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Chamberlain NR327 exam 2 study guide
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- answer ■ Performed within the first 48 hours following birth ■ Take measurements &use the Ballard Scale o Ballard Gestational Age Tool ■ Provides estimation of gestational age ■ Baseline for growth & development ■ Neuromuscular Maturity ■ 6 ranges ■ assigned # value from -1 to 5 (B)UBBLE - answer Breasts (size, contour, asymmetry, engorgement, redness, nipples: cracking, inverted, bleeding) (H)ER - answer Homan's sign ■ Assess legs for DVT, unilateral swelling, erythema, & warmth ■ Encourage ambulation
Accelerations in FHR - answer ■ Temporary increase - ■ Reassuring - no interventions Advantages of Breastfeeding - answer ■ Less likely to result to overfeeding leading to obesity ■ Immunological properties help fight infection in infant ■ Provide protection against food allergies ■ Promote optimal mother-infant bonding ■ Less expensive than formula ■ Promote postpartum weight loss ■ Lowers the risk of breast cancer Another family member - Bonding - answer May view them as competition or fear that they will be replaced ■ Reassurance & attention from parents will help them feel loved & important ■ Expect regression (sucking thumb, bedwetting) ■ Encourage discussion about the infant ■ Arrange for child to see infant in the hospital ■ Show photos of baby growing in mommy's belly
APGAR: Reflex irritability - answer 0= none 2= grimace, weak cry 3= Good cry APGAR: Respiration - answer 0=absent 1=slow/irregular weak cry 2=Good/Crying Appropriate for Gestational Age (AGA) - answer Weight, length, and head circumference are between the 10th and 90th percentiles for gestational age. Average newborn length - answer 17-22 inches Average newborn weight - answer 5.5 to 8. B(U)BBLE - answer Uterus (Fundal Height, Uterine Placement, and Consistency) ■ 2 hrs after birth- Fundus is between the umbilicus and the symphysis pubis ■ 6-12 hrs after birth the fundus usually is at the level of the umbilicus ■ The fundus progresses downward at a rate of 1 fingerbreadth (or 1 cm) per day after childbirth
■ If the fundus is not firm gently message the uterus using a circular motion until it becomes firm Baby blues (1-10 days) - answer characterized by mild depressive symptoms - mood swings, anger, anxiety, irritability, tearfulness (often for no reason) ■ the "blues" typically peak on postpartum 4 th & 5 th day, may last hours to days ■ usually resolves by day 10 w/o therapy
- nursing management: ■ encourage the mother to express her feelings to ease ■ be patient & understanding to her & family ■ suggest getting outside help w/ housework & infant care ■ provide telephone numbers that she can call when she's down ■ reassure patient that feelings are normal &; temporal
■ Progressive exercise - walking ■ Dietary fiber - found in whole grain breads/cereals & unpeeled fruits & vegetables ■ Extra water & fluid - 6-8 glasses per day Breastfeeding contraindications - answer ■ HIV ■ Street Drugs ■ Chemotherapy Drugs ■ Herpes Simplex ■ Untreated TB ■ Galactosemia Breastfeeding Nutirtion - answer ■ 4 servings of Fruits and Vegetables ■ 4-5 servings of milk ■ 12 or more servings Bread, Pasta, Cereal ■ 7 servings Meat, Poultry, Fish, Eggs ■ 5 servings Fats, Oils, and Sweets ■ Lower intake of saturated fats, trans fat, & cholesterol BU(B)BLE - answer Bowels and GI function ■ Spontaneous bowel movements may NOT occur for 2-3 days after giving birth b/c
of a decrease in muscle tone in the intestines during labor ■ Normal patterns of bowel elimination usually return within 8-14 days after birth ■ Inspect the woman's abdomen for distention, auscultate for bowel sounds in all 4 quadrants, & palpate for tenderness ■ Ask the woman if she has had a bowel movement or has passed gas since giving birth BUB(B)LE - answer Bladder ■ Assess the bladder for distention and adequate emptying after efforts to void ■ Note the location and condition of the fundus , a full bladder tends to displace the uterus up and to the right ■ Be alert for signs of infection, including infrequent or insufficient voiding (less than 200 ml) BUBB(L)E - answer Lochia ■ the postpartum vaginal discharge that typically continues for 4-6 weeks after childbirth ■ Report any abnormal findings, such as heavy, bright-red lochia w/ large tissue
risk for blood cloth ■ Elevated WBC for the first week ■ Check if calves & legs are soft & NOT painful - has she been up since delivery Circumcision Care - answer ■ NOT done immediately after birth due to low vitamin K levels ■ Heals in 7-10 days ■ If bleeding occurs, then apply pressure ■ Use petroleum jelly w/ gauze to cover the incision ■ Change diapers frequently ■ Yellow exudate forms in 2-3 days Circumcision contraindications - answer ■ Hypospadias (abnormal positioning of urethra) ■ Epispadias (urethra on top of head of penis) ■ Family history of bleeding disorders
■ Parents decline vitamin K for infant Colostrum - answer ■ thin, milky fluid secreted by the breast during pregnancy and during the first days after birth before lactation begins ■ delivers essential nutrients and antibodies in a form that the newborn can digest congenital hypothyroidism (cretinism) - answer ■ Screened b/c the thyroid is necessary for brain growth calorie metabolism and development ■ Expected findings - pot belly pale puffy face protruding umbilicus/tongue poor brain dev Cord infection manifestations - answer ■ Moist ■ Red ■ Foul odor ■ Purulent drainage ■ Notify DR. Immediately
■ Becoming a father requires a man to build on experiences throughout childhood & adolescences Fetal bradycardia - answer FHR drops below 110 for at least 10 minutes Fetal Bradycardia - Cause & Intervention - answer ■ Causes: uteroplacental insufficiency, umbilical cord prolapses, maternal hypotension, anesthetic meds mom received ■ Interventions: stop oxytocin, left side position, O2, notify provider Fetal tachycardia - answer FHR increases above 160 for over 10 minutes Fetal tachycardia - Cause & Intervention - answer ■ Causes: infection, cocaine use, dehydration ■ Interventions: antipyretics, oxygen, IV fluid bolus First period of reactivity - answer ■ Begins at birth & lasts from 30 minutes up to 2 hours ■ The newborn is alert, moving, may appear hungry ■ Period of alertness allows parents to interact w/ their newborn & to enjoy close contact w/ their baby
■ The appearance of sucking & rooting from a newborn provides good opportunity for initiating breastfeeding first stool of the newborn - answer meconium - greenish/black tarry consistency Galactosemia Screening Tests - answer ■ When there is a lack of the enzyme needed to turn the sugar from milk into glucose ■ Complications: poor weight gain, N/V, seizures, loss of eyesight, galactose buildup causing damage to brain, eyes, & liver H(E)R - answer Emotion: emotional status ■ Be alert of mood swings, irritability, or crying episodes, which could show postpartum depression or psychosis ■ Remember cultural considerations ■ Edenberg's PPD screening HE(R) - answer Rhogam ■ Administered 72 hours after birth to Rh negative moms who gave birth to Rh
■ Most common treatment for hyperalbuminemia Hypothermia nursing interventions - answer ■ Monitor for cyanotic trunk, depressed respirations ■ Warm infant slowly over a period of 2-4 hours in a radiant warmer - Preferred method: skin-to-skin ■ Check temp. every hour until stable ■ All exams & assessment should be performed under radiant warmer or during skin-to-skin Large for Gestational Age (LGA) - answer weight is greater than the 90th percentile Late deceleration: response after contraction - answer ■ Non-reassuring - needs intervention ■ Interventions: side-lying position, fluids, d/c oxytocin, O2, notify the provider, palpate uterus for tachysystole ■ Cause: uteroplacental insufficiency Lochia alba - answer Alba- white 10-14 days
Lochia large or heavy - answer The amount of lochia on the perineal pad is described as follows: Large or heavy: a pad is saturated within 1 hour after changing it Lochia light - answer The amount of lochia on perineal pad is described as follows: Light or small: an approx. 4-inch stain or a 10-25 mL loss Lochia moderate - answer The amount of lochia on the perineal pad is described as follows: Moderate: a 4-6-inch stain w/ an estimated loss of 25-50 mL Lochia rubra - answer Rubra- red 1-3 days Reddish or red-brown vaginal discharge that occurs immediately after childbirth; composed mostly of blood. (COAT) Lochia Scant - answer The amount of lochia on the perineal pad is described as follows: Scant: 1-2-inch lochia stain or approx. a 10 mL loss
application in 1-2 hours after birth ■ APGAR Newborn Blood Pressure - answer 50-75 systolic, 30-35 diastolic (Taken if low APGAR Score) Newborn Glucose - answer 40-60 mg/dL -first day then 50-90 mg/dL Newborn Hematocrit - answer 46-68% Newborn Hemoglobin - answer 17-23 g/dL Newborn Hepatic System - answer ■ At birth, the liver assumes the functions that the placenta handled during fetal life ■ Blood coagulation ■ Iron storage ■ Carbohydrate metabolism -the main source of energy for 1st several hours ■ Conjugation of bilirubin - when unconjugated bilirubin pigment is deposited in skin, jaundice occurs
Newborn HR - answer 120-160 bpm can increase to 180 if crying newborn hypothermia - answer ■ Normal temp. range for infant: 97.7 °F-99. °F s/s: ■ temp. less than 97.7 °F (36.5 °C) ■ cyanosis ■ increased RR ■ Assess temperature q30 min for the first 2 hours then q8 hours until discharge Newborn Jaundice - answer RBC die off in large numbers after birth phorphyrin rings (bilirubin) will overwhelm the immature liver causing it to process slowly Build up of bilirubin/biliberin in tissues treatment = UV light (phototherphy)
