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ATI RN MATERNAL NEWBORN NURSING
10.0 STUDY GUIDE COMPLETE
DOCUMENT 2021
ABCDE PRINCIPLE
Airway/Cervical Spine : This is the most important step in performing the primary survey. If a patent airway is not established, subsequent steps of the primary survey are futile. Protect the cervical spine if head or neck trauma is suspected. Breathing : After achieving a patent airway, assess for the presence and effectiveness of breathing. Circulation : After ensuring adequate ventilation, assess the circulation. Disability : Perform a quick assessment to determine the client’s level of consciousness. Exposure : Perform a quick physical assessment to determine the client’s exposure to adverse elements such as heat or cold.
MASLOW’S HIERARCHY OF NEEDS Physiological; oxygenation, circulation, nutrition, elimination, fluid balance, activity and exercise, rest and sleep Safety and security; living in a safe environment, adequate income, shelter from environmental elements Love and belonging; love, affection, relationships Self esteem; self respect, personal worth, social recognition Self Actualization; personal growth, fulfilling own potential
NY Heart Association Classifications Class I: means no symptoms and no limitations in ordinary physical activity Class II: mild symptoms and slight limitation during ordinary activity Class III: marked limitation in activity due to symptoms, even during less than ordinary activity. Class IV: severe limitations, with symptoms experienced at rest
RANDOM NOTES FROM ATI Q’s ● The Kleihauer-Betke test is used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization ● A pregnant client should take 600 mcg of folic acid daily to prevent neural tube defects. ● A pregnant client should drink 3 L water a day ● A pregnant client should increase protein intake to 71g during second and third trimester ● A pregnant client should increase caloric intake by 340 cal during the second trimester and 452 cal during the third trimester.
● If a pregnant patient is having a seizure, place oxygen on the patient to ensure adequate oxygenation to the fetus. ● If a pt is using patterned breathing during labor and has tingling and numbness, this is because the pt is hyperventilating. Placing an oxygen mask over the nose and mouth will help bring up CO2 levels and reduce the intake of oxygen. ● Rhogam ; given within 72 hours post delivery for Rh negative to prevent antibody formation for future pregnancy ● Hx of cholecystitis, htn, and migraine headaches is a contraindication for oral contraceptives ● Folate occurs naturally in foods like liver, dark-green leafy veggies, orange juice, legumes ● Meconium should be passed within 24 to 48 hours after delivery ● Erythromycin ointment in eye prevent infection such as gonorrhea ● Vitamin K given to prevent hemorrhage to infant at birth ● First immunization is Hep B at birth, then 1 or 2 months and then 6 months
● Ectopic pregnancy ○ When the ovum becomes implanted outside of the uterus, often the fallopian tubes ○ Comes with unilateral stabbing pain , and tenderness in the lower abd quadrant. ○ The fallopian tube bursting can be very dangerous for mom ○ Severe shoulder pain is a finding with ruptured ectopic pregnancy ○ Abdominal cramping can indicate ectopic pregnancy or manifestations of spontaneous abortion ● Molar pregnancy (Hydatidiform mole) ○ Proliferation and degeneration of trophoblastic villi in the placenta ○ Sx of bleeding that resembles prune juice/dark brown ● Placenta previa ○ When the placenta abnormally implants in the lower segment of the uterus, over/near the cervical os ○ Painless bright red vaginal bleeding during 2nd or 3rd trimester ○ Can be complete, incomplete or partial ○ If completely covering the cervical os, cesarean section is DEFINITELY needed ● Abruptio placentae ○ Premature separation of placenta from uterus ○ High rate of fetal and maternal morbidity/mortality ○ Sudden onset of excruciating and localized pain, bright red bleeding ● Incompetent cervix ○ Recurrent premature dilation of the cervix, or cervical insufficiency
● Breast changes (darkened areola) ● Quickening (fluttering movements 16-20 weeks) ● Uterine enlargement Probable signs of pregnancy ● Abdominal enlargement ● Hegar’s sign: softening and compressibility of uterus ● Chadwick’s sign: deepened violet bluish color of cervix and vaginal mucosa ● Goodell’s sign: softening of cervical tip ● Ballottement: rebound of unengaged fetus ● Braxton Hicks: false contractions ● Positive pregnancy test ● Fetal outline Positive signs of Pregnancy ● Fetal heart sounds ● Visualization of fetus by ultrasound ● Fetal movement GTPAL ❖ Gravidity (amount of pregnancies, to include current one) ❖ Term births (38 weeks or more) ❖ Preterm births (from viability up to 37 weeks/less than 38 weeks) ❖ Abortions/miscarriages (prior to viability) ❖ Living children Physiological changes in pregnancy ● Uterus increases in size and changes shape. Ovulation and menses cease. ● Cardiac output increases. Blood volume increases. ○ S1, S2, S3 more easily heard after 20 weeks. Murmurs may also be heard ○ Weight of the uterus on vena cava causes episodes of maternal hypotension ● Maternal oxygen needs increase. Respiratory rate increases and total lung capacity decreases. ● Musculoskeletal; body alterations and weight increase ● Nausea, vomiting, constipation ● Renal filtration increases. Urinary frequency is common. ● Placenta becomes endocrine organ that produces large amounts of HCG, progesterone, estrogen, human placental lactogen, and prostaglandins. ● Pulse increases 10-15/min around 32 weeks and remains elevated through remainder of pregnancy. ● Chloasma: increase of pigmentation on the face ● Linea Nigra: dark line from umbilicus to pubic area ● Striae gravidarum: stretch marks on abdomen and thighs
Biophysical Profile (BPP) ● Real time US (Ultrasound) used to visualize physical and physiological characteristics of fetus. Mixture of US and NST (nonreactive stress test). ● Potential Dx for use: NST, suspected oligo or polyhydramnios, suspected fetal hypoxemia or hypoxia. ● Client will present with: premature rupture of membranes, maternal infection, decreased fetal movement, IUGR (Intrauterine Growth Restriction) ● Prepare client just like reg US - full bladder ● What is scores : Reactive heart rate, breathing, body movement, fetal tone, amniotic fluid volume ○ Each area gets a score of 2 ● Score is between 0- ● Score; ○ Less than 4 abnormal - strongly suspect chronic fetal asphyxia ○ 4-6 abnormal suspect chronic fetal asphyxia ○ 8-10 normal, low risk of chronic fetal asphyxia TORCH ● Toxoplasmosis, other infections (hepatitis), rubella virus, cytomegalovirus, and herpes simplex are known as torch. These infections can cross the placenta and have teratogenic effects on the fetus. ● Rubella immunization is contraindicated because rubella infection can develop. ● Avoid crowds of young children. Avoid consuming undercooked meat while pregnant and cat liter boxes. ● Low titers prior to pregnancy should receive immunization Hyperemesis Gravidarum ● Excessive nausea and vomiting (poss related to elevated HCG levels) past 12 weeks ● Nursing Implications: IV fluids, administration of B6, antiemetics (Reglan, Zofran) ● Risk to the fetus for IUGR or preterm birth if condition persists ● Expected; vomiting, dehydration, weight loss, increased pulse, decreased BP, poor skin turgor ● LABS; Urinalysis for ketones and acetones (breakdown of protein/fat), elevated urine specific gravity (normal 1.000-1.030); Chem Profile revealing electrolyte imbalances Na, K, Chl reduced, Metabolic acidosis, Metabolic alkalosis, elevated liver enzymes, bilirubin level; Thyroid indicating hyperthyroidism; CBC with elevated Hct due to inability to retain fluids. Gestational Hypertension ● Caused by vasospasm, which causes poor vissue perfusion
○ Magnesium Sulfate (relax smooth muscle contractions) ○ Terbutaline - adverse effects are hyperglycemia, hypokalemia, and hypotension; used to stop contractions. ○ Betamethasone (Steroid) - promotes fetal lung maturity, prevents respiratory distress ● Premature rupture of membranes (PROM) ○ Nitrazine paper test will turn blue. Yellow would be urine. ○ Positive Ferning test can also indicate this ○ Abx may be used if it was caused by an infection Labor and Delivery ● Premonitory Signs : backache, weight loss 0.5 kg- 1.5 kg (1-3lbs), lightening (fetal head descends), contractions, increased vag dc or bloody show, energy burst (nesting), GI changes ● Testing done: Group B strep test and urinalysis (protein, infection) ● Five P’s: passenger, passageway (birth canal), powers (contractions), position (of the woman), psychological response
Stages of labor ● Stage 1 ○ (onset of labor until complete dilation) ○ Latent Phase: cervix dilates from 0-3 cm, contraction 30-45 seconds ■ Talkative, eager ○ Active Phase: cervix dilates from 4-7 cm, 40-70 seconds ■ Restless, anxious, helpless ○ Transition Phase: cervix dilates from 8-10 cm, 45-90 seconds ■ Feeling “can’t do this”, urge to push, feels like bowel movement is needed ● Stage 2: ○ Full dilation to Expulsion of the fetus ● Stage 3: ○ Birth of baby to delivery of placenta ● Stage 4: ○ Delivery of placenta until VS returns to normal
Bishop Score ● A score used to determine maternal readiness for labor. Five factors assigned a numerical value 0-3 and totaled. ● Cervical dilation, effacement, consistency, position, station of presenting part
Therapeutic procedures to assist with L&D ● Amnioinfusion; normal saline or lactated ringers instilled into amniotic cavity through a transcervical catheter. Reduces the severity of variable decelerations caused by cord compression. ○ Indications: oligohydramnios (scant amount of amniotic fluid) caused by uteroplacental insufficiency, premature rupture of membranes, post maturity of fetus, fetal cord compression. ● Vacuum Assist ○ Vertex presentation, absence of cephalic disproportion, ruptured membranes. Maternal exhaustion and ineffective pushing efforts, fetal distress. ● Amniotomy ○ Labor progression too slow ○ Artificial rupture of membranes. Labor begins within 12 hours. Increased risk for cord prolapse. ● Oxytocin ○ Post term preg, dystocia (prolonged diff labor), prolonged rupture membranes, fetal demise, chorioamnionitis, maternal medical complications (Rh, DM, pulmonary disease, Ges. htn). ○ Nurse must confirm fetus is engaged in birth canal at station 0. ○ Use infusion port closest to client. Connect piggyback to main line using a pump. ○ Monitor BP, pulse, respirations every 30-60 min. ○ DC if contraction is more often than 2 min, longer than 90 sec, intensity more than 90 mmhg BUBBLEHE ● Breasts, uterus, bowel, bladder, lochia, episiotomy, Homan’s (sign), emotional
Thermoregulation-Newborns ● Conduction ; loss of body heat from direct contact with cooler surface (weight scale/cold stethoscope) ● Convection; flow of heat from body to cooler environmental air (bassinet out of line with fan, swaddle) ● Evaporation; Loss of heat as surface liquid is converted to vapor (dry newborn after delivery/bath can cause this) ● Radiation; Loss of heat from body to cooler surface that is close to but not in direct contact (window/air conditioner)
Assessment of Fetal Wellbeing ● LS Ratio : Lecithin Sphingomyelin; tests for fetal lung maturity
○ Mother should be side lying, or proped on her side ● Spinal block ○ C sections ○ Lack of sensation from nipples to the feet ○ Maternal hypotension, headache, fetal bradycardia ○ Higher incidence of bladder and uterine atony
FHR monitoring ○ 110-160 bpm is normal, we want to see variability and accelerations, early decels okay ○ DO NOT WANT TO SEE LATE OR VARIABLE DECELERATIONS ○ Fetal Bradycardia ■ May want to Stop Pitocin, lay client on side, give more oxygen, notify MD ○ Fetal Tachycardia (over 160) ■ Can indicate Maternal infection ■ Give antipyretics and oxygen if needed ○ Late Decels ■ Uteroplacental insufficiency ■ Lack of fetal oxygenation ■ Side lying position, increase fluids, DC oxytocin, administer oxygen, notify MD ○ Variable Decels ■ Umbilical cord compression ■ Reposition onto side or do knee to chest, D/C oxytocin, administer oxygen
Umbilical cord compression/prolapse ○ Cord is being crushed by fetus’ head , protruding ○ Notify MD, sterile gloved hand, insert 2 finger into vagina, lift baby’s head off the cord ○ Reposition client into knee chest or trendelenburg ○ Warm sterile saline soaked towel on the cord
Fundal Height ○ From gestational weeks 18-32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. ○ Immediately after delivery; fundus firm midline with umbilicus ○ 12 hours PP; go up 1 cm above umbilicus ○ Every 24 hrs after that, descends 1-2 cm per day
○ 6 th^ postpartum day is should be half way down ○ 10 days after; not palpable
Lochia ○ Lochia Rubra; bright red bleeding, at 1-3 post birth, fleshy odor, not excessive ■ If a pad is saturated w/in 15 min, this indicates hemorrage and needs intervention ■ Extending past 3 days, concern for atony ○ Lochia Serosa; day 4-10 pp, serosanguinous, pinkish brown ○ Lochia Alba; day 11-6 weeks pp, yellowish, white, creamy, fleshy odor
Uterine Atony ○ If retaining urine, bladder will be distended, and the uterus will be deviated ■ Empty the bladder ○ May need fundal massage
Blood loss:
- Average during vaginal birth: 500mL
- Cesarean: 100mL
Phases of Maternal Role Attainment ○ Dependent taking in phase; ■ 24-48 hr after birth ■ Relied on others for assistance ○ Dependent independent taking hold phase ■ Day 2-3 goes up to the next couple weeks ■ Mom is focused on baby care and how to take care of baby ○ Interdependent letting go phase ■ Resuming role as a partner, it isnt all about the baby ■ Looking beyond baby care and into other aspects of her life
Discharge Teaching Breast Feeding ○ Milk comes in 2-3 days after birth, engorgement is common ○ If engorgement occurs, apply cold compress between feedings, warm shower before breastfeeding ○ Recommend to apply cold fresh cabbage leaves to breasts and/or take mild analgesics in order to help allevieate engorgement symptoms ○ If NOT breastfeeding,
■ Oxytocin (contract), Methylergonovine, Misoprostol (Cytotec) ○ Nursing Interventions : Ensure bladder is empty, massage the fundus
Postpartum Blues ○ Lasts about 10 days ○ Tearfulness, insomnia, lack of appetite, feeling of letdown
Postpartum Depression ○ Persistent feelings of sadness and mood swings ○ Occurs within 6 months of delivery ○ Estimately 10% of women are effected
Postpartum Psychosis ○ Disorientation, hallucination, paranoia, obsessive behaviors ○ Common if History of bipolar disorder
NEWBORN ASSESSMENT ● APGAR ○ 1 minutes, 5 minutes, and then 10 minutes if needed ○ optimal score is 7- ○ 4-6 indicates moderate distress ○ 0-3 severe distress ○ heart rate, respiration rate, muscle tone, reflex irritability, color ○ each topic is worth 0- ○ heart rate: needs to be greater than 100 for a score of 2 ○ respirations: needs to have a good cry to score 2 (weak is 1) ○ muscle tone: well flexed is 2 ○ reflex irritability: crying would be a 2, grimace would be 1 ○ color: completely pink is 2, acrocyanosis is 1, cyanotic is 0 ● New Ballard Scale ○ Neuromuscular maturity; ■ if baby is full term, they will be well flexed ■ Items included for this section are : Square window, scarf sign, popliteal window, arm recoil, heel to ear test ○ Physical Maturity (preterm vs full term) IMPORTANT ■ Preterm : Transparent, sticky skin, not a lot of plantar creases, un- developed breast buds, males have flat smooth scrotum, hypotonic, weak grasp, clitoris will be promnent and labia flat ■ Full Term : Wrinkled, cracked, leathery appearance (more so for late), lots of small creases on plantar, developed breast buds 5-
10mm, scrotum rugae and pendulum-like, clitoris not prominent, labia well developed ● NORMAL FINDINGS: ○ Mongolian spots, milia, head 2-3 cm larger than chest circumference, barrel shaped chest, Epstein's pearls, anterior fontanel diamond shaped, posterior triangle shape ● Fontanel: Sunken- dehydrated; bulging-hemorrhage or increased ICP ○ Caput succedaneum (cone head) is common with vaginally delivered baby for 3-4 days ○ Eyes blue/grey at birth, changes over time (within 3-12 months it should become established ○ Ears being low set can indicate chromosomal issue, such as down syndrome ○ Esptein’s pearls: small white cysts found on gums ● Grey-white patchs on gums and tongue can indicate thrush
Hypoglycemia in a newborn ● Respiratory distress, abnormal high pitched cry, jitteriness, lethargy, poor feeding, apnea, seizures, twitching, cyanosis, seizures, glucose under 40 ● Nursing Intervention: Get baby food! Breastfeeding or formula
Cord Care ● Keep cord dry, above the diaper. Fold diaper down below cord ● Sponge baths only until cord falls off (10-14 days post birth) ● Monitor for redness, odor, purulent drainage (infection) ● Nuchal cord is when the cord is wrapped around the fetus’ neck
Circumcision ● Clamp procedure: petroleum jelly, no tub bath until completely healed ● Film of yellowish mucus by day two, do not wash off ● Acetaminophen for pain to baby ● Usually healed after 2 weeks
Preterm Baby ● Thin translucent skin, few creases on plantar, hypotonic/not well flexed, weak cry, abundant lanugo, not a lot of fat
Macrosomic (Large for Gestational Age - LGA) ● (Cooked on outside, raw on the inside), born to moms with diabetes or post term infants
Oral contraceptives
- Adverse effects: Chest pain, SOB, leg pain, headache or eye problems for stroke or HTN
- Smokers should not get these oral contraceptives, Hx of blood clots, stroke, CV problems, breast or estrogen related cancers
Depoprovaera:
- Decrease in bone denisty, so need adequate intake of calcium/vitamin D
IUD:
- Increase risk of pelvic inflammatory disease, uterine perforation and ectopic pregnancy
- Look for change in string length, foul smell, pain with intercourse, fever, chills
Naegele's rule:
- A method of calculating when a woman’s due date is
- Add nine months and a week from date of last menstrual period (LMP) ending
Weight gain during pregnancy:
- Underweight: weight gain of 28-40 lbs
- Normal weight: Normal weight gain is 25-35 lbs of a women at a normal/healthy weight
- Overweight: weight gain should be 15-25 lbs
- First trimester - one should gain more than 1-2kg
- Second & third trimester - should be apprixmately 1 lbs gained per week
Calories during pregnancy:
- Extra 340 calories per dat during 2nd^ trimester
- 450-452 extra calories per day during third trimester
Calories during breastfeeding
- Approximately 300-400 extra calories per day
Ultrasound: Bladder should be full
Invasive procedures: Bladder should be empty
Non-stress test
- Measures fetal well being within the last trimester
- Measures response of the fetus heart rate to fetal movement
- Woman presses buttong when she feels fetal movement and the heart rate is monitored in response to that movement
- Considerede reactive (which is normal) if the fetal heart rate accelerates during movement o (You want a result that indicated REACTIVE)
- Considered non-reactive (abnormal/bad) if the fetal heart rate did not accelerate adequately during movement Contraction stress test (CST):
- Might be performed due to a non-reactive stress test
- A contraction is induced using pitocin/ocytocin or through nipple stimulation
- During the contraction, youll monitor fetal heart rate to see if late decelerations occur (which are never good)
- If no late decelerations occur then CST is negative (which is what you would hope for)
- If late decelerations do occur during the contraction, it means the CST is positive, which is not a good thing
- Inducing a test like this can possibly induce preterm labor
Iron deficiency Anemia:
- Iron supplement should be taken with Vitamin C to increase absorption
Non-pharmacological pain management (During labor)
Breathing techniques
- Slow-paced breathing: the patient inhales slowly through the nose and exhales slowly through the mouth (usually 6-9 times per minute and not fewer than 3-4).
- Modified-paced: the patient breaths slowly in and out through her mouth, and, as each contraction reaches it’s peak, she breaths faster (usually 32-40 breaths per minute), then she returns to slow breathing again.
- Pattern-paced breathing: requires more concentration as the patient sets up a pattern of breathing to help her through the final centimeters of cervical dilation. Breathing in and out of her mouth, she takes quick panting breaths and then exhales or blows forcefully (“Pant-pant-pant-blow” or “hee” and “hoo”)
Touch
- Counterpressure: Steady pressure a support person applies to the sacral area of the patient’s back. This is especially helpful for patients who have pain and internal pressure in the lower back because the fetal head is in a posterior position. The heels of the hand or fists are used to provide pressure
- Cramping is normal during breast feeding due to oxytocin stimulation with breast feeding
- Feed for 15-20 minutes per breast
- Try to completely empty breast
- Best indicator that baby is getting enough milk is if they are voiding 6-8 diapers per day
- Breast feed 8-12 times per day
Sleep:
- Infant should sleep supine/on back to prevent SIDS
- Newborns sleep approximately 17 hours per every 24 hours the first month or so
Car safety:
- Car seat in the back, rear facing, preferably in the middle seat until at least age 2
Tx of gonorrhea Medication to tx gonorrhea: ceftriaxone IM and azithromycin PO
Labor and delivery processes: teaching findings of false labor
- Contractions are painless, irregular, decrease, felt in lower back or abdomen above the umbilicus, often stop with sleep or hydration.
- Cervix: no change in dilation or effacement, remains in posterior position, no bloody show.
- Fetus: presenting part is not engaged in pelvis.
Phases of maternal postpartum adjustment
- During the first 2 to 6 weeks after birth, the pt goes thru a period of acquaintance w/ her newborn, physical restoration, and becoming a competent mother.
- Maternal identity is achieved around 4 months.
Engorgement of breasts
- Completely empty breast at each feeding. For engorgement, apply cool compresses after feedings, and warm after 24 hours and prior to breast feeding for circulation purposes.
- Due to decreased estrogen Sore nipples
- apply small amount of breast milk to the nipple and allow it to dry.
- Apply cream or wear breast shields in her bra to soften nipple. Prenatal care: second trimester
- Sex and pregnancy
- Fetal movement
- Complications like hypertension, diabetes, premature rupture
- Child birth classes
- Review birthing methods
- Develop a birthing plan. Auscultating fetal heart tones
- PMI (point of maximal impulse) is the best location. Best heard on the fetuses back.
- In vertex position: lower quad
- Breech position: upper quad Sibling adaption
- Give a toy from the infant to the sibling
- Have sibling tour the unit.
- Arrange for one parent to spend time with sibling and other with infant.
- Allow sibling to help with care of the infant.
Naegele’s rule: take the FIRST day of the woman’s last cycle, subtract 3 months, and then add 7 days. Measurement of fundal height: between 18 to 32 weeks. Placenta becomes an endocrine organ. Cardiac output increases 30-50% AND blood volume 30-45% to meet the greater needs. Blood Pressure normally decreases during 1st and 2nd^ trimesters, and return to baseline in 3rd^ trimester
1hr glucose tolerance: given glucose and assess 1 hour after. 3 hr glucose tolerance: fasting overnight prior to taking glucose and taking a sample at 1, 2, and 3 hours. Increase of 340 calories is recommended during the 2nd^ trimester and 452 during the 3rd trimester. If a patient becomes pregnant, they should take 600mcg of folic acid a day. Recommend 1,000mg a day for calcium. Drink 8 to 10 glasses a day. Take 27mg a day of iron. 71g of protein
Maternal phenylketonuria: start diet for at least 3 months prior to pregnancy and continue throughout pregnancy. Fish, poultry, meats, nuts, eggs and nuts should be avoided.
Biophysical profile: score of 8 to 10 is normal. 4 to 6 is abnormal and suspects chronical fetal asphyxia, less than 4 is strongly abnormal.
Amniocentesis
- Done at 14 weeks. Aspirate amniotic fluid by inserting a needle into the uterus.
- Have patient lay supine and place a wedge under the right hip.
- Administer Rho(D) immune after the procedure if the woman is Rh Negative.
