Study Guide for Final Exam OB Chapter 6, Study Guides, Projects, Research of Nursing

Download Study Guide for Final Exam OB Chapter 6 and more Study Guides, Projects, Research Nursing in PDF only on Docsity! Study Guide for Final Exam OB Chapter 6 • Alterations in cyclic bleeding: oligomenorrhea, menorrhagia, • oligomenorrhea • is often used to describe decreased menstruation, either in amount, duration, or both. • more correctly refers to infrequent menstrual periods characterized by intervals of 40 to 45 days or longer and hypomenorrhea to scanty bleeding at normal intervals. • Causes • abnormalities of hypothalamic, pituitary, or ovarian function. • Oligomenorrhea can also be physiologic or part of a woman’s normal pattern for the first few years after menarche or for several years before menopause • most common causes of scanty menstrual flow is OCPs. If a woman is considering OCPs for contraception, it is important to explain in advance that the use of OCPs can decrease menstrual flow by as much as two-thirds. This effect is caused by the continuous action of the progestin component, which produces a decidualized endometrium with atrophic glands. • Treatment • aimed at reversing the underlying cause if possible. HT using progestins, with or without estrogens, may also be used to prevent complications of unopposed estrogen production (endometrial hyperplasia or carcinoma) or of absent estrogen (vaginal dryness, hot flashes or flushes, or osteoporosis). • Menorrhagia (hypermenorrhea) • defined as excessive menstrual bleeding, in either duration or amount. The causes of heavy menstrual bleeding are many, including hormonal disturbances, systemic disease, benign and malignant neoplasms, infection, and contraception (IUDs). • Causes • A single episode of heavy bleeding may signal an early pregnancy loss. This type of bleeding is often thought to be a period that is heavier than usual, perhaps delayed, and is associated with abdominal pain or pelvic discomfort. • Infectious and inflammatory processes such as acute or chronic endometritis and salpingitis may cause heavy menstrual bleeding. • Medications may also cause abnormal bleeding. Chemotherapy, anticoagulants, neuroleptics, and steroid hormone therapy have all been associated with excessive flow. • Uterine leiomyomas (fibroids or myomas) are a common cause of heavy menstrual bleeding • Other uterine growths ranging from endometrial polyps to adenocarcinoma and endometrial cancer are common causes of heavy menstrual and intermenstrual bleeding • Treatment • Treatment options include pharmacologic and surgical management • Pharmacologic treatment is directed toward temporarily reducing symptoms, shrinking the myoma, and reducing its blood supply. This reduction is often accomplished with the use of a GnRH agonist or ulipristal acetate (UPA) • Perimenopause and Menopause • Menopause- Menopause refers to the complete cessation of menses and is a single physiologic event said to frequency, dysuria, uterine prolapse, and stress incontinence. Vaginal relaxation with cystocele, rectocele, and uterine prolapse is not caused by reduced estrogen levels but may be a delayed result of childbearing or another cause of weakness of the pelvic support structures. Urinary frequency sometimes occurs after menopause because the distal portion of the urethra, which has the same embryologic origin as the reproductive organs, shortens and shrinks. Irritants have easier access to the urinary tract with its short urethra and may cause frequency and urinary tract infections. • Urinary incontinence and uterine displacement are two other common age- related rather than menopause-related findings in the postmenopausal period. These conditions are discussed in Chapter 11 . • Vasomotor instability • Vasomotor instability in the form of hot flashes or flushes is a result of fluctuating estrogen levels and is the most common disturbance of the perimenopausal years, occurring in up to 75% of women having natural menopause • occurs most frequently in the first two postmenopausal years; the number of episodes decreases over time • Other problems associated with perimenopausal fluctuations of vasoconstriction or vascular spasms include dizziness, numbness and tingling in fingers and toes, and headaches. • Mood and behavioral responses • Women with hot flashes and night sweats do report insomnia, fatigue from loss of sleep, and depressed mood. They complain of feeling more emotionally labile, nervous, or agitated, with less control of their emotions. However, the interaction of psychologic, biologic, and sociocultural factors is so complex that it is As the uterus enlarges, it also changes in shape and position. By 12 weeks the uterus changes from its nonpregnant pear shape to a more spherical or globular shape. Later, as the fetus grows, the uterus becomes larger and more ovoid. During the first trimester the uterus is a pelvic organ; by 12 weeks it rises out of the pelvis into the abdominal cavity. The pregnancy may “show” after the 14th week, although this depends to some degree on the woman’s height and weight. Abdominal enlargement may be less apparent in the nullipara with good abdominal muscle tone. Posture also influences the type and degree of abdominal enlargement that occurs. In normal pregnancies, the uterus enlarges at a predictable rate. As the uterus grows, it can be palpated above the symphysis pubis sometime between the 12th and 14th weeks of pregnancy (Fig. 13.1). The uterus rises gradually to the level of the umbilicus by 20 to 22 weeks of gestation and nearly reaches the xiphoid process at term. Between weeks 38 and 40, fundal height decreases as the fetus begins to descend into the pelvis (lightening) in preparation for birth (see Fig. 13.1, dashed line). In general, lightening occurs in the nullipara approximately 2 weeks before the onset of labor and in the multipara at the start of labor. As the uterus enlarges and rises in the abdomen, it rotates to the right, probably because of the presence of the rectosigmoid colon on the left side. There is increased tension on the broad and round ligaments as the uterus enlarges; some women experience discomfort as this occurs. Eventually the growing uterus touches the anterior abdominal wall and displaces the intestines to either side of the abdomen (Fig. 13.2). When a pregnant woman is standing, most of her uterus rests against the anterior abdominal wall and contributes to altering her center of gravity. At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment (uterine isthmus) occurs (Hegar sign) (Fig. 13.3 ). This results in exaggerated uterine anteflexion during the first 3 months of pregnancy. In this position, the uterine fundus presses on the urinary bladder, causing the woman to have urinary frequency. • Blood components Blood Components By term, there is an increase in red blood cell (RBC) mass of 250 to 450 mL, or approximately 20% to 30% over prepregnancy values (Mastrobattista & Monga, 2019 ). The percentage of increase in RBCs depends on the amount of iron available. Because the plasma increase is greater than the increase in RBC production, there is a decrease in normal hemoglobin and hematocrit values (Table 13.2). This state of hemodilution is referred to as physiologic anemia of pregnancy . The decrease is more noticeable during the second trimester, when rapid expansion of blood volume occurs faster than RBC production. A pregnant woman is considered anemic if the hemoglobin is less than 11 g/dL or the hematocrit is less than 33% during the first or third trimester or if the hemoglobin is less than 10.5 g/dL or the hematocrit is less than 32% during the second trimester (West, Hark, & Catalano, 2017). The total white blood cell count begins to increase as early as the 2nd month, then levels off in the second or third trimester (Blackburn, 2018 ). This increase is primarily in the granulocytes, nonclassic monocytes, and polymorphonuclear leukocytes; the lymphocyte count stays approximately the same throughout pregnancy (see Table 13.2 ) (Cunningham, Leveno, Bloom, et al., 2018). Pregnancy is considered a hypercoagulable state in which women are at a fivefold to sixfold increased risk for thromboembolic disease (Antony et al., 2017). The circulation time decreases slightly by week 32 and returns to near normal by term. There is a greater tendency for blood to coagulate during pregnancy because of increases in various clotting factors (i.e., factors VII, VIII, IX, and X and fibrinogen) and decreases in factors that inhibit coagulation (e.g., protein S) (see Table 13.2). This tendency, combined with the fact that fibrinolytic activity (the splitting up or dissolving of a clot) is depressed during pregnancy and the postpartum period, provides a protective function to decrease the Cardiovascular Changes in Pregnancy Parameter Change Blood pressure Systolic Slight or no decrease from prepregnancy levels Diastolic Slight decrease to midpregnancy (24–32 weeks) and gradual return to prepregnancy levels by end of pregnancy Blood volume Increases by 1200–1500 mL or 40%– 50% above prepregnancy level Cardiac output Increases 30%–50% Data from Antony, K.M., Racusin, D.A., Aagaard, K., et al. (2017). Maternal physiology. In: S.G. Gabbe, J.R. Niebyl, J.L. Simpson, et al., (Eds.) Obstetrics: Normal and problem pregnancies (7th ed.). Philadelphia: Elsevier. Cardiac Output Cardiac output (CO) increases 30% to 50% during pregnancy, reaching a peak by 25 to 30 weeks and declining to approximately a 20% increase at 40 weeks of gestation. This elevated CO is largely a result of increased stroke volume and heart rate and occurs in response to increased tissue demands for oxygen (Mastrobattista & Monga, 2019). CO increases with any exertion such as labor and birth. Table 13.1 summarizes cardiovascular changes in pregnancy. Chapter 14 • Gravidity and parity • Nagele’s rule • Box 14. 1Use of the Naegele Rule • December 10, 2019, is the 1st day of the last menstrual period. Month Day Year Last menstrual period 12 10 2019 –3 +7 +1 Estimated date of birth: 9 17 2020 • The estimated date of birth is September 17, 2020. • Prenatal Labs • Laboratory Tests in the Prenatal Period Laboratory Test Purpose Hemoglobin, hematocrit, Detects anemia and • Laboratory Tests in the Prenatal Period Laboratory Test Purpose WBCs, differential infection Hemoglobin electrophoresi s Identifies women with hemoglobinopathies (e.g., sickle cell anemia, thalassemia) Blood type, Rh, and irregular antibody Identifies women whose fetuses are at risk for developing erythroblastosis fetalis or hyperbilirubinemia in the neonatal period Rubella titer Determines immunity to rubella Tuberculin skin testing; chest film after 20 weeks of gestation in women with reactive Screens for exposure to tuberculosis • Laboratory Tests in the Prenatal Period Laboratory Test Purpose risk factors; done at 24- 28 weeks for pregnant women at risk whose initial screen was negative and for others who were not previously tested 3-h glucose toleran ce Tests for gestational diabetes in women with elevated glucose level after 1- h test; must have two elevated readings for diagnosis Cardiac evaluation: ECG, chest x- ray, and echocardiogra m Evaluates cardiac function in women with a history of hypertension or cardiac disease BUN, Blood urea nitrogen; ECG, electrocardiogram; FTA-ABS, fluorescent treponemal antibody absorption; GBS, group B streptococcus; hCG, human chorionic gonadotropin; HIV, human immunodeficiency virus; HPV, human papillomavirus; RBCs, red blood cells; RPR, rapid plasma reagin; VDRL, Venereal Disease Research Laboratory; WBCs, white blood cells. Chapter 16 • Fetal attitude Fetal Attitude Attitude is the relation of the fetal body parts to one another. The fetus assumes a characteristic posture (attitude) in utero partly because of the mode of fetal growth and partly because of the way the fetus conforms to the shape of the uterine cavity. Normally the back of the fetus is rounded so that the chin is flexed on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees. The arms are crossed over the thorax, and the umbilical cord lies between the arms and the legs. This attitude is termed general flexion (see Fig. 16.2). FIG. 16.2 Examples of fetal vertex (occiput) presentations in relation to front, back, or side of materna l pelvis. Deviations from the normal attitude may cause difficulties in childbirth. For example, in a cephalic presentation, the fetal head may be extended or flexed in a manner that presents a head diameter that exceeds the limits of the maternal pelvis, leading to prolonged labor, forceps- or vacuum-assisted birth, or cesarean birth. Certain critical diameters of the fetal head can be measured by ultrasound. The biparietal diameter, which is about 9.25 cm at term, is the largest transverse diameter and an important indicator of fetal head size (Fig. 16.4B). In a well-flexed cephalic presentation, the biparietal diameter is the widest part of the head entering the pelvic inlet. Of the several anteroposterior diameters, the smallest and the most critical one is the suboccipitobregmatic diameter (about 9.5 cm at term). When the head is in complete flexion, this diameter allows the fetal head to pass through the true pelvis easily (Fig. 16.5A; see Fig. 16.4A). As the head is more extended, the anteroposterior diameter widens, and the head may not be able to enter the true pelvis (see Fig. 16.5). • Primary Powers Powers Involuntary and voluntary powers combine to expel the fetus and placenta from the uterus. Involuntary uterine contractions, called the primary powers, signal the beginning of labor. Once the cervix has dilated, voluntary bearing-down efforts by the woman, called the secondary powers, augment the force of the involuntary contractions. The involuntary contractions originate at certain pacemaker points in the thickened muscle layers of the upper uterine segment. From the pacemaker points, contractions move downward over the uterus in waves, separated by short rest periods. Terms used to describe these involuntary contractions include frequency (the time from the beginning of one contraction to the beginning of the next), duration (length of contraction), and intensity (strength of contraction at its peak). The primary powers are responsible for the effacement and dilation of the cervix and descent of the fetus. Effacement of the cervix means the shortening and thinning of the cervix during the first stage of labor. The cervix, normally 2 to 3 cm long and approximately 1 cm thick, is obliterated or “taken up” by a shortening of the uterine muscle bundles during the thinning of the lower uterine segment that occurs in advancing labor. Only a thin edge of the cervix can be palpated by an examiner when effacement is complete. Effacement generally progresses significantly in first-time term pregnancy before more than slight dilation occurs. In subsequent pregnancies, effacement and dilation of the cervix tend to progress together. Degree of mechanical stretching of the cervix occurs. Stretch receptors in the posterior vagina cause release of endogenous oxytocin that triggers the maternal urge to bear down, or the Ferguson reflex. Uterine contractions are usually independent of external forces. For example, laboring women who are paralyzed because of spinal cord lesions above the 12th thoracic vertebra have normal but painless uterine contractions. In addition, use of epidural analgesia during labor does not decrease the frequency or intensity of contractions (Cunningham et al., 2018). Chapter 17 • Medication administration IV route INTRAVENOUS ROUTE The preferred route of administration of medications such as meperidine, fentanyl, remifentanil, or nalbuphine is through IV tubing, administered into the port nearest the point of insertion of the infusion (proximal port). The medication is given slowly, in small amounts, during a contraction. It may be given over a period of three to five consecutive contractions if needed to complete the dose. It is given during contractions to decrease fetal exposure to the medication because uterine blood vessels are constricted during contractions and the medication stays within the maternal vascular system for several seconds before the uterine blood vessels reopen. The IV infusion is then restarted slowly to prevent a bolus of medication from being administered. With this method of injection, the amount of medication crossing the placenta to the fetus is minimized. With decreased placental transfer, the mother’s degree of pain relief is maximized. The IV route has the following advantages: 1. • Onset of pain relief is rapid and more predictable. 2. • Pain relief is obtained with small doses of the drug. 3. • Duration of effect is more predictable. • Medication for IV sedation • Narcan • Medication Guide • Naloxone Hydrochloride (Narcan) • Classification • Opioid antagonist • Action • Blocks both μ and κ opioid receptors from the effects of opioid agonists • Indication • Reverses opioid-induced respiratory depression in woman or newborn; may be used to reverse pruritus from epidural opioids • Dosage and Route • Adult • Opioid overdose: 0.4-2 mg IV, may repeat at 2- to 3- min intervals until a maximum of 10 mg has been given; if the intravenous route is unavailable, intramuscular or subcutaneous administration may be used. • Newborn • Although naloxone has been used in newborns, there is insufficient evidence to evaluate the safety and efficacy of this practice. Animal studies and case reports have raised concerns about complications from naloxone, including pulmonary edema, cardiac arrest, and seizures. • Adverse Effects • Maternal hypotension or hypertension, tachycardia, hyperventilation, nausea and vomiting, sweating, and tremulousness • Nursing Considerations • The woman should delay breastfeeding until the medication is out of her system (approximately 2 h after the last dose has been given). Do not give this medication to the woman or the newborn if the woman is opioid dependent as that may cause abrupt withdrawal in both the woman and newborn. If given to the woman for reversal of respiratory depression caused by an opioid analgesic, pain will return suddenly. The duration of action of naloxone is shorter than that of most opioids. Therefore the woman must be monitored closely for the return of Client Problem Expected Outcome Interventions Rationales birth plan created by the client and her support person supportive strategies that address specific needs Teach the woman and support person different positions and the use of pillows To reduce stiffness, aid circulation, and promote comfort Decreased ability to cope The client will demonst rate increase d ability to cope with the contracti ons Assess client behaviors/ac tions during contractions To determine if strategies other than those she is currently using might better help her cope with contraction s Client Problem Expected Outcome Interventions Rationales Demonstrate focusing, relaxation and breathing techniques, effleurage, and sacral pressure (if client complains of back pain) To enhance chances of success in using these techniques Teach the support person how to assist the laboring woman To provide continuous support and increase the likelihood of a positive response to comfort measures Chapter 18 • Fetal heart tracing assessment BOX 18. 1Three-Tier Fetal Heart Rate Classification System Category I Category I FHR tracings include all of the following: 1. • Baseline rate 110-160 beats/min (bpm) 2. • Baseline FHR variability: moderate 3. • Late or variable decelerations: absent 4. • Early decelerations: either present or absent 5. • Accelerations: either present or absent Category II Category II FHR tracings include all FHR tracings not categorized as category I or category III. Examples of category II tracings include any of the following: 1. • Baseline rate 2. 1. • Bradycardia not accompanied by absent baseline variability 2. • Tachycardia 3. • Baseline FHR variability 4. 1. • Minimal baseline variability 2. • Absent baseline variability not accompanied by recurrent decelerations 3. • Marked baseline variability 5. • Accelerations 6. 1. • No acceleration produced in response to fetal stimulation 7. • Periodic or episodic decelerations 8. 1. • Recurrent variable decelerations accompanied by minimal or moderate baseline variability 2. • Prolonged decelerations (≥2 min but <10 min) • External and Internal Modes of Monitoring External Mode Internal Mode sufficiently dilated during the intrapartum period. Internal Monitoring The technique of continuous internal FHR or UA monitoring provides a more accurate appraisal of fetal well-being during labor than external monitoring because it is not interrupted by fetal or maternal movement or affected by maternal size (Fig. 18.4). For this type of monitoring, the membranes must be ruptured, the cervix sufficiently dilated (at least 2 to 3 cm), and the presenting part, which is usually the fetal head, low enough to allow placement of the spiral electrode or IUPC, or both. Internal and external modes of monitoring may be combined (i.e., internal FHR with external UA or external FHR with internal UA) without difficulty. FIG. 18.4 Internal Monitoring.Diagrammatic representation of internal invasive fetal monitoring with intrauterine pressure catheter and spiral electrode in place (membranes ruptured and cervix dilated). FHR, Fetal heart rate. Internal monitoring of the FHR is accomplished by attaching a small spiral electrode to the presenting part. For UA to be monitored internally, an IUPC is introduced into the uterine cavity. The catheter has a pressure-sensitive tip that measures changes in intrauterine pressure. As the catheter is compressed during a contraction, pressure is placed on the pressure transducer. This pressure is then converted into a pressure reading in millimeters of mercury. The IUPC can objectively measure the frequency, duration, and intensity of UCs, and uterine resting tone. Because it can measure the intensity of individual UCs precisely, the IUPC can be used to evaluate the adequacy of UA for achieving progress in labor. Montevideo units (MVUs) are calculated by subtracting the baseline uterine pressure from the peak contraction pressure for each contraction that occurs in a 10-minute window and then adding together the pressures generated by each contraction that occurs during that period of time. Spontaneous labor usually begins when MVUs are between 80 and 120 (see Table 18.1) (Cunningham, Leveno, Bloom, et al., 2018 ; Miller et al., 2017 ). Chapter 19 • Interview during labor Interview The woman’s primary reason for coming to the hospital is determined in the interview. Her primary reason may be, for example, suspicion of ruptured membranes or desire for a period of observation because she is unsure about the onset of labor. Labor triage units offer time without official hospital admission to evaluate for labor or other concerns (Paul et al., 2017). Fig 19.3 shows the Maternal Fetal Triage Index developed by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), a tool for screening pregnant women who present to a hospital for care (Ruhl, Scheich, Onokpise, & Bingham, 2015 ). During the triage process, the nurse must determine the status of the woman’s amniotic membranes. If the woman has noticed a gush or leakage of fluid, the membranes may have ruptured (spontaneous rupture of membranes [SROM]). If there has been a discharge that may be amniotic fluid, in many instances a sterile speculum examination and Nitrazine (pH) and fern tests can determine whether the membranes have ruptured (Box 19.1 ). FIG. 19.3 Maternal Fetal Triage Index (MFTI). From Ruhl, C., Scheich, B., Onokpise, B., & Bingham, D. (2015). Interrater reliability BOX 19. 1Procedure: Tests for Rupture of Membranes Nitrazine Test for pH 1.• Explain procedure to the woman or couple. Procedure 1. 2. Perform hand hygiene and put on sterile gloves. Use a cotton-tipped applicator impregnated with Nitrazine dye for determining pH (differentiates amniotic fluid, which is slightly alkaline, from urine and purulent material [pus], which are acidic). 3.• Dip the cotton-tipped applicator deep into the vagina to sample fluid (this procedure may be performed during speculum examination). Read Results 1.• Membranes probably intact: identifies vaginal and most body fluids that are acidic: of testing the maternal triage index. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 46(6), 710–716. Bloody show is distinguished from vaginal bleeding by the fact that it is pink and feels sticky because of its mucoid nature. There is very little bloody show in the beginning, but the amount increases with effacement and dilation of the cervix. A woman may report a small amount of brownish-to-bloody discharge that may be attributed to cervical trauma resulting from vaginal examination or coitus (intercourse) within the preceding 48 hours. Yellow pH 5.0 Olive-yellow pH 5.5 Olive-green pH 6.0 BLADDER FUNCTION The mother should void spontaneously within 6 to 8 hours after giving birth. The first several voidings should be measured to document adequate emptying of the bladder. A volume of at least 150 mL is expected for each voiding. Some women experience difficulty in emptying the bladder, possibly as a result of diminished bladder tone, edema from trauma, or fear of discomfort. Nursing interventions for inability to void and bladder distention are discussed in the “Preventing Bladder Distention” section earlier in the chapter. Urinary incontinence is not uncommon, especially if there was significant perineal trauma with birth. Pelvic floor muscle training, also known as Kegel exercises, helps to strengthen muscle tone, particularly after vaginal birth. Kegel exercises help women to regain the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength benefit years later by retaining urinary continence. Women must learn to perform Kegel exercises correctly (see Guidelines box: Kegel Exercises in Chapter 4). Some women perform the exercises incorrectly and can increase the risk for incontinence, which can occur when inadvertently bearing down on the pelvic floor muscles, thrusting the perineum outward. The health care provider can assess the woman’s technique during the pelvic examination at her follow-up visit by inserting two fingers intravaginally and noting whether the pelvic floor muscles correctly contract and relax. • Rhogam Medication Guide Rh Immune Globulin, RhoGAM, Gamulin Rh, HypRho-D, Rhophylac Action Suppression of immune response in nonsensitized women with Rh-negative blood who receive Rh-positive blood cells because of fetomaternal hemorrhage, transfusion, or accident Indications Routine antepartum prevention at 28 weeks of gestation in women with Rh-negative blood; suppress antibody formation after birth, miscarriage, pregnancy termination, abdominal trauma, ectopic pregnancy, amniocentesis, version, or chorionic villus sampling Dosage and Route Standard dose: 1 vial (300 mcg) IM in deltoid or gluteal muscle; microdose: 1 vial (50 mcg) IM in deltoid muscle; Rho(D) immune globulin (Rhophylac) can be given IM or IV (available in prefilled syringes). Adverse Effects Myalgia, lethargy, localized tenderness and stiffness at injection site, mild and transient fever, malaise, headache; rarely nausea, vomiting, hypotension, tachycardia, possible allergic response Nursing Considerations 1. • Give standard dose to mother at 28 weeks of gestation as prophylaxis or after an incident or exposure risk that occurs after 28 weeks of gestation (e.g., amniocentesis, second-trimester miscarriage or abortion, and after external version). 2. • Give standard dose within 72 h after birth if neonate is Rh-positive. 3. • Give microdose for first-trimester miscarriage or abortion, ectopic pregnancy, chorionic villus sampling. 4. • Verify that the woman is Rh-negative and has not been sensitized, if postpartum that Coombs test is negative, and that baby is Rh-positive. Provide explanation to the woman about the procedure, including the purpose, possible side effects, and effect on future pregnancies. Have the woman sign a consent form if required by agency. Verify correct dosage and confirm lot number and woman’s identity before giving injection (verify with another registered nurse or by other procedure per agency policy); document administration per agency policy. Observe client for at least 20 min after administration for allergic response. associated with sore nipples, the mother may apply topical preparations or hydrogel pads (see Chapter 25 ). Breast engorgement can occur whether the woman is breastfeeding or formula feeding. The discomfort associated with engorged breasts may be reduced by applying ice packs or cabbage leaves (or both) to the breasts (Fig. 25.17) and wearing a well-fitted support bra. Antiinflammatory medications such as ibuprofen can also be helpful in relieving some of the discomfort. Decisions about specific interventions for engorgement are based on whether the woman chooses breastfeeding or formula feeding. For example, breastfeeding mothers can feed frequently and use hand expression or a breast pump to reduce engorgement and promote comfort (see Chapter 25 ). Formula-feeding mothers with engorged breasts should not express breast milk as it can stimulate milk production and worsen engorgement. Chapter 23 • Thermoregulation THERMAL FACTORS With birth the newborn enters the extrauterine environment in which the temperature is significantly lower. The profound change in environmental temperature stimulates receptors in the skin, resulting in stimulation of the respiratory center in the medulla. • Caput vs. cephalohematoma • • Caput succedaneum is a generalized, easily identifiable edematous area of the scalp, most often on the occiput (Fig. 23.15A ). With vertex presentation, the sustained pressure of the presenting part against the cervix results in compression of local vessels, slowing venous return. The slower venous return causes an increase in tissue fluids within the skin of the scalp, and edema develops. This edematous area, present at birth, extends across suture lines of the skull and usually disappears spontaneously within 3 to 4 days. Infants who are born with the assistance of vacuum extraction usually have a caput in the area where the cup was applied. Bruising of the scalp is often seen in the presence of caput succedaneum. • Cephalhematoma is a collection of blood between a skull bone and its periosteum. Therefore a cephalhematoma does not cross a cranial suture line (see Fig. 23.15B ). A cephalhematoma is firmer and better defined than a caput. Often caput succedaneum and cephalhematoma occur simultaneously. A cephalhematoma usually resolves in 2 to 8 weeks. As the hematoma resolves, hemolysis of RBCs occurs, and hyperbilirubinemia can result. • Establishing respirations Establishing Respiration At term the lungs hold approximately 20 mL of fluid per kilogram. Air must be substituted for the fluid that filled the fetal respiratory tract. Traditionally it had been thought that the thoracic squeeze occurring during normal vaginal birth resulted in significant clearance of lung fluid. However, it appears that this event plays a minor role. In the days preceding labor, there is reduced production of fetal lung fluid and concomitant decreased alveolar fluid volume. Shortly before the onset of labor, there is a catecholamine surge that seems to promote fluid clearance from the lungs, which continues during labor. The movement of lung fluid from the air spaces occurs through active transport into the interstitium, with drainage occurring through the pulmonary circulation and lymphatic system. Retention of lung fluid can interfere with the infant’s ability to maintain adequate oxygenation, especially if other factors that compromise respirations (e.g., meconium aspiration, congenital diaphragmatic hernia, esophageal atresia with fistula, choanal atresia, congenital cardiac defect, immature alveoli) are unusual. The ribs of the infant articulate with the spine at a horizontal rather than a downward slope; consequently, the rib cage cannot expand with inspiration as readily as that of an adult. Because neonatal respiratory function is largely a matter of diaphragmatic contraction, abdominal breathing is characteristic of newborns. The newborn infant’s chest and abdomen rise simultaneously with inspiration. • Signs of respiratory distress Signs of Respiratory Distress Signs of respiratory distress can include nasal flaring, intercostal or subcostal retractions (in-drawing of tissue between the ribs or below the rib cage), or grunting with respirations. Suprasternal or subclavicular retractions with stridor or gasping most often represent an upper airway obstruction. Seesaw or paradoxic respirations (exaggerated rise in abdomen with respiration as the chest falls) instead of abdominal respirations are abnormal and should be reported. A respiratory rate of less than 30 or greater than 60 breaths/min with the infant at rest must be evaluated. The respiratory rate of the infant can be slowed, depressed, or absent as a result of the effects of analgesics or anesthetics administered to the mother during labor and birth. Apneic episodes can be related to events such as rapid increase in body temperature, hypothermia, hypoglycemia, or sepsis. Tachypnea can result from inadequate clearance of lung fluid, or it can be an indication of respiratory distress syndrome (RDS). Tachypnea can be the first sign of respiratory, cardiac, metabolic, or infectious illnesses (Gardner, Enzman-Hines, & Nyp, 2016 ). Changes in the infant’s color can indicate respiratory distress. Normally, within the first 3 to 5 minutes after birth, the newborn’s color changes from blue to pink. Acrocyanosis, the bluish discoloration of hands and feet, is a normal finding in the first 24 hours after birth. Transient periods of duskiness while crying are common immediately after birth; however, central cyanosis is abnormal and signifies hypoxemia. With central cyanosis, the lips and mucous membranes are bluish (circumoral cyanosis). It can be the result of inadequate delivery of oxygen to the alveoli, poor perfusion of the lungs that inhibits gas exchange, or cardiac dysfunction. Because central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears. Infants who experience mild TTN often have signs of respiratory distress during the first 1 to 2 hours after birth as they transition to extrauterine life. Tachypnea with rates up to 100 breaths/min can be present along with intermittent grunting, nasal flaring, and mild retractions. Supplemental oxygen may be needed. TTN usually resolves in 48 to 72 hours (Blackburn, 2018 ). In neonates with more serious respiratory problems, symptoms of distress are more pronounced and tend to last beyond the first 2 hours after birth. Respiratory rates can exceed 120 breaths/min. Moderate to severe retractions, grunting, pallor, and central cyanosis can occur. The respiratory symptoms can be accompanied by hypotension, temperature instability, hypoglycemia, acidosis, and signs of cardiac problems. Common respiratory complications affecting neonates include RDS, meconium aspiration, pneumonia, and persistent pulmonary hypertension of the newborn (PPHN). Congenital defects such as anomalies of the great vessels, diaphragmatic hernia, or chest wall defects can cause severe respiratory problems. Blood incompatibilities such as hydrops fetalis can result in respiratory compromise (Gardner, Enzman- Hines, & Nyp, 2016) (see Chapter 36). Chapter 24 • Vitamin K Vitamin K Prophylaxis At birth, neonates have low vitamin K levels related to limited transplacental transfer of vitamin K and the lack of normal intestinal flora necessary for vitamin K synthesis. The establishment of normal intestinal flora begins with early 1991). Box 24.2 highlights specific maneuvers used in gestational age assessment. • Car seat safety Car Seat Safety Infants and toddlers to the age of 2 years should travel only in federally approved rear-facing safety seats secured in the rear seat using the vehicle safety belt or an anchor and tether system (Fig. 24.24). A car safety seat that faces the rear gives the best protection for an infant’s disproportionately weak neck and heavy head. In this position, the force of a frontal crash is spread over the head, neck, and back; the back of the car safety seat supports the spine (AAP, 2018 ). Additional information related to car seat safety is located in the Teaching for Self-Management box: Key Points About Car Seat Safety. FIG. 24.21 Holding The Baby Securely With Support for Head.(A) Holding infant while moving infant from scale to bassinet. Baby is undressed to show posture. (B) Holding baby upright in “burping” position. (C) “Football” (under the arm) hold. (D) Cradling hold. A, Courtesy Kim Molloy, Knoxville. B, C, and D, Courtesy Julie Perry Nelson, Loveland, CO. FIG. 24.22 Sunglasses Protect the Infant’s Eyes. Courtesy Julie Perry Nelson, Loveland, CO. FIG. 24.23 Newborn in Sleep Sack. Courtesy Allison and Matthew Wyatt, Eagle, CO. Teaching for Self-Management Key Points About Car Seat Safety General 1. • Always place your baby in an approved car safety seat when traveling in a motor vehicle (car, truck, bus, van), train, or airplane. 2.• Your baby should be in a rear-facing infant car safety seat from birth for as long as possible until exceeding the car seat’s limits for height and weight. The car safety seat should be in the back 1.Rear-facing infant seats should never be placed in the front seat, because if the air bag deploys it can be dangerous, even fatal, for the infant. 2.• If the infant must ride in the front seat, the air bag must be turned off. 3.• Before purchasing an infant car seat, investigate which car seat is the most appropriate based on the infant’s size and the type of vehicle in which the car seat will be installed (htt p s : // w w w .nht s a . g o v / e qui pm e nt / c a r - s e a t s - a nd- booster-seats). 4.• For help with proper installation of the car seat, go to a car seat safety station in your community (h t tp s : / / c e r t.s a fe ki d s . o r g / ge t - c a r - s e a t - c he c k e d ). 5. • The car seat should have a five-point safety harness that goes over both shoulders and both hips, and buckles at the crotch. 6. • Shoulder harnesses are placed in the slots at or below the level of the infant’s shoulders. The harness should be snug, and the retainer clip should be placed at the level of the infant’s armpits, not on the abdomen or neck area. 7. • Position infant at a 45-degree angle in the car seat to prevent slumping and airway obstruction; a tightly rolled blanket may be placed on either side of infant if needed. 8. • Avoid bulky clothing on the infant; this could cause the harness to loosen and increase the risk of infant injury. 9. • Blankets on top of the infant may be added for warmth. 10. • An infant car seat challenge is recommended by the AAP for infants who are born at less than 37 weeks’ gestation. This test is performed for at least 90-120 min or a period of time equal to the length of the car ride home. The infant is monitored for apnea, bradycardia, and a decrease in oxygen saturation. If the infant exhibits any of these clinical signs, travel home should be in an approved car bed. Cars with front air bags Cars with side air bags 1. Parents need to read the vehicle owner’s manual for information about car seat placement. Data from ). Rear facing car seats for infants and toddlers. Itasca, IL: Author. Retrieved from ; . Guidelines for perinatal care (8th ed.). Elk Grove Village, IL: Author; . Safe transportation of preterm and low birth weight infants at hospital discharge. Pediatrics, 123(5), 1424–1429. FIG. 24.24 Rear-facing car seat in rear seat of car. Infant is placed in seat when going home from the hospital. Courtesy Brian and Mayannyn Sallee, Tucson, AZ.) Safety Alert If the parents do not have a car safety seat, arrangements should be made to make an appropriate seat available for purchase, loan, or donation. Parents need to be cautioned about purchasing a secondhand car safety seat without knowing its history. They should never use a car seat that was involved in a moderate to severe crash, is too old, has visible cracks, does not have a label with the model number and manufacture date, does not come with instructions, is missing parts, or was recalled (AAP, 2018 ). • Hyperbilirubinemia HYPERBILIRUBINEMIA ASSESSMENT AND SCREENING The majority of newborn infants experience some level of jaundice, most of which is benign. In most cases, this is physiologic jaundice, caused by increased levels of The second way to assess for hyperbilirubinemia is to draw a serum bilirubin value. The levels, TcB or TSB, are interpreted by plotting them on an hour-specific nomogram to determine the infant’s risk for hyperbilirubinemia. Repeat testing is based on the risk level (low, intermediate, or high), the age of the neonate, and the progression of jaundice (AAP Subcommittee on Hyperbilirubinemia, Pediatrics 2004; Barrington, Sankaran, & CPS Fetus and Newborn Committee, 2007/2018). Many providers use a bilirubin tool (www.bilitool.org) that facilitates calculating the risk for neonatal hyperbilirubinemia. Infants in the low-risk category are less likely to develop hyperbilirubinemia. However, the AAP warns that all infants should be considered as being at potential risk for hyperbilirubinemia, even if they were identified as being in the low-risk category. This means that all newborns should be followed after discharge from the birthing facility for the development of unexpected jaundice, and that parents should be given printed and oral information about newborn jaundice (AAP & ACOG, 2017). Adequate feeding is essential in preventing hyperbilirubinemia. Newborns should breastfeed early (within 1–2 hours after birth) and often (at least 8–12 times/24 hours) (AAP Section on Breastfeeding, 2012; AAP Subcommittee on Hyperbilirubinemia, 2004). Frequent feedings help decrease the risk of hyperbilirubinemia. Colostrum acts as a laxative to promote stooling, which helps rid the body of bilirubin. Formula- fed infants should be fed within the first hour of life and then at least every 8 to 12 times every 24 hours. Newborns should be assessed for risk factors for severe hyperbilirubinemia. The most common risk factor is gestational age less than 35 to 36 weeks. Close follow-up of infants at risk for hyperbilirubinemia is essential; parents should be educated and encouraged to follow postdischarge recommendations (AAP Subcommittee on Hyperbilirubinemia, 2004). Follow-up should occur 48 to 72 hours after discharge from the birthing facility, or sooner based on the length of stay and presence of risk factors for hyperbilirubinemia (AAP & ACOG, 2017). If an infant appears jaundiced in the first 24 hours of life, a TcB or TSB level should be measured and results interpreted based on the newborn’s age in hours according to the hour- specific nomogram for infants born at 35 weeks of gestation or later (AAP Subcommittee on Hyperbilirubinemia, 2004). This type of jaundice is called pathologic. Repeat testing is based on the risk level (low, intermediate, or high), the age of the newborn, and the progression of jaundice. Additional labs may also be ordered for this newborn. THERAPY FOR HYPERBILIRUBINEMIA The decision to treat an infant for hyperbilirubinemia is based on TSB levels, the infant’s gestational age, and the presence of risk factors. Using a nomogram that plots bilirubin levels according to the infant’s age in hours at the time the specimen was drawn, the provider determines the appropriate management plan. The AAP established guidelines that provide direction for health care providers in determining the need for phototherapy or exchange transfusion (AAP Committee on Hyperbilirubinemia, 2004). FIG. 24.7 Transcutaneous Monitoring of Bilirubin With a Transcutaneous Bilirubinometry Monitor. Courtesy Cheryl Briggs, RNC, Annapolis, MD. The goal of treatment of hyperbilirubinemia is to reduce the newborn’s serum levels of unconjugated bilirubin. There are two ways to reduce unconjugated bilirubin levels: phototherapy and exchange blood transfusion. Phototherapy is the most common treatment. Exchange transfusion is used to treat those infants whose serum bilirubin levels are rising rapidly despite the use of intensive phototherapy. Phototherapy Phototherapy uses light energy to change the shape and structure of unconjugated bilirubin, converting it into a conjugated form that can be excreted through urine and stool. Phototherapy can be delivered by a lamp, blanket, pad, or cover-body devices. The severity of the newborn’s Safety Alert When phototherapy lights are used, no ointments, creams, or lotions should be applied to the newborn’s skin because they can absorb heat and cause burns. Urine output can be decreased or unaltered; the urine can have a dark gold or brown appearance. The number and consistency of stools are monitored. Bilirubin is excreted primarily through the stool, so it is important that the infant is having bowel movements. Bilirubin breakdown increases gastric motility, which can result in loose stools that can cause skin excoriation and breakdown. The infant’s buttocks must be cleaned after each stool to help maintain skin integrity. Infants under phototherapy lights need to be repositioned at least every 2 to 3 hours to maximize skin exposure. Transient skin rashes or tanning of the skin can occur during phototherapy. In rare instances, there can be bullous eruptions or the development of bronze baby syndrome in which the skin appears grayish brown (Kamath-Rayne et al., 2016). There is a lack of evidence regarding the long-term effects of phototherapy (Bhutani & Committee on Fetus and Newborn, 2011). In addition to phototherapy lights, other systems are used for phototherapy. A bassinet system provides special blue light above and beneath the infant. Another phototherapy device is a fiberoptic blanket that is connected to a light source. The blanket is flexible and can be placed around the infant’s torso or underneath the infant in the bassinet. There are also bilirubin beds with LED lights in a pad that covers the surface of the bassinet (Fig. 24.9). The LEDs do not produce heat and can be used with radiant warmers. These devices are usually less effective when used alone as compared with conventional phototherapy lights. They can be very useful in combination with overhead phototherapy lights. In certain instances, the infant’s bilirubin levels increase rapidly and intensive phototherapy is required; this situation involves the use of a combination of conventional lights and fiberoptic blankets to maximize bilirubin reduction. Although fiberoptic lights do not produce heat as do conventional lights, staff should ensure that a covering pad is placed between the infant’s skin and the fiberoptic device to prevent skin burns, especially in preterm infants. The newborn can remain in the mother’s room in an open crib or in her arms during treatment. The use of eye patches depends on whether the devices are used alone or in combination with phototherapy lights. FIG. 24.9 Infant Receiving Phototherapy Using a Bilirubin Bed. Courtesy Cheryl Briggs, RNC, Annapolis, MD. The use of home phototherapy should be reserved for healthy term infants with bilirubin levels in the “optional phototherapy” range according to the nomogram. The concern is that home phototherapy units do not provide the same level of irradiance or body surface coverage as phototherapy devices used in the hospital (AAP Committee on Hyperbilirubinemia, 2004). The use of home phototherapy is also dependent on the newborn’s insurance coverage; many companies do not cover this therapy. Phototherapy treatment is associated with concerns related to psychobehavioral issues,including parent-infant separation, potential social isolation, decreased sensorineural stimulation, altered biologic rhythms, altered feeding patterns, and activity changes. Parental anxiety can be greatly increased, particularly at the sight of the newborn with eyes covered and under special lights. The interruption of breastfeeding for phototherapy is a potential deterrent to successful maternal- infant attachment and interaction. Although there are conflicting opinions about continuous versusintermittent phototherapy, for most infants phototherapy can safely be interrupted for feedings, parental interaction, assessments, and obtaining bloodsamples for testing (Kamath- Rayne et al., 2016). Close follow-up is needed for infants who have been treated for hyperbilirubinemia. Repeat testing of serum bilirubin levels and follow-up visits with the pediatric health care provider are expected. In some cases, a nurse may conduct a home visit to regular feeding promotes normoglycemia. There is no need to routinely assess glucose levels of healthy term infants. Infants considered to be at risk for hypoglycemia should be screened during the first several hours of life. Infants at risk include those who are preterm or late preterm; SGA or LGA; low birth weight; infants of mothers with diabetes; and infants who experienced perinatal stress such as asphyxia, cold stress, or respiratory distress (AAP & ACOG, 2017; Wight, Marinelli, & Academy of Breastfeeding Medicine, 2014 ). Screening and treatment protocols vary across institutions. Glucose levels should be measured in all newborns with risk factors for hypoglycemia and in any newborn with clinical manifestations of hypoglycemia. The frequency of glucose testing is determined by the risk factors for each individual newborn. According to the AAP, late preterm and term SGA, infants of mothers with diabetes/LGA neonates are at risk for hypoglycemia and should be fed within the first hour, with glucose testing done 30 minutes after feeding. For at least the first 24 hours after birth, these infants should be fed every 2 to 3 hours, with glucose levels measured before each feeding. Further testing is based on glucose levels and feeding skills (Adamkin & Committee on Fetus and Newborn, 2011). Early, frequent breastfeeding and SSC with the mother for as long as possible after birth promote thermoregulation and stabilization of glucose levels (Wight et al., 2014 ). Nurses should observe all newborns for signs of hypoglycemia. Glucose testing should be done on any infant with clinical signs of hypoglycemia. These signs can be transient or recurrent and include jitteriness, lethargy, poor feeding, abnormal cry, hypotonia, temperature instability (hypothermia), respiratory distress, apnea, and seizures (Rozance et al., 2016 ). It is important to remember that hypoglycemia can be present in the absence of clinical manifestations. Bedside glucose monitoring is performed using reagent test strips with or without a reflectance colorimeter. Because of variations in devices and operator techniques, it is recommended that any level less than 45 mg/dL should be Nursing Alert A heel warmer should be applied prior to every glucose assessment via heelstick. If the extremity is cool, the test result can be falsely low. confirmed with a stat serum glucose level, depending on facility policy. However, treatment of hypoglycemia should not be delayed while awaiting serum glucose results (Rozance et al., 2016; Wight et al., 2014 ). Protocols for treatment of hypoglycemia vary and change frequently based on new evidence. In general, for newborns who are clinically stable and well appearing, early and frequent oral feedings are suggested. Infants who are at an increased risk for aspiration, who have poor perfusion, or are thought to have a bowel obstruction are not enterally fed and will need intravenous fluids to normalize and maintain their blood glucose levels (Karlsen, 2012). (See Chapters 23 and Chapter34 for more information on hypoglycemia.) • Circumcision Newborn Male Circumcision (NMC) POLICIES AND RECOMMENDATIONS Circumcision is the removal of the foreskin (prepuce) of the penis, exposing the glans. Usually it is performed during the first few days of life but is sometimes done at a later time for preterm or ill neonates or for religious or cultural reasons. The most recent data from the CDC indicates that rates of newborn circumcision performed in U.S. hospitals peaked at 64.5% in 1981, dropping to a low of 55.4% in 2007. Rates increased slightly to 58.3% in 2010 (Owings, Uddin, & Williams, 2013). Changes in recommendations from the AAP regarding NMC have likely influenced U.S. circumcision rates. The AAP policy on circumcision that was issued in 1999 and reaffirmed in 2005 recognized potential benefits of NMC, although the AAP did not deem them sufficient to recommend routine newborn Legal Tip Newborn Male Circumcision Circumcision requires informed consent. Although the health care provider who will perform the procedure is legally responsible for educating parents about newborn circumcision so they can make an informed decision, nurses are often involved in discussions on this topic and should provide parents with current evidence-based information. Any questions or concerns regarding the procedure should be communicated with the provider so the parents have the opportunity to have those questions or concerns addressed prior to the procedure being performed. are considerations in the parents’ decision-making process. Parents need to make an informed choice regarding newborn circumcision based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families can help parents make an informed choice about newborn circumcision by providing factual, unbiased, evidence-based information. They can provide opportunities for discussion about the benefits and risks of the procedure. Expectant parents need to begin learning about circumcision during the prenatal period, but circumcision often is not discussed with the parents. An excellent resource for parents can be found at www.acog/org/Patients/FAQs/Newborn-Male- Circumcision. In many instances, it is only when the mother is being admitted to the hospital or birthing unit that she is first confronted with the decision regarding circumcision. Because the stress of the intrapartum period makes this a difficult time for parental decision making, this is not an id al tim to broach th t pic of circumcision and expect a well-informed decision. PROCEDURE Circumcision is not performed immediately after birth because of the danger of cold stress and decreased clotting factors but is usually done in the hospital before discharge. The circumcision of a Jewish male infant is commonly performed on the eighth day after birth at home in a ceremony called a bris. This timing is logical from a physiologic standpoint because clotting factors decrease somewhat immediately after birth and do not return to prebirth levels until the end of the first week. Feedings may be withheld up to 2 to 3 hours before the circumcision to prevent vomiting and aspiration, although in some hospitals, infants are allowed to breastfeed until they are taken to the nursery for the procedure. To prepare the infant for the circumcision, he is positioned on a plastic restraint form (Fig. 24.16), and the penis is cleansed with an antiseptic solution such as povidone- iodine. The infant is draped to provide warmth and a sterile field, and the sterile equipment is readied for use. FIG. 24.16 Positioning of Infant for Circumcision in Immobilizer Device. Note swaddling of upper body and use of pacifier as measures to reduce discomfort. Courtesy Paul Vincent Kuntz, Texas Children’s Hospital, Houston, TX. In the hospital setting, newborn circumcision is usually performed using the Gomco (Yellen) or Mogen clamp or the PlastiBell device. The technique is usually based on health care provider training and preference. The procedure takes only a few minutes to perform. Use of the Gomco or Mogen clamp involves surgical removal of the foreskin. The clamp technique minimizes blood loss (Fig. 24.17). After the circumcision is completed, a small petrolatum gauze dressing is applied to the penis for the first 24 hours; thereafter, parents are instructed to apply petrolatum with each diaper change for 7 to 10 days to keep the penis from adhering to the diaper (AWHONN, 2018). With the PlastiBell technique, the plastic bell is first fitted over the glans, a suture is tied around the rim of the bell, and excess foreskin is cut away. The plastic rim remains in place for about 1 week; it falls off after healing has taken place, usually within 5 to 7 days (Fig. 24.18). Petrolatum or dressings are usually not applied to the penis following circumcision with the PlastiBell (AWHONN, 2018). Teaching for Self-Management Care of the Circumcised Newborn at Home FIG. 24.18 The PlastiBell Technique.(A) The PlastiBell is placed over the glans inside the prepuce. (B) A string is then tied around the prepuce and positioned in the groove of the bell. The excess foreskin is trimmed, and the handle is broken off the bell. The foreskin remnant and bell are expected to slough in 1 to 2 weeks. From Holcomb, G.W., Murphy, J.P., Ostlie, D.J. [2014]. Ashcraft’s pediatric surgery [6th ed.]. Philadelphia: Elsevier. CARE OF THE NEWLY CIRCUMCISED INFANT Postcircumcision protocols vary. In many settings, the circumcision site is assessed for bleeding every 15 to 30 minutes for the first hour and then hourly for the next 4 to 6 hours. The nurse monitors the infant’s urinary output, noting the time and amount of the first voiding after the circumcision. If bleeding occurs from the circumcision site, the nurse applies gentle pressure with a folded sterile gauze pad. A hemostatic agent such as Gelfoam powder or sponge can be applied to help control bleeding. If bleeding is not easily controlled, a blood vessel may need to be ligated. In this event, one nurse notifies the health care provider and prepares the necessary equipment (i.e., circumcision tray and suture material) while another nurse maintains intermittent pressure until the provider arrives. Nurses provide education for parents related to care of the circumcised infant, which includes observing for complications such as bleeding or infection (see the Teaching for Self- Management box: Care of the Circumcised Newborn at Home). Parents need support and encouragement as they perform postcircumcision care. Newborns typically cry when the diaper is changed and when petrolatum gauze is removed and reapplied. This can make new parents feel anxious because they do not want to inflict pain on the infant. Nurses can inform parents that the discomfort is usually temporary and will soon subside. In addition, nurses can teach parents a variety of nonpharmacologic comfort measures. Wash hands or use a waterless hand cleaner before touching the newly circumcised penis. Check for Bleeding 1. • Check circumcision site for bleeding with each diaper change. 2. • If bleeding occurs, apply gentle pressure with a folded sterile gauze square. If bleeding does not stop with pressure, notify the pediatric health care provider. Observe for Urination 1. • Check to see that the infant urinates after being circumcised. 2. • Infant should have a wet diaper 2-6 times per 24 h the first 1-2 days after birth and then at least 6-8 times per 24 h after 3-4 days. Keep Area Clean 1. • Change the diaper often. Inspect the circumcision with each diaper change. 2. • For the first 3-4 days cleanse the penis gently with water only. Do not use baby wipes. 3. • For 4-7 days apply petrolatum to the glans with each diaper change (petrolatum is usually not used after PlastiBell circumcision). 4. • If a PlastiBell was used: 5. 1. • With diaper changes inspect the position of the plastic ring. Notify the pediatric care provider if the ring moves onto the shaft of the penis. 2. • The plastic ring should fall off after 1 week. If it is still in place after 8 days, notify the pediatric care provider. 6. • Apply the diaper loosely over the penis to prevent pressure on the circumcised area. 7. • Use sponge bathing for the first week, until the circumcision is healed. Check for Infection 1. • The glans of the penis is dark red after circumcision and then becomes covered with yellow exudate in 24-48 h, which is normal and will persist for 2-3 days. Do not attempt to remove this exudate; this is granulation tissue and is part of the healing process. 2. • Redness, swelling, discharge, or odor indicates infection. Notify the pediatric health care provider if you think the circumcision area is infected. Provide Comfort 1. • Circumcision is painful. Handle the area gently. 2. • Provide comfort measures such as holding the baby skin to skin, breastfeeding, cuddling, swaddling, or rocking. Data from American Association of Pediatrics. (2016). How to care for your baby’s penis. Retrieved from https://www.healthychildren.org/English/ages- stages/baby/bathing-skin-care/Pages/Caring-For-Your-Sons- Penis.aspx; Association of Women’s Health, Obstetric and Neonatal Nurses. (2018). Neonatal skin care: Evidence-based clinical practice guideline (4th ed.). Washington, DC: Author; World Health Organization & Jhpiego. (2010). Manual for early infant male circumcision under local anesthesia. Geneva, Switzerland: WHO Press. • Apgar Apgar Score The Apgar score is a routine rapid assessment of the newborn’s overall status and response to resuscitation (AAP & American College of Obstetricians and Gynecologists [ACOG], 2017). This assessment is based on five signs that indicate the physiologic state of the neonate: (1) heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord; (2) respiratory effort, based on observed movement of the chest wall; (3) muscle tone, based on degree of flexion and movement of the extremities; (4) reflex irritability, based on presence of a grimace, crying, or active withdrawal; and (5) generalized skin color, described as pallid, cyanotic, or pink (see Table 24.2 ). Evaluations can be completed by the nurse or Box 25. 2 Signs of Effective Breastfeeding Mother 1. • Onset of copious milk production (milk is “in”) by day 3 or 4 2. • Firm tugging sensation on nipple as infant sucks but no pain 3. • Uterine contractions and increased vaginal bleeding while feeding (first week or less) 4. • Feels relaxed and drowsy while feeding 5. • Increased thirst 6. • Breasts soften or feel lighter while feeding 7. • With milk ejection (let-down), can feel warm rush or tingling in breasts, leaking of milk from opposite breast Infant 1. • Latches without difficulty that parents can use to track infant feedings and urine/stool output. The infant’s output is highly indicative of feeding adequacy. It is important that parents are aware of the expected changes in the characteristics of urine output and bowel movements during the early newborn period. As the volume of breast milk increases, urine becomes more dilute and should be light yellow; dark, concentrated urine can be associated with inadequate intake and possible dehydration. (Note: Infants with jaundice often have darker urine as bilirubin is excreted.) Infants should have at least six to eight sufficiently wet diapers (light yellow urine) every 24 hours after day 4. The first 1 to 2 days after birth, newborns pass meconium stools, which are greenish black, thick, and sticky. By day 2 or 3, the stools become greener, thinner, and less sticky. If the mother’s milk has transitioned by day 3 or 4, the stools start to appear greenish yellow and are looser. By the end of the first week, breast milk stools are yellow, soft, and seedy (they resemble a mixture of mustard and cottage cheese). If an infant is still pa sing meconium stool by day 3 or 4, breastfeeding effectiveness and milk transfer should be assessed. 3. 4. 5. 6. Audible swallowing is present Easily releases breast at end of feeding Infant appears content after feeding Has at least three substantive bowel movements and six to eight wet diapers every 24 hrs after day 4. Infants should have at least three stools (quarter-size or larger) per day for the first month. Some babies stool with every feeding. The stooling pattern gradually changes; breastfed infants can continue to stool more than once per day, or they may stool only every 2 or 3 days. As long as the baby continues to gain weight and appears healthy, this decrease in the number of bowel movements is normal. Assessment of Effective Breastfeeding The nurse should observe at least one breastfeeding session every 8 to 12 hours to assess feeding effectiveness while the mother and newborn are in the hospital; at least one assessment is needed during the 8 hours prior to discharge (Evans, Marinelli, Taylor, et al., 2014). The assessment should include positioning, latch, and milk transfer. Using a standard breastfeeding scoring tool such as the LATCH tool (Jenson, Wallace, & Kelsay, 1994) to document observations provides consistency in assessment criteria. With the LATCH assessment tool, each letter represents a scored item: Latch, Audible swallowing, Type of nipple, Comfort level of the mother, and Hold (positioning). During the feeding assessment, the nurse can provide education about breastfeeding, help with feeding techniques, and offer support. If the mother’s partner or other family members are present, the nurse can include them in the teaching and demonstrate how they can help the mother and provide support. Other parameters of the feeding effectiveness assessment relate to the well-being of the neonate. The nurse examines the infant for clinical jaundice and performs daily weights to assess for weight loss. The infant’s output is closely monitored; assessment includes the number of voidings and stools, stool color and transition, and presence of uric acid crystals (Evans et al., 2014 ). • Formula feeding Formula-Feeding Parent Education Many infants receive at least some amount of commercial infant formula during their first year of life. Some parents choose formula-feeding instead of breastfeeding; others combine the two methods. If the infant is weaned from breastfeeding before the first birthday, iron-fortified infant formula should be given (AAP Section on Breastfeeding, 2012). It is important for nurses and other health care professionals to be intentional about providing education for parents related to formula preparation, feeding, and common problems they can encounter. Because of the lack of clear information about the practical aspects of formula-feeding, parents often rely on advice from friends and family. If that advice is incorrect and the parents use unsafe practices for formula preparation and feeding, the infant is at risk for foodborne illness and burns (see Teaching for Self-Management: Formula Preparation and Feeding). Readiness for Feeding Ideally the first feeding of formula is given after the neonate’s initial transition to extrauterine life. Feeding- readiness cues include stability of vital signs, effective breathing pattern, presence of bowel sounds, an active sucking reflex, and signs described earlier for breastfed infants. Feeding Patterns In the first 24 to 48 hours of life, a newborn typically consumes 15 to 30 mL of formula at a feeding. Intake gradually increases during the first week of life. Most newborns drink 90 to 150 mL at a feeding by the end of the second week or sooner. Many parents do not peaceful relaxation with the infant. Mothers Evidence-Based Practice Caregiver Feeding Styles and Childhood Obesity who bottle-feed should be encouraged to spend some time with their newborns in skin-to-skin contact. Safety alert A bottle should never be propped with a pillow or other inanimate object and left with the infant. This practice can result in choking, and it deprives the infant of important interaction during feeding. Moreover, propping the bottle has been implicated in causing nursing-bottle caries or decay of the first teeth resulting from continuous bathing of the teeth with carbohydrate- containing fluid as the infant sporadically sucks the nipple.Newborns must learn to coordinate sucking, swallowing, and breathing as they feed. The typical fast flow of milk from bottles can create difficulty for an infant trying to learn to feed. A slow- flow nipple is often used for the first few weeks. Traditionally parents are told to position the infant in a semi- reclining position and to hold the bottle so that fluid fills the nipple and none of the air in the bottle is allowed to enter it (Fig. 25.18A). A more physiologic approach to bottle-feeding is called paced bottle-feeding. With this method of feeding, the bottle is held at more of a horizontal angle (approximately 45 degrees); when the baby pauses between bursts of sucking, the parent withdraws the nipple, allowing it to rest on the baby’s lip until he or she is ready to resume sucking (Lauwers & Swisher, 2016). This position slows the flow of milk from the bottle so the infant is more in control. Paced bottle- feeding works well for infants who are primarily breastfeeding but are occasionally fed from a bottle. If the infant falls asleep, spits out the nipple, seals the lips, turns the head away, or ceases to suck, it usually indicates that he or she has consumed enough formula to feel satiated. Teach parents to look for these cues and avoid overfeeding, which can contribute to obesity (see Evidence-Based Practice box). Ask the Question Does caregiver responsiveness to infant feeding cues have an effect on obesity in early childhood and beyond? Search for the Evidence Search Strategies: English language research-based publications on infant, feeding, satiety, breastfeeding, overweight, obesity were included. Databases Used: Cochrane Collaborative Database, National Guideline Clearinghouse (AHRQ), CINAHL, PubMed, and UpToDate Critical Appraisal of the Evidence Childhood obesity can have its roots in the feeding patterns established in infancy (Gross, Mendelsohn, Fierman, et al., 2014). Overfeeding can impair the infant’s ability to self- regulate. Infants whose caregivers are responsive to an infant’s hunger and satiety (full) cues are significantly less likely to be overweight (Bahorski, Childs, Loan, et al., 2019 ). Discordant responsiveness occurs when the caregiver perceives that the infant cannot recognize hunger or satiety. Restrictive feeding style is associated with maternal fear of causing obesity. Pressuring feeding style is associated with caregiver concern that the infant has poor appetite and will be underweight (Bahorski et al., 2019 ). Low-income, food-insecure mothers are more likely to be discordant, either restrictive or pressuring, than food- secure mothers (Gross et al., 2014 ). Authoritative parenting style is associated with pressuring to eat (\ 1. • Parents can be taught typical feeding cues that let them know their baby’s readiness to eat, as well as cues that the baby is satisfied. The nurse should point out the infant cues, and praise the parents for appropriate responsiveness. 2. • Videos and printed material, as well as warm lines, should be made available to new parents. Specific suggestions as to how much formula to feed initially and as the infant grows, and how voiding and stool patterns and weight gain reflect adequate nutrition can provide education guidelines. Safety alert The type of commercial infant formula that parents choose should be based on the recommendation of the pediatric health care provider. Specialty formulas are designed for infants with specific needs and should be used only if recommended or prescribed by the health care provider. heat can cause the release of BPA from plastic, polycarbonate bottles should never be boiled, heated in the microwave, or washed in a dishwasher. Parents should be instructed in proper cleaning of all equipment used in formula preparation and feeding. See Teaching for Self-Management: Formula Preparation and Feeding. Infant Formulas Commercial Formulas Commercial infant formulas are designed to resemble human milk as closely as possible, although none has ever duplicated it. The exact composition of infant formula varies with the manufacturer, but all must meet specific standards. The FDA regulates the manufacture of infant formula in the United States to ensure product safety. Infants who are not breastfed should be given commercial iron-fortified formulas. The AAP recommends iron-fortified formulas from birth to 1 year of age for infants who are not breastfed and for those who are partially breastfed (Baker et al., 2010 ). The most widely used commercially prepared formulas are cow’s milk–based formulas that have been modified to closely resemble the nutritional content of human milk. The caloric content of standard infant formula is 19 to 20 kcal/oz. These formulas are altered from cow’s milk by removing butterfat, decreasing the protein content, and adding vegetable oil and carbohydrate. The major carbohydrate is lactose. Regardless of the commercial brand, the standard cow’s milk–based formulas have essentially the same compositions of vitamins, minerals, Teaching For Self-management Formula Preparation and Feeding Formula Preparation protein, carbohydrates, and essential amino acids, with minor variations such as the source of carbohydrate; nucleotides to enhance immune function; and long-chain polyunsaturated fatty acids (DHA and ARA), which are thought to improve visual and cognitive function. Some formulas contain added probiotic and others are fortified with prebiotics in the form of oligosaccharides to mimic natural oligosaccharides in human milk. Some parents choose to feed only organic infant formulas. Many desire a natural formula without preservatives; without artificial flavors, colors, or sweeteners; made from milk produced by cows fed only organic foods, without pesticides or herbicides, growth hormones, antibiotics, steroids, or other harmful additives. Protein hydrolysate formulas, also known as predigested formulas, contain proteins that are broken down into smaller particles for easier digestion; they are lactose free. These formulas are either partially hydrolyzed or extensively hydrolyzed. Infants at risk for atopic disease (e.g., eczema) and those with documented IgE allergies caused by cow’s milk should be fed an extensively hydrolyzed protein formula. Extensively hydrolyzed formulas are recommended for infants with intolerance to cow milk or soy proteins. Amino acid formulas are used for infants who have dairy protein allergy and are unable to tolerate hydrolyzed formulas (Parks, Shaikhkhalil, Groleau, et al., 2016 ). Soy protein–based formulas are free of cow milk– based protein and lactose; sucrose, corn syrup solids, and/or maltodextrin are added to meet the caloric content; fat content is similar to cow milk–based formulas. Uses of this type of infant formula are limited; soy protein–based formulas are recommended for infants with galactosemia and congenital lactase deficiency; infants with secondary lactase deficiency may benefit as well. Soy protein–based formulas have not been proven 1. • Using warm soapy water, wash your hands, and arms, and clean under your nails; rinse well. Clean and sanitize the surface where you will be preparing the bottles. 2. • In a basin that is only used for cleaning equipment used in formula preparation and feeding, thoroughly wash bottles, nipples, rings, caps, can opener, and other preparation utensils in hot soapy water and rinse thoroughly. Squeeze water through nipples to make sure that the holes are open. 3. • Place bottles, nipples, rings, and caps in a pot, and cover with water; boil for 5 minutes; remove items from pot with sanitized tongs, and allow them to air dry. (Do this before using items the first time; thereafter you can continue to do this or place items in the dishwasher.) 4. • Note the expiration date on the formula container. It should be used before the expiration date. Any unopened expired formula should be returned to the place of purchase. 5. • Read the label on the container of formula, and mix it exactly according to the directions. 6. • Mix formula with tap water deemed safe by the local health department. Allow cold water to run for 1 minute before collecting it. If water is unsafe or the safety is uncertain, it should be boiled for 1 minute and allowed to cool, but not for longer than 30 minutes, before mixing with formula. If using bottled water, make sure that it is labeled as “sterile”; unsterile bottled water must be boiled. 7. • If using a can of ready-to-feed or concentrated formula, wash the top of the can with hot soapy water and rinse well. Shake the can before opening. 8. • Mixing formula 9. 1. • Ready-to-feed: No mixing is needed; do not add water. Pour desired amount of formula into clean bottle; add nipple and ring.