper blue)
46
what are 3 characteristics of amniotic fluid
should be clear or straw colored
odor should NOT be foul
meconium staining could indicate some level of fetal distress
47
what do we assess with an apgar score
heart rate
respiratory effort
muscle tone
reflex irritability
color
48
what does an apgar score of 0 in each category mean
heart rate- absent
respiratory effort- no spontaneous respirations
muscle tone- limp
reflex irritability- no response to stimulation or suction
color- blue or pale
49
what does an apgar score of 1 in each category mean
heart rate- below 100
respiratory effort- slow; weak cry
muscle tone- minimal flexion; sluggish
reflex irritability- grimace or minimal response
color- body pink; extremeties blue
50
what does an apgar score of 2 in each category mean
heart rate- 100 beats or greater
respiratory effort- spontaneous strong cry
muscle tone- active flexed posture
reflex irritability - prompt response
color- completely pink; lack of cyanosis
51
at what times do you take an apgar
1 min & 5 min; may take at 10 mins if babys previous scores were very low
52
what vitals of the neonate should the nurse report
temp greater than 100.4
apical pulse less than 110 or greater than 160 bpm
respirations greater than 60 or less than 30
noisy respirations
nasal flaring or chest retractions
grunting
blood glucose less than 40
53
what do we assess with the babies head
feel for separation of fontanels
feels for bumps
presence of caputs
54
what is a caput succedaneum
localized swelling of the soft tissue of the scalp that may be caused by pressure on the head during labor and is an expected finding
55
what is a cephalohematoma
a collection of blood between the periosteum and the skull bone that covers it; does NOT cross the suture line, usually resolves spontaneously in 3-6 weeks
56
what do we assess with the baby's face
eyes- inspect eye structures
ears- draw an imaginary line from inner to outer canthus of newborns eye; the eye should be even with the upper tip of the pinna
nose- newborns are nose breathers
mouth- assess for palate closure and strength of sucking
57
What are the 5 P's of the birthing process?
Passageway (birth canal)
Passenger (fetus and
placenta)
Powers (contractions)
Position (maternal)
Psychological response
58
When is the fetal head "engaged"
When it reaches "0" station
59
How to calculate fetal stations
-Station is the measurement of fetal
descent (in cm) with station 0 being level
with the ischial spines.
-Minus number is given if above the spines
-Plus number is given if below the spines
60
Types of different fetal head presentaions
-cephalic
-face
-vertex
-brow
61
Types of fetal breech presentation
-Frank (butt first)
-complete breech
-footling breech (foot first)
62
what is fetal lie?
The relationship of
the maternal
longitudinal axis
(spine)to the fetal
longitudinal
access(spine)
-transverse lie and longitudinal lie are the two types
63
Uterine contractions: Frequency
beginning of one contraction to the beginning of the next contraction (in minutes)
64
Uterine contractions: Duration
Beginning to end of one contraction (in minutes)
65
Uterine contractions: Strength/Intensity
strength of the contraction at its peak described as mild, moderate or strong
66
Placenta Previa
Placenta previa occurs when the placenta abnormally implants in the
lower segment of the uterus near or over the cervical os.
Abnormal implantation results in bleeding in the 3rd trimester as the cervix begins to dilate and efface
67
Placental Abruption
-Normal implantation of the placenta
-Premature separation of the placenta from the uterus which can be partial or complete detachment
-Significant maternal and fetal morbidity and mortality
-Leading cause of maternal death
68
Ectopic pregnancy: subjective data
•Unilateral pain in the lower abdominal quadrants
•+/- bleeding
•Referred shoulder pain if rupture with peritoneal cavity irritation
•Faintness, dizziness from blood loss
69
Ectopic pregnancy: objective data
•Signs of hemorrhage and shock
•Ruptured ectopic pregnancy would be a medical emergency
70
What is an ectopic pregnancy?
Ectopic is abnormal implantation of fertilized ovum (zygote) outside
the uterine cavity, usually the fallopian tube
71
Treatment of an ectopic pregnancy?
1. No action
2. Treatment with methotrexate IM to inhibit cell division (stop folic acid)
3. Surgery to remove pregnancy from the tube
• Salpingostomy by laparoscope to save tube
• Salpingectomy by laparoscope with removal of the tube
72
Methods of heat loss
EVAPORATION – heat loss through wet skin
CONVECTION – heat loss from cooler air when exposed
CONDUCTION – heat loss through direct through direct
contact with a cold surface (e.g. scales, un-warmed
mattress)
RADIATION – heat loss from heat moving towards a cooler surface
73
Nonshivering thermogenesis
NEWBORN’S PRIMARY METHOD OF HEAT PRODUCTION!
Brown fat is oxidized in response to cold exposure
74
Characteristics that predispose newborns to heat loss (thermoregulation)
• Thin skin with blood vessels close to the surface
• Increased skin permeability to water
• Lack of shivering ability to produce heat until 3 months old
• Limited stores of metabolic substrates (glucose, glycogen, fat)
• Limited use of voluntary muscle activity or movement to produce heat
• Large surface area-to-body mass ratio
• Lack of subcutaneous fat, which provides insulation
• Inability to change position , adjust clothing, or communicate if cold
75
what is lochia?
Vaginal discharge that occurs after birth and may continue 4-6 weeks postpartum
76
Different types of lochia?
• Rubra -Bright red, lasts 3-5 days.
• Serosa- Pinkish/brown and lasts 3-10 days.
• Alba- Creamy white or light brown, occurs from 10-14 days, but can last 10-14 days but is still normal if it lasts 3-6 weeks.
77
Phases of maternal role attainment: Dependent (taking in phase)
•First 24 to 48 hours
•Focus on meeting personal needs
•Rely on others for assistance
•Excited, talkative and need to review birth experience with
others.
•May not have slept well in hospital
78
Phases of maternal role attainment: Interdependent (letting go phase)
• Focus on family as a unit
• Resumption of role (intimate partner, individual)
79
Phases of maternal role attainment: dependent/independent (taking hold phase)
-begins day 2-3
-Focus on baby
care and improving
competency of baby care
-Wants to take
charge but needs
acceptance of
others
-Wants to learn and practice
80
Postpartum hemmorhage meds
Oxytocin(Pitocin)
• Promotes uterine contractions(dose specific)
Methergine(ergot alkaloid)
• Controls postpartum hemorrhage
• *Monitor BP- can cause hypertension
Misoprostol (Cytotec) synthetic prostaglandin E2
• Controls postpartum hemorrhage (dose specific)
81
what do we assess postpartum in the first 2 hours
vitals q15 min & PRN
fundus tone & position
lochia
perineum
hemorrhoids q 15 min
bladder; encourage voiding
listen to lungs & bowels
assess sensation of anesthesia
82
what do we assess the epidural site for
redness & draining
83
what does it mean if the uterus is boggy
it is not contracted; could mean bleeding
84
what can we expect postpartum in relation to the cardiovascular system
decrease in blood volume
diaphoresis and diuresis during first 2-3 days
coagulation factors and fibrinogen levels increase during pregnancy and remain elevated 2-3 weeks postpartum
bp unchanged
increase in temp during first 24 hours from dehydration
85
what warrants further investigation postpartum, bradycardia or tachycardia
tachycardia; bradycardia is ok
86
where should the fundus be immediately after delivery
at the midline of the umbilicus
87
how often do we assess the fundus postpartum
q8h during the recovery after childbirth while in the hospital
88
what do we always ask patients to do before a uterine assessment
empty her bladder
89
what are the risk factors for postpartum hemorrhage
uterine atony
previa or abruption during pregnancy
precipitous delivery (less than 3 hours of labor)
lacerations and/or hematomas
retained placental fragments
prolonged labor
90
what are the risk factors for retained placenta
excessive traction on the umbilical cord
placental tissue abnormally adherent to the uterine wall
91
what are physical findings of retained placenta
uterine atony
excessive bleeding
return to lochia rubra after progressing to alba
foul odor
elevated temp
clots bigger than an egg
92
what are the risk factors for postpartum lacerations and/or hematomas
operative birth(vacuum or forceps)
precipitous birth
cephalopelvic disproportion (CPD)
macrosomic infant
woman who have light skin;especially red heads
93
what are symptoms of postpartum blues
irritability, anxiety, fluctuating mood, and increased emotional reactivity
94
what are symptoms of postpartum depression
excessive guilt, anxiety, anhedonia, depressed mood, insomnia/hypersomnia, suicidal ideation, & fatigue
95
what are the symptoms of postpartum psychosis
mixed or rapid cycling, agitation, delusions, hallucinations, disorganized behavior, cognitive impairment, and low insight
96
when teaching a patient when to call their provider postpartum what would you include
fever greater than 100.4
changes in vaginal discharge with increased amount, large clots, or foul odor
episiotomy site increased pain
abdominal or pelvic pain
breast pain, tenderness, or redness
calf pain
burning with urination
97
what are some postpartum disorders
hemorrhage
DVT
infection
retained placenta
lacerations/hematomas
98
what is considered early term
between 37 weeks 0 days and 38 weeks 6 days
99
what is considered full term
between 39 weeks 0 days and 40 weeks 6 days
100
what is considered late term
between 41 weeks 0 days and 41 weeks 6 days
101
what is considered post term
42 weeks and beyond
101
what is considered post term
42 weeks and beyond
102
when are newborns most alert
1st period of reactivity- begins at birth and lasts 30 minutes to 2 hours
103
when is a good time to first breastfeed
within the 1st period of reactivity when the baby is super alert
104
what happens in the period of decreased responsiveness
baby is very tired, muscles are relaxed, difficult to arouse, no interest in feeding
105
the higher the serum bilirubin level the greater risk of.....
neurological damage
106
what is physiological jaundice
most common cause of newborn jaundice and occurs in more than 50% of babies
107
what is breast milk jaundice
occurs in 1-2% of breastfed babies
caused by a special substance that some mothers produce in their breast milk
(not harmful)
108
a bilirubin increase of what requires careful investigation
5 mg/dl in 24 hours
109
what is the treatment of newborn jaundice
phototherapy
110
when do testes descend into the scrotum
before birth
111
whether or not a family decides to circumsize their child or not, we must teach them
proper cleaning techniques
112
what is our first intervention if a newborn is showing signs of hypoglycemia
heal stick to get an accurate blood glucose reading
113
how do we first supply glucose to a hypoglycemic newborn
glucose gel on our finger and rub it on the inside of their cheeks
114
what is tachysystole?
uterine hyperstimulation that may occur with or without FHR changes and is defined as:
4 or more contractions in 10 minutes over a 30 minute period OR contractions lasting more than 2 minutes in duration OR contractions of normal duration occurring within 60 seconds of each other
115
What are nursing interventions for tachysystole?
immediately turn off oxytocin infusion (to prevent fetal anoxia and uterine rupture), turn women on left side (to improve fetal placental blood flow), increase primary IV rate to 200ml/hr unless contraindicated (to provide adequate intravascular volume, support maternal bp, and IV route for emergency use), notify MD prn if does not resolve
116
What can happen with tachysystole?
it can reduce fetal oxygenation by interrupting maternal blood flow to the placenta during contractions and can cause uterine rupture
117
What is the fourth stage of labor?
2-3 hours after birth; starts with delivery of the placenta and lasts until vital signs stable
118
What is the major goal in the fourth stage of labor?
preventing pp hemorrhage
119
What to assess in postpartum period- first 2 hours?
BP, HR, RR, maternal O2 sat (every 15 minutes and prn); temperature (x1 and prn q 4hrs); assess fundus tone and position, lochia, perineum, hemorrhoid (q 15 minutes and prn); maternal bladder (encourage voiding prn); sensation of anesthesia if epidural; facilitate bonding with baby; assist with skin to skin and breastfeeding; encourage food and hydration
120
what is the average blood loss after birth?
500ml or less for vaginal, up to 1000ml for C-section
121
what increases during pregnancy and remains elevated until 2-3 weeks pp?
coagulation factors and fibrinogen levels (increases risk for hemorrhage pp)
122
what warrants further investigation pp?
tachycardia (impending sign of something else) and temp over 100 degrees
123
Immediately after delivery, what should fundus be like?
firm and at midline at level of umbilicus
124
how often do you assess fundus while patient is in hospital?
at least q 8
125
where should fundus be by day 6 and by day 10?
day 6- halfway between umbilicus and symphysis pubis;
day 10- true position
126
always ask the patient to what before uterine assessment?
empty bladder
127
what are risk factors for pp hemorrhage?
uterine atony, complications during pregnancy (previa orr abruption), precipitous delivery, lacerations and/or hematomas, retained placental fragments, increased risk for pp hemorrhage with multiple babies, prolonged labor
128
nursing care for pp hemorrhage?
vital sign assessment; assess fundus; assess lochia; assess for signs of bleeding from lacerations, episiotomy, or hematoma; assess for bladder distention
129
What are the physical findings that need to be reported to MD for pp hemorrhage?
clots larger than a quarter or the size of an egg; pad soaked through in less than 15 minutes; tachycardia and hypotension (hypovolemic shock); oliguria
130
normal pregnancy placenta
the placenta attaches to a temporary layer in the uterus thats shred at delivery
131
placenta accreta
when the placenta attaches too deeply into the uterine wall; has to be C section in OR
132
placenta increta
when the placenta attaches into the uterine muscle
133
placenta percreta
when the placenta goes completely through the uterine wall, sometimes invading nearby organs like the bladder
134
nursing interventions for pp period (cervix, vagina, and perineum)
observe for erythema, edema, or hematoma; assess episiotomy site or tear for approximation, drainage, quantity and quality of bleeding, and stitches; promote measures to soften stool; educate on use of peri bottle and patting dry perineum from front to back; sitz bath with epsom salts
135
when does the pp chill happen?
first 2 hours pp
136
Decreased estrogen pp is associated with what?
breast engorgement and diuresis of extracellular fluid
137
where is prolactin released from and what does it do?
anterior pituitary gland and initiates breast milk production
138
what to teach for breast care when breastfeeding?
tight, supportive bra 24/7; cabbage leaves for engorgement/mastitis; nipple cream applies often to help with cracks/pain; avoid exposing breasts to direct warm water when engorged; avoid stimulating breasts, tylenol for discomfort; ice to breasts and axilla
139
symptoms of mastitis?
usually unilateral, flu like symptoms with temp, sudden onset, swollen and inflamed tissue, may be a hard lump on breast (clogged duct)
140
what is BUBBLEH?
maternal assessment-
B- breast size, shape, and engorgement
U- uterus: firm or boggy
B- bladder: tender or distended
B- bowel movement
L- lochia: amount, odor, color, clots
E- episiotomy location, stitches, edema, and redness
H- homans signs (DVT indication)
141
What 3 things does an infant have to do before being discharged from nicu?
ability to maintain a normal body temp fully clothed in an open bed with normal ambient temperature;
ability to coordinate suckle feeding, swallowing, and breathing while ingesting an adequate volume of feeding;
ability to grow at an acceptable rate
142
urine output for babies with immature kidneys?
1-3 ml/kg/hr
143
manifestations of respiratory distress syndrome (RDS)?
can take up to several hours after birth to manifest;
respirations increase to 60 breaths/min or higher; tachypnea may be accompanied by gruntlike sounds, nasal flaring, cyanosis, and intercostal and sternal retractions; edema and apnea occur as condition worsens
144
tx for RDS?
betamethasone (if L/S ratio shows lung immaturity and this can be given 2 days before delivery to stimulate lung maturity); surfactant can be administered via ET tube at birth or when symptoms occur
145
when is improvement seen with RDS after surfactant is given?
generally seen within 72 hours, but immediate improvement is most common... second dose will be given after 12 hours is not improved
146
nursing care of infant with RDS?
monitor vs, minimal handling of infant to help conserve energy, IV fluids are prescribed, monitor I&O, oxygen therapy (monitor pulse oximetry), infant on oxygen is at high risk for oxygen toxicity
147
what is bronchopulmonary dysplasia?
toxic response of lungs to oxygen therapy- can result in "chronic lung"
148
major signs of sepsis in preterm infant?
low temp, tachypneic, bradycardic
149
how is retinopathy of prematurity classified?
5 stages, stage 1 (mild abnormal blood vessel growth) to stage 5 (completely detached retina and end stage of disease)
150
what is neonatal abstinence syndrome?
fetal exposure to drugs in utero;
many illicit drugs cross the placental barrier, therefore an infant born to a woman who is an addict will suffer differing degrees of drug withdrawal after birth
151
symptoms of NAS?
hyperirritability (primary sign), wakefulness, diarrhea, poor feeding, sneezing, yawning
152
tx of NAS?
swaddling, quiet environment, morphine, methadone, fentanyl, buprenorphine
153
what are the methods of heat loss?
evaporation, convection, conduction, radiation
154
what is conduction?
heat loss by conduction occurs when a baby is placed on a cooler surface or touching them with cool objects or hands
155
what is convection?
when heat is transferred to the air surrounding the infant. If AC is kept on or when people move around the infant, increase of heat loss occurs
156
What is evaporation?
heat loss through wet skin; dry infant immediately after birth and immediately after bathing
157
what is radiation?
loss of body heat to cooler, solid surfaces that are not indirect contact; neonates lose heat to walls of incubators even if surrounding air is warm- incubators need to be double walled and should be placed away from walls and windows
158
how can an infant be infected with HIV?
transplacentally, through contact with infected maternal secretions at birth, or through breast milk (NO breastfeeding)
159
what should a pregnant women with HIV do?
take HIV medications to reduce the risk of mother to child transmission of HIV and to protect their own health
160
How does hydrocephalus look?
-Increase in size of head
-Cranial sutures separate to accommodate enlarging mass
-Scalp is shiny
-Veins are dilated
-Eyes deviated downward
161
Treatment for hydrocephalus?
-Medications to reduce production of CSF
-Surgery to place a shunt
162
Signs of increasing intracranial pressure
-Increased blood pressure
-Decrease in pulse rate
-Decrease in respirations
-High-pitched cry
-Unequal pupil size or response to light
-Bulging anterior fontanelle
-Irritability or lethargy
-Poor feeding
163
What is the most common spina bifida?
Spina bifida cystica (sac or cyst). It is the most severe form and can accompany with other abnormalities.
164
What is a meningocele?
spinal canal remains open along several vertebrae in the lower or middle back in spina bifida. VERY high risk of infection
165
What do you do immediate after a baby with spina bifida is born?
-put it in an incubator
-lay baby on side or belly
-place a moist sterile dressing on the opening/sac to keep wet
166
clubfoot treatment for a nurse?
follow up and start range of motion ASAP after birth. It is very important to treat immediately
167
what treatment is used for hip dysplasia?
a Pavlik harness
168
treatment for a patient with a tracheal esophageal fistula?
Surgical repair is essential for survival. The baby will not survive without surgery
169
Usual immunizations for newborns
-Hep B
-Vitamin K (not immunization)
-erythromycin for eyes (also not immunization)
