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399 Cards in this Set

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Nursing diagnoses for a mother who has a baby who
says "This baby's ugly. I don't know that I can take it home". My husband can't take this fact." What is an appropriate response?
Ineffective individual coping
What is an appropriate nursing diagnosis for a family who is screaming in the hallway?
?
Make sure to look at jaundice stuff, COOMBS, appropriate interventions. There will be nursing diagnosis. There will be nursing interventions.
?
What is an appropriate nursing diagnosis for in labor nursing?
Alteration of comfort
Anxiety
Nursing diagnosis for epidural would be?
high risk for injury related to epidural
What is a direct and indirect Coombs and how do I utilize it?
?
What is membrane stripping?
The doctor goes in to check woman's dilation and if he thinks you're near enough date, he'll do an aggressive grooming to see if he can pull out the mucus plug to stimulate labor.
Define FETAL ductus arteriosus?
large with no tone; blood flow from pulmonary artery to aorta
Define NEWBORN ductus arteriosus?
reversal of blood flow; now from aorta to pulmonary artery because of increased left arterial pressure
Define FETAL foramen ovale?
patient with large blood flow from right atrium to left atrium
Define NEWBORN foramen ovale?
increased pressure in left atrium attempts to reverse blood flow and shuts one-way valve
Define FETAL ductus arteriosus?
large with no tone; blood flow from pulmonary artery to aorta
Define NEWBORN ductus arteriosus?
reversal of blood flow; now from aorta to pulmonary artery because of increased left atrial pressure; ductus is sensitive to increased oxygen and body chemmicals and begins to constrict
Define FETAL pulmonary blood vessels?
constricted with very little blood flow; lungs not expanded
Define NEWBORN pulmonary blood vessels?
vasocilation and increased blood flow; lungs expanded; increased oxygen stimulates vasodilation
During transition from fetal to newborn....there is initiation of respiration (expansion of lungs) which leads to increased _______ levels.
P02
Explain steps leading up to closure of foramen ovale in newborn when P02 levels are increased following expansion of lungs?
decreased pulmonary vascular
resistance
increased pulmonary blood
flow
increased pressure in left
atrium
closure of foramen ovale

(there is also decreased right atrial pressure which also assists in closure of foramen ovale)
Explain steps leading up to closure of ductus venosus following expansion of lungs in newborn?
expansion of lungs
increased PO2 levels
increased systemic vascular
resistance
decreased systemic venous
return
cessation of umbilical
venous return
closure of ductus venosus
Explain steps leading up to closure of ductus arteriosus?
Expansion of lungs
increased P02 levels
increased systemic vascular
resistance
systemic resistance greater
than pulmonary
closure of ductus arteriosus

(there is also pulmonary resistance less than systemic...leads to left-to-right shunt)
Name the five major areas of change in cardiopulmonary adaptation?
increased aortic pressure and
decreased venous pressure
increased systemic pressure
and decreased pulmonary
artery pressure
closure of foramen ovale
closure of ductus arteriosus
closure of ductus venosus
Explain increased aortic pressure and decreased venous pressure in newborn?
Clamping of umbilical cord eliminates the placental vascular bed and reduces the intravascular space. Then, aortic (systemic) b.p. increases. At same time, blood return via the IVC decreases, resulting in decreased right atrial pressure and a small decrease in pressure within the venous circulation.
Explain increased systemic pressure and decreased pulmonary artery pressure in newborn?
With the loss of the low-resistance placenta, systemic resistance increases, resulting in greater systemic pressure. At the same time, lung expansion increases pulmonary blood flow, and the increased blood P02 associated with initiation of respiration dilates pulmonary blood vessles. The combo of vasodilation and increased pulmonary blood flow decreases pulmonary artery resistance. As the pulmonary vascular beds open, the systemic vascular pressure increases, enhancing perfusion of the other body systems.
Explain closure of foramen ovale in newborn?
Closure of the foramen ovale is a function of changing atrial pressures. In utero, pressure is greater in the right atrium, and the foramen ovale is open after birth. Decreased pulmonary resistance and increased pulmonary blood flow increase pulmonary venous return into the left atrium, thereby increasing left atrial pressure slightly. The decreased pulmonary vascular resistance and the decreased umbilical venous return to the right atrium also cause a decrease in right atrial pressure. The pressure gradients across the atria are now reversed, with left atrial pressure greater, and the foramen ovale is functionally closed 1 to 2 hours after birth. However, a slight right-to- left shunting may occur in the early neonatal period. Any increase in pulmonary resistance or right atrial pressure, such as occurs in crying, acidosis, cold stress, or induced hypoxia, may cause the foramen ovale to reopen, causing a right- to-left shunt. Permanent closure of the foramen oval occurs within 6 months.
Explain closure of ductus arteriosus?
Initial elevation of the systemic vascular pressure above the pulmonary vascular pressure increases pulmonary blood flow by reversing the flow through the ductus arteriosus. Blood now flows from aorta into pulmonary artery. Also, although the presence of oxygen causes the pulmonary arterioles to dilate, an increase in blood P02 triggers the opposite response in the ductus arteriosus--it constricts.
Functional closure is done within 15 hours of birth, and fibrosis of ductus occurs within 3 weeks after birth.
Explain closure of ductus venosus in newborn?
Although the mechanism of initiating closure of ductus venosus is not known, it appears to be related to mechanical pressure changes that result from severing of the cord, redistribution of blood, and cardiac output. Closure of the ductus venosus forces perfusion of the liver. Fibrotic closure occurs within 2 months.
What is the purpose of the DeLee mucus trap?
to remove excess secretions from the mouth and nares due to possible depressed respirations or if amniotic fluid was meconium stained
What is the preparation for performing nasal pharyngeal suctioning using the DeLee mucus trap?
Tighten DeLee lid or other suction device collection bottle to avoid spillage of secretions and prevent air from leaking out of lid.
Connect one end of DeLee tubing to low suction.
Procedure for performing nasal pharyngeal suctioning using DeLee or other suction device?
*gloves
*suction turned off
*insert free end of DeLee tubing 3 to 5 inches into newborn's nose or mouth
*place thumb over suction control and begin to apply suction; continue to suction as you slowly remove the tube, rotating it slightly
*continue to reinsert tube and provide suction for as long as fluid is aspirated
*if it is necessary to pass tube into newborn's stomach to remove meconium secretions that newborn swallowed before birth, insert tube through the newborn's mouth into stomach; apply suction and continue to suction as you withdraw tube
*document completion of procedure and amount and type of secretions
What is the rationale behind inserting free end of DeLee tubing 3 to 5 inches into newborn's nose or mouth?
applying suction while passing the tube would interfere with smooth passage of the tube
What is the rationale behind placing thumb over suction control and beginning to apply suction; continue to suction as you slowly remove the tube, rotating it slightly?
Suctioning during withdrawal removes fluid and avoids redepositing secretions in the newborn's nasopharynx
What is the rationale for continuing to reinsert tube and provide suction for as long as fluid is aspirated and not excessively aspirating?
Excessive suctioning can cause vagal stimulation, which decreases the heart rate.
What is the rationale behind
passing tube into newborn's stomach to remove meconium secretions that newborn swallowed before birth, insert tube through the newborn's mouth into stomach; apply suction and continue to suction as you withdraw tube?
Because the newborn's nares are small and delicate, it is easier and faster to pass the suction tube through the mouth
Explain the rationale behind documenting the completion of the procedure and the amount and type of secretions?
This documentation provides a record of the intervention and the status of the infant at birth.
What is the purpose of the DeLee mucus trap?
to remove excess secretions from the mouth and nares due to possible depressed respirations or if amniotic fluid was meconium stained
What is the preparation for performing nasal pharyngeal suctioning using the DeLee mucus trap?
Tighten DeLee lid or other suction device collection bottle to avoid spillage of secretions and prevent air from leaking out of lid.
Connect one end of DeLee tubing to low suction.
Procedure for performing nasal pharyngeal suctioning using DeLee or other suction device?
*gloves
*suction turned off
*insert free end of DeLee tubing 3 to 5 inches into newborn's nose or mouth
*place thumb over suction control and begin to apply suction; continue to suction as you slowly remove the tube, rotating it slightly
*continue to reinsert tube and provide suction for as long as fluid is aspirated
*if it is necessary to pass tube into newborn's stomach to remove meconium secretions that newborn swallowed before birth, insert tube through the newborn's mouth into stomach; apply suction and continue to suction as you withdraw tube
*document completion of procedure and amount and type of secretions
What is the rationale behind inserting free end of DeLee tubing 3 to 5 inches into newborn's nose or mouth?
applying suction while passing the tube would interfere with smooth passage of the tube
What is the rationale behind placing thumb over suction control and beginning to apply suction; continue to suction as you slowly remove the tube, rotating it slightly?
Suctioning during withdrawal removes fluid and avoids redepositing secretions in the newborn's nasopharynx
What is the rationale for continuing to reinsert tube and provide suction for as long as fluid is aspirated and not excessively aspirating?
Excessive suctioning can cause vagal stimulation, which decreases the heart rate.
What is the rationale behind
passing tube into newborn's stomach to remove meconium secretions that newborn swallowed before birth, insert tube through the newborn's mouth into stomach; apply suction and continue to suction as you withdraw tube?
Because the newborn's nares are small and delicate, it is easier and faster to pass the suction tube through the mouth
Explain the rationale behind documenting the completion of the procedure and the amount and type of secretions?
This documentation provides a record of the intervention and the status of the infant at birth.
What is the purpose of the DeLee mucus trap?
to remove excess secretions from the mouth and nares due to possible depressed respirations or if amniotic fluid was meconium stained
What is the preparation for performing nasal pharyngeal suctioning using the DeLee mucus trap?
Tighten DeLee lid or other suction device collection bottle to avoid spillage of secretions and prevent air from leaking out of lid.
Connect one end of DeLee tubing to low suction.
Procedure for performing nasal pharyngeal suctioning using DeLee or other suction device?
*gloves
*suction turned off
*insert free end of DeLee tubing 3 to 5 inches into newborn's nose or mouth
*place thumb over suction control and begin to apply suction; continue to suction as you slowly remove the tube, rotating it slightly
*continue to reinsert tube and provide suction for as long as fluid is aspirated
*if it is necessary to pass tube into newborn's stomach to remove meconium secretions that newborn swallowed before birth, insert tube through the newborn's mouth into stomach; apply suction and continue to suction as you withdraw tube
*document completion of procedure and amount and type of secretions
What is the rationale behind inserting free end of DeLee tubing 3 to 5 inches into newborn's nose or mouth?
applying suction while passing the tube would interfere with smooth passage of the tube
What is the rationale behind placing thumb over suction control and beginning to apply suction; continue to suction as you slowly remove the tube, rotating it slightly?
Suctioning during withdrawal removes fluid and avoids redepositing secretions in the newborn's nasopharynx
What is the rationale for continuing to reinsert tube and provide suction for as long as fluid is aspirated and not excessively aspirating?
Excessive suctioning can cause vagal stimulation, which decreases the heart rate.
What is the rationale behind
passing tube into newborn's stomach to remove meconium secretions that newborn swallowed before birth, insert tube through the newborn's mouth into stomach; apply suction and continue to suction as you withdraw tube?
Because the newborn's nares are small and delicate, it is easier and faster to pass the suction tube through the mouth
Explain the rationale behind documenting the completion of the procedure and the amount and type of secretions?
This documentation provides a record of the intervention and the status of the infant at birth.
Define physiologic jaundice?
Tabors: caused by accelerated destruction of fetal RBCs, impaired conjugation of bilirubin, and increased bilirubin reabsorption from intestinal tract...not pathologic...a normal biologic response to newborn...there are six factors giving rise to it

lecture notes: newborn has too many RBC's, with a shorter lifespan than adults..the RBCs are dying off... and an immature liver that can't handle the metabolic breakdown

text: occurs after first 24 hours of life
during first week of life, bilirubin should not exceed 13 mg/dL;
some pediatricians allow levels up to 15 mg/dL;
bilirubin levels peak at 3 to 5 days in term infants
Six factors (H & S)which give rise to physiologic jaundice are?
*increased amounts of bilirubin delivered to liver
*defective uptake of bilirubin from plasma
*defective conjugation of bilirubin
*defect in bilirubin excretion
*inadequate hepatic circulation
*increased reabsorption of bilirubin from intestine
Define kernicterus?
*a form of jaundice occurring in newborns during the second to eighth day after birth
*the basal ganglia and other areas of the brain and spinal cord are infiltrated with bilirubin, a yellow substance produced by the breakdown of hemoglobin. The disorder is treated by phototherapy and exchange transfusion to limit neurological damage. The prognosis is quite poor if the condision is left untreated.
(per lecture, kernicterus is when the byproduct adheres to the meninges of the brain and causes mental retardation)
Physiological jaundice and lecture notes.
baby has excessive amount of RBCs...liver is immature...typically the RBC's break down....they are metabolized through the liver...but they can't be metabolized efficiently in the immature liver...typically, the break down of a RBC results in bilirubin...it's part of that conjugation of the RBC...the bilirubin is what gives us the yellow tint and we have a problem...since the etiology of physiological jaundice has to do with longevity of the RBCs, we find that these babies end up getting yellow, lethargic, and at a certain level of above 20, they can possibly become kernicterus.
Kernicterus is gotten when the mother smokes a lot, so there's a hypoxic environment and malnutrition...so baby creates an excessive amount of RBC's whose break down can't be metabolized because of it's immature liver...hence jaundice..

Again...there's an increased amount of bilirubin in the liver...the newborn RBC's go to his liver, become conjugated and becomes excreted...how is jaundice/bilirubin excreted? In the stool.

What helps the baby's stool?
Eating...so instead of eating every 3-4 hours...eat every two hours.
One way to treat physiologic jaundice is to assist newborn with?
eating frequent meals, about every 2 hours instead of every 4 hours...not with water but with something that increases peristalis...a food of some sort...whether it's breastfeeding colostrum or the bottle feeding.
Why does breast feeding in a physiologic jaundice case have an advantage over bottle feeding?
breast feeding metabolizes faster and it has a cathartic or laxative effect...so it stimulates peristalsis much faster than formula does. More stools are eliminated more frequently which helps eliminate more of the bilirubin.
Phototherapy is used in physiologic jaundice cases when?
the bilirubin is excessively high...usually 14 at birth...15...but they don't want bilirubin to hit 20...damage doesn't typically occur until it hits 20...can cause brain damage, mental retardation. It can also cause hearing loss.
Babies that get physiologic jaundice but who's bilirubin may not get high enough (borderline) to get Mental retardation may still have some loss of ?
hearing
Lecture: Diagram
bilirubin going into liver and hepatic system begins to conjugate it and begins to eliminate it. What isn't eliminated is absorbed back into the circulatory system and as it is circulated, it becomes unconjugated and you cannot eliminate unconjugated bilirubin...it has to be conjugated to be eliminated. There's a defective uptake because newborn's liver is immature
okay
Inteventions for physiologic jaundice?
push fluids
If for some reason, the baby is placed under phototherapy treatments, then you have to do things to protect the baby from phototherapy injury which includes:
*protect eyes by patching...it's like sunbathing...so the baby bronzes which is not a good thing
*expose as much skin surface as possible even if it means having the baby naked
*turn babies frequently to avoid bronzing
*protect baby from dehydration...light dehydrates...like being out in the sun
*don't impair the bonding process most of all
Phototherapy works in jaundice cases by?
breaking down bilirubin and
helps unconjugated bilirubin become conjugated so that it can be eliminated...unconjugated won't eliminate
When operating a phototherapy session, make sure you are
calibrating the machine properly
that you know how much it's putting out so that you're using effective phototherapy.
What can cause physiologic jaundice?
ABO incompatibilities can cause bilirubin...
Rh incompatibilities can cause elevated bilirubin...
those are the abnormal ones...

breast milk on some babies can cause bilirubin (this is a late onset)...
babies mom's who have been induced with ptosin increases bilirubin...
babies who get overdoses of aquamethycin? get bilirubin..
How was phototherapy discovered?
babies who are next to the window have a lower bilirubin count than those who aren't...that's how phototherapy was discovered
What may lead to an increased bilirubin count?
delayed cord clamping
leading to increased blood
volume
use of forceps causing trauma
to newborn
inadequate ingestion of
calories by newborn
hypothyroidism
fatty acids in breast milk
vs albumin competing for
binding sites
bacterial flora and decreased
intestinal motility
congenital infection
decreased oxygen due to
mother smoking or
congenital heart disease
reduced bowel motility
intestinal obstruction
delayed passage of meconium
What is the Coombs test?
a lab test for presence of antibodies, usually blood type antibodies, in serum.
The patient's serum is incubated with RBCs with known antigenic markers; if antibodies to the antigen are present in the serum, they bind with RBCs. When antihuman globulin is added, RBC clumpong occurs. The test is used for crossmatching blood before transfusion to ensure that no antigen antibody reaction will occur and to test for the presence of specific antibodies to RBCs
What is indirect Coombs?
?
What is direct Coombs?
?
There's a direct and indirect Coombs...one is for mom..one for baby. which one indicates there's an ABO or Rh problem? Which one indicates it's a regular physiological jaundice and to go ahead and proceed?
Know for bilirubin as well as for RH incompatibility, know the Coombs measurements.
?
What is breast milk jaundice?
Bilirubin levels begin to rise about the fourth day after mature breast milk comes in.
Peak of 5-10 mg/dL is reached at 2 to 3 weeks of age
It may be necessary to interrupt breastfeeding for a short period when bilirubin reaches 20 mg/dL
Newborns don't have enough vitamin K to heal their cord and keep them from being at risk for bleeding so we give them?
AquaMEPHYTON
or AquaNephatin??
Vitamin K 0.1 mg always in the vastus lateralus (outside of foot)
use 5/8" syringe, one time shot
(make sure to give 0.1 mg because if 1 mg given, the baby will be at risk for hyperbilirubinemia)
How does a nurse minimize the exposure of the newborn to mother's AIDS before giving Vitamin K shot?
Babies should not get Vitamin K shot until after their initial bath because mother's who have AIDS can infect the baby during pregnancy, during delivery, during breastfeeding, or during exposure to fluids afterwards. We don't know when it occurs.
Meds on hand for hospital nursery are minimal and might include?
AquaMEPHYTON (vitamin K)
something to treat eyes
something to treat bleeding
circumcision (epinephrine,
topical)
(just a few stocked drugs, because nursery looks for healthy babies)
When first assessing baby
measure their length by measuring from?
the tip of the head to the heel. A slide may be used and a pencil. Some meaasure from the crown to the rump and down (which is not as accurate)
Measure the circumference of head from?
Lecture: Just over the eyebrows, just above the ears.
Text: Because of molding, the circumference of newborn's head should be measured immediately following birth and about 3 days later
breech born and cesarean births circumference is not affected
Measure the chest by?
measure under the arms, across the back and across the nipple line
When assessing cord, make sure there is?
one vein
two arteries
Check placenta for all of it's?
condylile ??? part in it and not fragmented
Weight loss in newborn in first week attributable to?
fluids that are moved from the intracellular to extracellular. This is when we get them urinating more frequently. We also get some dehydration and add that to phototherapy...more insensible loss...
How much is stomach capacity of newborn?
50 to 60 mls
(not good to start off with an 8 ounce bottle...use 4 ounce bottle to prevent regurgitation)
Cardiac sphincter which holds the food in newborn stomach is immature so they'll spit up, so?
burp them frequently until the food settles below the air and that they won't have projectile vomiting.
Bottle feeders should burp their babies about?
every ounce
Newborns will usually pass meconium no later than?
8 - 24 hours or doctor wants to investigate typically...there may be some abnormal problem like Hirsprung's disease, megacolon...maybe no connection from colon to rectal sphincter (surgical procedure possibly)
The nurse should anticipate a messy black tarry stool in healthy newborn.
Define phenylketonuria?
Tabors: a congenital, autosomal recessive disease marked by failure to metabolize the amino acid phenylalanine to tyrosine.
Results in severe neurological deficits in infancy if it is unrecognized or left untreated
Phenylalanine
an amino acid...food products must tell the consumer that it contains phenylalanine because it converts to tyrosine and it doesn't convert in people with PKU who are unable to break it down to a usable amino acid that can be absorbed (gum is another source)
It it contains phenylalanine
(almost all cooked products, premade products).
It really makes a problem because kids can't break it down so there's an increase of phenylalanine in their blood. That's why in 3 weeks they go back to the pediatrician for this test to detect whether or not they have the PKU...
How does phenylalanine affect children throughout growth?
Children who can't break down phenylalanine have to avoid it during their whole growth process.
Every increase in phenylalanine can cause bilirubin and kernicterus and possible mental retardation. This occurs because phenylalanine and its byproducts accumulate in the body, esp. nervous system where it can cause MR.
How to test newborns for PKU?
Tabors: heel-stick specimen of blood, which is allowed to dry on blottingn paper before being sent to the lab; confirm high levels with additional test

Lecture: 24 hours after eating...make sure heel is nice and warm, squeeze it enough to be able to wipe off first drop of blood with alcohol...saturate strip...put it in assay tray and check thyroid (Cretenism), PKU, thalacemia, and others not done in Texas...PKU usually done 2-3 weeks after birth (AFTER 24 HOURS and FOOD intake) in doctor's office.
don't bruise the baby when doing PKU...be kind and gentle
Recommended newborn screening for PKU is?
Tabors: before discharge from nursery or in first 2 weeks of life
The PKU test is most accurate if performed no sooner than?
Tabors: 24 hours after birth
Lecture: to get an adequate test, the baby needs to have eaten at least 24 hours to cause a change in their blood...so if there's a baby that's not eating well...you could get a false negative if you take the test too early.
Some women with PKU who are childbearing ability, should avoid phenylalanine during pregnancy or keep it low amounts which will prevent _____ _______ in the fetus.
Tabors: fetal malformation
Congenital hypothyroid?
an inborn enzyme deficiency...can be from lack of dietary iodine...especially in Africa where they use salt without iodine...there's an increase of goiters and congenital hypothyroidism.
the check is done at birth for both in Texas. Also done for thalacemia (Mediterranean blood dyscrasia) and there's a whole list of tests that can be done at the same time that are not done in Texas.
NCLEX focuses on universal.
Kids will receive thyroid their whole life.
All newborn's have a _____
tinge to their skin regardless of genetic background.
pink
What is choanal atresia?
*congenital blockage of the passageway between nose and pharynx
*newborn will be cyanotic at rest and pink only with crying
*if crying increases cyanosis, heart or lung problems may be suspected
Very pale newborn may indicate?
anemia
hypovolemia (low b.p.)
What is acrocyanosis?
bluish discoloration of the hands and feet
What is acrocyanosis due to?
poor peripheral circulation, which results in vasomotor instability and capillary stasis, esp when the baby is exposed to cold;
if central circulation is adequate, blood supply should return quickly to extremity after blanching
Don't use blue hands and nails to assess?
oxygenation of newborn
Face and mucous membranes should be pink and are the best indicatior for assessing?
adequate oxygenation
Define mottling?
lacy pattern of dilated blood vessels under skin
Mottling occurs as a result of?
general circulation fluctuations
How long may mottling last?
several hours to several weeks or come and go periodically; may be related to chilling or prolonged apnea
What is Harlequin sign?
clown
a deep color develops over one side of the newborn's body while the other side remains pale, so that the skin resembles a clown's suit
How does Harlequin sign develop?
results from a vasomotor disturbance in which blood vessels on one side dilate while the vessels on the other side constrict; usually lasts from 1 to 20 minutes; may be single or multiple episodes, are transient and not of clinical significance
Define jaundice?
first detectable on face (where skin overlies cartilage) and mucous membranes of mouth
How is jaundice evaluated primary to sclera?
by blanching tip of nose, forehead, or gum line under proper lighting
yellowish cast following blanching is indicator
Besides face, what other area can indicate jaundice?
sclera
Jaundice may be related to?
Text:
breastfeeding
hematomas
immature liver function
bruises from forceps
blood incompatibility
oxytocin (pitocin)
severe hemolytic process
Define erythema toxicum?
perifollicular eruption of lesions that are firm, vary in size from 1-3 mm, and consist of a white or pale yellow papule or pustule with an erythematous base;
often called "newborn rash" or "flea bite" dermatitis
Define milia?
*exposed sebaceous glands
appear as raised white spots
on face, esp. across nose
*no treatment necessary because they clear up
*transient neonatal pustual melanosis in Africans
How to assess newborn skin turgor?
*used to assess hydration,
initiate early feedings, infectious processes
*asess over the abdomen or thigh
*skin should be elastic and return rapidly
Define vernix caseosa?
*whitish cheeselike substance which covers fetus while in utero and lubricates skin of newborn
*skin of term or postterm newborn has less vernix and is frequently dry
*peeling is common, esp. hands and feet
What is the birthmark telangiectatic nevi (stork bites)?
pale pink or red spots and are frequently found on eyelids, nose, lower occipital bone, nape of neck
*lesions common in light-complexioned newborns and are more noticeable during periods of crying; have no clinical significance and usually fade by second birthday
What are Mongolian spots?
*macular areas of bluish black or gray-blue pigmentation found on the dorsal area and the buttocks (base of spine)
*common in newborns of Asian and African descent and other dark-skinned races
*may be mistaken for bruises and should be documented in
newborn's chart
IT'S NORMAL!
What is nevus flammeus (port wine stain)?
*a capillary angioma directly below the epidermis
*nonelevated, sharply demarcated, red to purple area or dense capillaries
*Africans may appear as a purple-black stain..size and shape varies...commonly appears on face...does not grow in size...does not fade with time...does not blanch; may be concealed by cosmetic cream
Define nevus vasculosus (strawberry mark)
capillary hemangioma
consists of newly formed and
enlarged capillaries in
dermal and subdermal layers
raised, clearly delineated,
dark red, rough-surfaced
birthmark commonly found
in head region
What is lanugo?
fine downy hair covering body..if born prematurely, they will have more lanugo than if full-term.
covers ears, shoulders, arms which wears away with time
Respirations of newborn are?
Lecture: fast, irregular,
abdominal and obligatory nose breathers; apnea no longer than 10 seconds okay; color changes should not be apparent
Text: 30-60 respirations per minute
predominantly diaphragmatic but synchronous with abdominal movements
respirations are counted for 1 full minute
The newborn's head is large, about _____-______ of body size with soft pliable skull bones.
one-fourth
What is molding?
asymmetry in vertex presentation
What causes molding?
overriding of cranial bones during labor and birth
When does molding go away?
within a few days after birth and then suture lines become palpable
Any extreme differences in head size may indicate?
microcephaly
hydrocephalus
Define fontanelles?
useful indicator of newborn's condition
soft spots
openings at the juncture of the cranial bones measured with fingers in cms
appear smaller at birth because of molding
How is the measurement of fontanelles carried out?
sitting position
not crying
anterior fontanelle 3-4 cm by 2-3 cm; closes in 18 months
posterior fontanelle 0.5 cm by 1 cm; closes in 8-12 wks
The anterior fontanelle may _____ when the newborn ________ or passes a stool or may pulsate with ________
which is normal
swell
cries
heartbeat
A bulging fontanelle usually signifies increased ___________ _____________
intracranial pressure
A depressed fontanelle usually indicates _________
dehydration
The newborns head has a?
recedingn jaw
small mouth
reflexes that are intact and are to be checked for
frenulum (dip in lip) if it's
absent, it's abnormal
may have a blister on upper
lip from sucking thumb or
lip throughout utero.
they don't normally have teeth, but occasionally one is born with a tooth
What is a rooting, sucking, and gagging reflex?
lecture: stroke the cheek
baby will open it's mouth and turn toward the side of the stimulus
when baby searches for finger, then quickly check for soft palate...while finger is being sucked on, advanced finger slightly so baby gags to check gag reflex
What is caput succedaneum?
a localized, easily identifiable soft area of scalp, generally resulting from a long and difficult labor or vacuum extraction
What happens to newborn in caput succedaneum?
*there is compression of local blood vessels
*venous return is slowed
*causes increase in tissue fluids...edematous swelling....occasional bleeding under periosteum
How long does it take the fluid from caput s. to reabsorb?
within 12 hours to a few days after birth
The difference between caput s. and cephalhematoma is?
caput overrides suture lines and cephalahematoma never crosses a suture line...
caput is present at birth and cepha. is not
Any extreme differences in head size may indicate?
microcephaly
hydrocephalus
Define fontanelles?
useful indicator of newborn's condition
soft spots
openings at the juncture of the cranial bones measured with fingers in cms
appear smaller at birth because of molding
How is the measurement of fontanelles carried out?
sitting position
not crying
anterior fontanelle 3-4 cm by 2-3 cm; closes in 18 months
posterior fontanelle 0.5 cm by 1 cm; closes in 8-12 wks
The anterior fontanelle may _____ when the newborn ________ or passes a stool or may pulsate with ________
which is normal
swell
cries
heartbeat
A bulging fontanelle usually signifies increased ___________ _____________
intracranial pressure
A depressed fontanelle usually indicates _________
dehydration
The newborns head has a?
recedingn jaw
small mouth
reflexes that are intact and are to be checked for
frenulum (dip in lip) if it's
absent, it's abnormal
may have a blister on upper
lip from sucking thumb or
lip throughout utero.
they don't normally have teeth, but occasionally one is born with a tooth
What is a rooting, sucking, and gagging reflex?
stroke the cheek
baby will open it's mouth and turn toward the side of the stimulus
when baby searches for finger, then quickly check for soft palate...while finger is being sucked on, advanced finger slightly so baby gags to check gag reflex
What is caput succedaneum?
a localized, easily identifiable soft area of scalp, generally resulting from a long and difficult labor or vacuum extraction
What happens to newborn in caput succedaneum?
*there is compression of local blood vessels
*venous return is slowed
*causes increase in tissue fluids...edematous swelling....occasional bleeding under periosteum
How long does it take the fluid from caput s. to reabsorb?
within 12 hours to a few days after birth
The difference between caput s. and cephalhematoma is?
caput overrides suture lines and cephalahematoma never crosses a suture line
Define cephalahematoma?
collection of blood between cranial (usually parietal) bone and periosteal membrane...
doesn't cross suture lines...
doesn't increase in size with crying...appears on firrst and second day...disappears after 2-3 weeks ormay take months
What is the pre-auricular hole?
Sometimes when ear forms it forms a false indentation dimple right in front of the ear (preauricular hole)
The abdomen is _________
rounded.
Describe nipples?
With boy or girl, breast buds may be slightly swollen or inflamed due to female hormone, estrogen.
chest and abdomen and respiration
the chest will not have as much respiratory motion as abdomen...there should be no intercostal retraction...check clavicle
Ophthalmascope eye check for?
*cataracts
*transient strabismus
*red reflex should be symmetric in both eyes...either offset to one side...but they should be symmetrical
The base of the spine should have a indention called?
sinusoidal dimple
it is sometimes considered spina bifida
it can develop into a cyst later on in life because of the many hairs in it
just document it and don't do anything about it
What is the step reflex?
Standing a newborn up will make him take a slow step..pick up other foot and take another slow step
Trunk and head are disproportionately long compared to ______
legs
Genitalia on males?
Lecture: may have enlarged scrotum again from the hormones;
breech babies have larger scrotums because of the trauma of being born breech.
What is hypospadias?
occurs when the urinary meatus of male infants is located on the ventral surface of penis
What is phimosis?
a condition occurring in newborn males in which the opening of foreskin (prepuce) is small, and foreskin cannot be pulled back over glans at all...may interfere with urination, so adequacy of urinary stream should be evaluated
Female genitalia on fullterm?
will have enlarged labia majora...labia minora should not be visible in fullterm or barely visible...
clitoris may or may/not be enlarged due to hormone...
Female genitalia on preterm?
very minor labia majora and labia minora will be more present
The arms and legs of newborn are typically?
flexed...they like the fetal position and warmth.
Hands of newborn are typically?
closed, fist-like, palmar grasp
What is the plantar response?
newborn's toes curl when fingers placed under them
What is Babinski reflex or plantar reflex?
Lecture: flaring of toes

Tabors: dorsiflexion of great toe when sole of foot is stimulated; normal in infants under age 6

Text: fanning and hyperextension of all toes, occurs when the lateral apsect of the sole is stroked from the heel upward across the ball of foot..in adults, by contrast, the toes flex
Define Ortolani maneuver?
rules out congenital hip dysplasia
place quiet newborn on firm surface
What angle are hips and knees at with Ortolani maneuver?
90 degree
With Ortolani maneuver, what does nurse grasp?
text: infant's thigh with middle finger over greater trochanter
With Ortolani maneuver, how does nurse lift infant's thigh?
text: to bring femoral head from its posterior position toward acetabulum
With Ortolani's maneuver, what happens after abducting thigh?
text: the femoral head is returned to the acetabulum and examiner feels a sense of reduction or a "clunk"; the reduction is palpable and cannot be heard
What is Ortolani's maneuver per lecture?
take baby, lay on back, bring knees up to a parallel position and push back toward table...when pushing back toward table, rotate hips outward and down, and feel a click (abnormal) or give (abnormal) in the hip socket that isn't well-formed...they will monitor that hip and start doing treatments to keep that hip aligned in the socket as the hip continues to grow...a minimally invasive treatment is to double-diaper them...the double-diaper will deep seat it.
Don't let small children sit in front of television on floor with legs behind them, because that rotates them too much. They can also put them in braces at night with shoes and brace across the two feet to keep the legs splayed so that the hips stay more aligned. If surgical intervention called for, they'll spika cast them.
A spika cast goes from just above the waist down to the knee on one side and usually down past and a cutout for elimination. They stay in that for months. Can't put him in a carseat...mom has to carry child and a 50 pound cast, dressing them, feeding them, skin break down.
What is talipes?
Lecture: Hold knee of baby, and see whether the foot stays turned in or whether he gets into alignment...
newborn can exercise those muscles to help (physical therapy)...soft shoes are better than hard shoes of yesterday

Tabor: any of several deformities of the foot, esp. those occurring congenitally; a nontraumatic deviation of the foot in the direction of one or two of the four lines of movement
Assessing back?
*baby prone
*spine should appear straight and flat because lumbar and sacral curves don't develop until infant begins to sit
What is the text's dermal sinus called nevus pilosus?
(Same as sinusoidal dimple in lecture.)
*look for dermal sinus
*nevus pilosus ("hairy nevus") may be found at base of spine in newborns, but significant in association with spina bifida; examine to make sure no connection with spinal canal
Possible nursing diagnosis? (6)
Ineffective airway
Ineffective thermoregulation
Risk for altered nutrition
Risk for infection
Risk for injury
Altered family
Do initial temperature of newborn by rectum, not axillary because?
to see if rectum is patent...care must be taken not to damage rectum if it's not patent...what is the hospital's protocol...some are getting away from rectal temperatures because of perforation...just check patency by stool
Warm room important because we don't want the newborn to lose heat through?
evaporation
convection
conduction
radiation
When assessing head to toe, do quiet things first. Don't start with blood pressure. Start with _____.
Do palpations last.
Measure the newborn head and length, talk softly.
respiration
What is motor or startle reflex?
take the crib and lift and drop...babies arms will go outward like they're falling...fingers and thumbs will go into C shape. That's a good thing.
What is the tonic neck reflex?
text: fencer position
elicited when the newborn is supine and the head is turned to one side; in response, the extremities on the same side straighten, whereas on the opposite side they flex; this reflex may not be seen during the early newborn period, but once it appears, it persists until about the third month
lecture: lay baby on back, turn him to one side, he's going to extend the arm out on the side he's turning into and he'll put his other arm over his head...it eventually goes away...it's normal.
Nursing diagnosis for newborn cleft palate might be?
risk for altered nutrition
Nursing diagnosis for newborn with mother with PKU is?
risk for altered nutrition
Nursing diagnosis for mother with beta-hemolytic strip that was positive and they didn't have time to treat her because she delivered rapidly?
risk for infection
Nursing diagnosis for ruptured membrane?
risk for infection
Nursing diagnosis for 14 yo mother with lack of maternal experience?
risk for injury related to 14 yo mother and lack of experience
Nursing diagnosis for male mental IQ equal to 6 yo?
risk for injury
History of previous pregnancy important because?
she may be a gravida six, and a para 2 so what has she gone through to have this baby...maybe she's not experienced as you anticipated...maybe she has complications...maybe newborn came out with complications...2 vessels, an artery and a vein...instead of 2 arteries and a vein...how fast does she normally delivery...
The most important information concerning prenatal history is?
immunizations
If she didn't have prenatal care and we don't know what her status or lifestyle has been. Is she immune to measles, does she have Rh factor? Has she taken prenatal vitamins? What's her weight gain? Low iron?
okay
Parent-child relationships or bonding
okay
Reba Rubin?
she discusses stages of bonding. Look her up!
Maslow?
where does sense of belonging fall in hierarchy of needs?
Erickson? What is the first stage of development?
trust vs mistrust
What is the grasping reflex?
elicited by stimulating the newborn's palm with a finger or object...
newborn will grasp and hold the object or finger firmly enough to be lifted momentarily from the crib
What is the Moro's reflex?
elicited when the newborn is startled by a loud noise or is lifted slightly above the crib and then suddenly lowered...
in response the newborn straightens arms and hands outward while the knees flex...
slowly the arms return to the chest, as in an embrace..
fingers spread, forming a C, and the newborn may cry...this reflex may persist until about 6 months of age
What is the rooting reflex?
elicited when the side of the newborn's mouth or cheek is touched. In response the newborn turns toward that side and opens the lips to suck (if not fed recently)
What is the sucking reflex?
elicited when an object is placed in the newborn's mouth or anything touches the lips...newborns suck even while sleeping; this is called nonnutritive sucking,and it can have a quieting effect on the baby
What is trunk incurvation or Galant reflex?
seen when the newborn is prone...stroking the spine causes theh pelvis to turn to the stimulated side
Arteries are delivering _______ blood back to mother and the vein is delivering __________ blood
unoxygenated
oxygenated
What is the state of newborn's oxygen when born?
When the newborn is born, it looks somewhat blue...it's in a hypoxic state...just enough to survive...we couldn't survive
Discuss clamping?
Some doctors like to wait until the cord stops pulsating to clamp it and cut it. That used to be one of the old thinkings. They felt at that point, the baby has converted over to extrauterine circulation and it was safe to go ahead and clamp. Other doctors thought that delaying that allowed too much blood from the placenta to pass to the baby and increased the risk for hyperbilirubinemia...
Now it's common knowledge that sudden clamping of the cord helped the baby transition faster.
Where is the clamping of umbilical cord done?
One is close to the baby with a Hollister clamp because it's a plastic clamp that when it's clamped (Hollister's who made it)..it doesn't come undone...it stays locked. It has to be cut or broken. The other is a Kelly forcep and you cut between the two clamps. If you didn't clamp on the other side, when you cut it, everything would come out of the placenta, blood would continue to flow, and there'd be a puddle of mush. So clamp both ends.
So after flow stops from umbilical vein, you get started closure of patent ductus arteriosus which comes from the aortic arch and goes across to pulmonary.
This is transient in nature. It takes anywhere from 24 to 72 hours to close completely. Once it closes completely, it becomes a ligament. It just shrinks up. When you're listening to the baby's heart rate, you may hear it because it's gonna close over time.
Then the foramen ovale closes.
okay
What is PFC?
persistent fetal circulation
causes hypertension in pulmonary vessels..and the more resistance and hypertension in the pulmonary vessels, the less oxygen is picked up...the more it continues to stimulate the fetal circulation and it's a self-fulfilling prophecy.
What is done in the case of PFC or persistent fetal circulation?
give medication to keep PDA open...because newborn won't survive if it's closed
What are the drugs used to treat PFC?
phenobarbitol??
indomethycin??
others?
Once these closures happen, pulmonary circulation is increased because of resistance that was in the pulmonary circulation decreases. If for some reason, the baby has what we used to term as hyland membrane disease?? which is now immature fetal surfactant so they don't have surfactant to keep the pulmonary sacs open so they get what is called hyaline???membrane disease. So increased pulmonary circulation with help with circultation.
okay
Transitory murmurs. These are associated with PDA. Listen to newborn hearts...they're so fun to listen to....murmurs, clicks, are normal.
okay
Take blood pressure in ankle or thigh. Normal systollic will be greater than _____.
40
Hypotension condition will be less than _____?
40
So newborns will have a higher _____ _____ and a lower ______ _______.
heart rate
blood pressure
Why do newborns have a rapid loss of heat loss?
*there is a great amount of body surface to body mass index newborn have
*limited amount of insulating subcutaneous fat ...out of shower...infant is bathed in warm fluid and then out into a cold environment all wet
*there is heat loss internally and externally
*it's not impaired heat production, IT'S excessive heat LOSS!
How does heat transfer occur in newborn?
*increase in oxygen consumption
*depletion of glycogen stores
*metabolizing of brown fat
What is convection?
text:
*loss of heat from warm body surface to cooler air currents
*air-conditioned rooms, air currents with a tem. below infant's skin temp, oxygen by mask, and removal of infant from an incubator for procedures increase convective heat loss of newborn

lecture:
loss of heat to air...so if surrounding air is cooler than you...you'll lose heat
Define radiation?
Losses occur when body heat rises to cooler surfaces and objects not in direct contact with the body...the walls of a room or an incubator are potential causes of heat loss by radiation, even if the ambient temp. of the incubator is within the neutral thermal range for the infant...placing cold objects (such as ice for blood gases) onto the incubator or near the infant in the radiant warmer will increase radiant heat losses
Define evaporation?
loss of heat incurred when water is converted to a vapor...the newborn is particularly prone to heat loss by evaporation immediately after birth, when the baby is wet with amniotic fluid, and during baths; thus drying the newborn is critical
Define conduction?
loss of heat to a cooler surface by direct skin contact...chilled hands, cool scales, cold examination tables, and cold stethoscopes can cause heat loss by conduction...even if objects are warmed to the incubator temperature, there still may be a significant temperature difference between the infant's core temperature and the ambient temperature...this results in heat transfer
Which two of the four avenues result in the highest heat losses?
radiation
convection
Explain shivering in newborn?
rarely seen in newborn...
means the newborn metabolic rate has already doubled...
extra muscular activity does little to produce needed heat
Define brown adipose tissue (BAT)?
uniquie and assists in nonshivering thermogenesis in newborn...
primary source of heat in newborn..
first appears in fetus 26 to 30 weeks gestation...
continues to increase until 2 to 5 weeks afer birth of term infant, unless depleted by cold stress
Where is brown adipose tissue BAT found?
midscapular area
around neck
axillas
deeper placement around trachea
esophagus
abdominal aorta
kidneys
adrenal glands
How much of newborn's total body weight is BAT and why is it called BAT?
2% to 6%
receives name from its dark color, which is due to its enriched blood supply, dense cellular content, and abundant nerve endings
How about BAT and preterm babies?
have less BAT
Newborn is considered hypoglycemic if blood sugar heel stick is less than _____?
45???
(if this low, probably okay to give 5% sugar or dextrose water...babies who have not had a tried esophageal gag and swallow, makes it easier on the lungs if it's aspirated) also can put baby to breast because colostrum has some glucose
Don't heel stick the inner part of the foot because?
there are arteries and nerves there and easily bruised
(use lateral part of heel and warm it up)
In cases of hypoglycemia, the baby is using up oxygen and glucose, they're also using up calories...so they're at risk for?
metabolic acidosis and ketoacidosis
(like adults who get on diet and start exercising)
it also reduces the amount of surfactant production they continue to make...
this is a normal risk for normal babies...it typically doesn't become a big problem
How big is a US male baby?
female baby?
about 7.5 pounds
about 7.2 pounds
What is the average length of US Caucasian male baby?
female baby?
19-21 inches?
Baby sleeps about ______ to _____ per day for first 2 weeks.
16-20
(this depends on if breastfeeding or bottle feeding...because breastfed babies are satified more quickly but eat more often, because they break down the food more quickly...whatever mother eats, happens...if mom ingest caffeine, baby feels effects...baby wired)
Describe shapes of fontanelles of newborn?
back fontanelle is a triangle, it's very small, should not be able to put whole fingertip into it, just feel it...
the front fontanelles where the 3 or 4 plates come together is a diamond...should be able to put 2-3 fingertips to palpate it...they should be flat and have some spring to them...check when not crying or fontanelles will bulge...
if fontanelles are sunken, it may indicate dehydration...check in sitting up position, not laying down
What is normal for umbilical cord?
2 arteries and 1 vein...if one artery and 1 vein then at risk for kidney or heart defects
About the 26th week, the baby might experience respiratory effort, because baby breathes in amniotic fluid...there might be less surfactant in those arterioles by the 35th week.
What diagnostic test can be done?
can do amniocentesis to determine whether the baby can be born or not...if there's a problem going on...and that's because the baby breathes amniotic fluid in and it bathes the lungs and comes back out and causes respiratory effort...picking up materials
When there is decreased surfactant, there's nothing to keep the balloon inflated when it empties of air and it reinflates. Surfactant gives it elasticity and causes it not to stick. When a baby has meconium and has stool that's in utero, so when alveoli is collapsing to let air back out, there's a stop valve...alveoli become overinflated similar to COPD...there's the same kind of effect because of lack of surfactant...so baby uses intercostal muscles...there's flaring...grunting
okay
Baby's are obligatory nose breathers. So which does the nurse suction first, nose or mouth?
suction nose first...first one nares then the other
(baby won't switch to mouth breathing)
Within first minute of life, the nurse would expect from newborn?
loud lusty cry
no respiratory distress
no retractions of intercostal
muscles
no grunting or sighing
respiratory rate less than
60
there will be a seesaw
diaphragmatic abdominal
movement for breathing
Apnea in newborn may last about ____ _____. This is normal. Baby's have paradoxical pulses...
they increase and decrease with the inner thoracic pressure...heart rate fluctuates
10 seconds
(if 10 seconds exceeded, baby at risk for SIDS; males at greater risk than females; twins are a risk)
O2 consumption in newborn is increased with what condition?
lecture:
hypothermia leading to metabolic acidosis
Hematocrit of infant is _____
than adult
higher
because they have a higher number of RBCs, because their RBCs only live about 90 days...adults live 120 days...they're in a hypoxic environment so body makes more RBCs to compensate...they're thrombocytopenic or hypocytopenic by nature...
babies will have high hematocrit...if hematocrit is higher than 70, what kind of workload is that for the baby?...it increases viscosity
What is phospholipid substance which is phospho-sincomyelin that lines alveoli??? (lecture)
allows lungs to expand when baby takes a breath
Having a stool in utero is an abnormal sign. If the baby has recently stooled, there needs to be aggressive resuscitative efforts done while the baby is still in the?
birth canal.
(dr will aggressively suction the baby's head at perineum before delivering the chest...this is to avoid the big gasp that baby makes when he emerges...don't want to bring the meconium back down into the lungs any more than necessary.
Meconium will arrive in first ______ hours and it will be black
24
Fetal hypoxia can occur?
up to a few days before delivery. There's a lot of things that can cause fetal hypoxia...parents may have done something to cause it too...not just medical staff
Discuss acceleration and deceleration?
Watch fetal activity...accelerations are a good sign, followed by deceleration, which is return to baseline...it can become a concern of hypoxia especially if it occurs over and over....or a slowing of the fetal heart rate where it can become bradycardic...
Discuss decreased variability?
lecture:
could be asleep or medicated, or if hypoxic...if it occurs longer than 15 minutes...if not medicated...something's wrong if baby's hypoxic for over 15 minutes.
Meconium staining at birth?
baby has already inhaled fluid while in utero...won't pink up real well...turn to a paleness instead of pink...have lower APGAR scores...aggressively go in and suction with a DeLee suction
Nursing diagnosis for presence of mucus or meconium?
ineffective airway clearance

so suction prn
place in side-lying position
observe for respiratory
distress: grunting, nasal
flaring, sternal
retractions
Nursing diagnosis for immature nervous system?
ineffective thermoregulation

so...provide appropriate heat source, hat and blankets, monitor room and infant's temperature frequently, avoid cold stress
Nursing diagnosis for limited food intake or poor sucking reflex?
risk for altered nutrition

so...weigh infant daily, assess mother-infant success at breast feeding and teach accordingly, assess bottlefeeding, monitor I&O
Nursing diagnosis for immature immune response?
risk for infection

so...proper handwashing

eye prophylaxis..use
erythromycin..kills
chlamydia and gonorrhea;
ointment is given in
conjunctival sac not on
sclera...will decrease
visual bonding between
newborn and mom...let mom
know...lasts couple hours

keep away from sick people

provide daily hygiene and skin care

does baby need daily bath?
not necessary

diaper changes - how often?
6 or more wet diaper per
day indicates adequate
nutrition as long as baby
is not just taking in water
*1 gram equals 1 ml of
fluid; weigh diaper
of output is normal

cord care - diaper under umbilicus so cord doesn't stay moist...try to keep cord dry...will turn black in 10-14 days and fall off...don't pull on it...use alcohol at the base or soap and water and keep it dry and clean...a smell coming from the cord is abnormal...avoid tub baths until cord falls off
Nursing diagnosis for immature blood clotting mechanism
risk for injury so...administer and chart vitamin K
Nursing diagnosis for immature liver function
risk for injury
so...monitor skin and scalp for jaundice...press nose for blanching
Nursing diagnosis for circumcision
risk for injury

so care for circumcision; very little care...just change diaper frequently...be careful not to pull on plastibell or ring that's left on...if using more traditional surgery with just a piece of foreskin left that hasn't epithelialized and it's mucosa...then use vaseline gauze to keep it from sticking and adhering to diaper and tearing skin...
Nursing diagnosis for heel sticks for lab work
risk for injury
so...monitor condition of heel; alter sites; warm heel
Nursing diagnosis for maturational crisis
altered family process

so...provide for human contact equals bonding
Nursing diagnosis for birth of term infant
altered family processes

so...promote healthy relationships...who's your momma?
Nursing diagnosis for changes in family unit
altered family processes

so...refer to social services or women's services
EVALUATION (end of pp)
*no signs of respiratory *distress
*vital signs WNL
*I?O WNL
*Passing stool appropriately
weight loss less than 10%
no evidence of jaundice or skin breakdown
*parents demonstrate successful bonding
If last menstrual period is Sept. 20, 2005, what is expected date of delivery?
June 27, 2006
(add 12 months, subtract 3 months, add 7 days)
A pregnancy is considered a _____
pregnancy event
A birth is considered a ____ _____. It has nothing to do with numbers of children
birth event
Gravida/para is very simple...
the experience in and of itself counts as one
Pre-term is considered anything before?
36 weeks
T-PAL is?
Term - full 38 weeks
Preterm-before 36 weeks per lecture and before 37 weeks per text pg 485
Abortion-spontaneous too
Living (count multiples as
one each..so it's
nice to be living
and it's nice to be
counted...count
LIVING multiples)
Figure T-PAL

1 live birth @ 38 weeks
1 miscarriage @ 10 weeks
1 termination @ 14 weeks
1 set of twins @ 34 weeks
Term 1
Preterm 1 (twins before 36-37 weeks and it's one
experience)
Abortion 2
Living 3 because "LIVING
multiples count"
Cardiac output in maternal and PHYSIOLOGICAL edema?
Mother has 31% cardiac output increase because of increased serum...a lot of that is going to address physiological edema...what stage will physiological edema be seen?..typically not until the second trimester when we get all of that extra blood flow...dilutes hemoglobin down...rbcs haven't decreased...just diluted...so it's called physiological edema and not pathological edema
Take a newborn to the mother and give her instructions on breastfeeding because she's never breastfed. Which of the four criteria is most important to assess?
breast size
nipple size
method of delivery
whether nipples are inverted or extroverted?
inverted nipples because of latching...baby needs full latch to full nipple...needs areola not just nipple
What 3 criteria must I have to put on a fetal scalp electrode with an internal monitor?
dilate to at least 2
baby would have to be
descended in pelvis
and not ???
membranes have to be ruptured
What is the biggest advantage of internal fetal monitoring (fetal scalp monitor)?
more accurate heart rate monitoring...so if there's difficulty monitoring heart rate...mom's having difficult contractions due to obesity, catonic contractions, baby's active all over, etcet...use this method
What is the greatest disadvantage of a fetal scalp internal monitor?
infection for mom and baby because there's a wire in the birth canal
What is the advantage of the IUPC or intrauterine pressure catheter?
intensity
it's the only objective data to collect intensity of contractions
What is the disadvantage of the IUPC or intrauterine pressure catheter?
infection...uterine perforation...it's placed by trained nurses...but uterus is already stressed and it has to go in and goes by baby's presenting part and into amniotic fluid...but as thin as the walls are...if you try to force it..you could perforate the uterus which would essentially see an emergency
What are types of fetal monitoring?
doppler (intermittent) which
is low risk
external fetal monitoring
ex: toco
internal fetal monitoring
What is a tocodynamometer?
external monitor placed against fundus of uterus (area of greatest contractility) and holds it in place with an elastic belt or other adhesive material; amplified contractions are transmitted on graph paper...measures frequency and duration..but not intensity because of difference between thin and obese women affects reading
Advantage of toco (external fetal monitor?..ob clinic experience
may be used both prior to and following rupture of membranes and provides continuous recording of duration and frequency of contractions; noninvasive and can be used intermittently if woman wants shower, ambulate, whirlpool
Disadvantages of toco (external fetal monitor)?
ob clinic experience
cannot assess intensity of contractions

belt may bother woman

woman may be bothered by
frequent adjustments
What is IUPC or intrauterine pressure catheter?
provides info regardingn frequency and duration of uterine contractions, but also assesses intensity of contractions

can be used if amniotic membranes ruptured

used for closer uterine monitoring

if amniofusion is indicated

if woman switches from c-section to vaginal birth, it helps avoid hyperstimulation and possible uterine rupture

prolonged labor

has 1% risk of infection
Mucous plug?
can be lost up to a week before, especially if one just had a vaginal exam that day...
Typical OB visit schedule?
see ob doctor monthly until 6th month
see bimonthly in 7th month
see weekly in 8-9 month
Bloody show?
it's the consistency of rubber cement used to glue stuff
has estrogen in it
it can happen with aggressive exam by doctor...
happens due to thinning of cervix
How do we measure thinning of cervix?
effacement in percentage..
opening of cervix is measured in centimeters
What's the most important thing to document when a patient comes in with a ruptured membrane?
time it happened...then what it looked like...if the nurse is in attendance when it happens, the most important thing to assess is fetal heart rate...because there's two patients and it's the response of the baby to the rupture
Basic nursing interventions if ruptured membrane?
keep them dry
First stage of labor is what lecture calls?
Ouch to holy cow! 0-10

broken into 3 phases...only stage with phases
latent...happy and excited
active...a little fearful
transition...get the *&* out
of my face
Second stage?
hello baby
dilation to delivery
typically lasts up to 2 hrs in primagravida
multigravida 20 minutes
Third stage?
another contraction?
lost tone
after thought
Fourth stage?
newborn bonding period;
during immediate recovery the nurses focus is vital signs, uterus is firm at umbilicus, she's not bleeding, peripad count??
Peri-pads?
Count them hourly...did she completely saturate a pad in one hour period
If the mother begins bleeding and it's spurts of blood vs a steady trickle, what is the first nursing intervention be?
massage the uterus...effleurage...stimulate the uterus muscle to contract
Who is more likely to bleed?
the multigravida who just delivered twins or primagravida who just had a 6lb 10oz baby?
multigravida...because she overextended uterus...over-sized uterus...prolonged labor...muscle tone of uterus impaired so more likely to have bleeding...if adding assistance such as forceps or vac, then there's potential lacerations
What would be a nursing intervention for the latent phase of labor?
education
What would be an appropriate nursing intervention for transition?
pain management
(giving them guideposts and
reassurance, amnesia time,
the mom has tunnel vision
and is focusing on pain;
get in their face and let
them know what's going
on, how long it's going
to last, and that they
will survive and won't die)
What's appropriate nursing intervention for a late deceleration?
turn them on side
check vitals
call doctor most of all...this is uteroplacental problems...that's not going to change with just turning...this is either she has lupus, smoker, diabetic, and the baby's tiring...baby's compensatory mechanism has worn out...so possible risk for meconium stool running out...so typically turn them, start oxygen and get doctor for possible STAT c-section...the OMINOUS one...turn them and have someone else call doctor...have OR set up...some have c-sections set up daily and tear them down at the end of the day
What is an appropriate intervention for a variable deceleration?
TURNING is very significant in these cases...caused by cord compression...so cord compression can be caused in response to uterine contractions or just that the baby moved and layed on the cord...the longer the cord, the greater the risk for getting hung up...shorter cord is safer except may be a problem with getting them to emerge all the way. Most cords are about 18"

if membranes are ruptured, then use IUPC and irrigate them with normal saline or lactated ringers to give the cord more buoyancy and keep them more hydrated.

If they have ptosin on, then turn ptosin off first before TURNING them because ptosin has a very short half life and it'll stop those contractions and increase the perfusion.
#1 nursing intervention for an early deceleration?
good sign so assess dilation

it's not an ominous sign
it's a vagal response

I want to see if their down enough to push...because it's head compression...so if the baby's coming down, does that mean they're dilated enough?
Prolonged deceleration nursing intervention?
STAT call doctor and check for prolapsed cord....nurse will be using hand to push fetal head off of it and getting someone else to call the doctor and wheeling nurse into OR on bed with patient
What is an appropriate nursing diagnosis for a first time mom who is welcoming her first baby into the family postpartum?
deficient knowledge
regardless of how much
the new mom has prepared
Identify uterine frequency?
beginning of one contraction to beginning of next in a period of time
What's apex, peak, or acme?
all the same
the heighth or intensity of the contraction
List the 4 interventions which require assessment of fetal heart rate prior to implementation?
medication administration

induction of labor (artificial rupture of membrane)

epidural (may cause hypotension which can affect FHR)

before mom ambulates

(need baseline before implementing any kind of treatment that may affect FHR)
List interventions requiring assessment of FHR following implementation?
epidural

membrane rupture

anesthetic
What is polyhydramnios?
(what is the normal amount of fluid?)
Tabors:
condition in which volume of amniotic fluid exceeds 2000 ml during last half of pregnancy

if 3000 ml hit, then may cause interference with diaphragmatic excursion, vena caval compression, maternal sob and increased dependent edema


Lecture:
too much fluid might cause prolapsed cord
too much fluid increases chance of prolapsed cord

too much fluid can make baby float so chance of prolapsed cord is increased
How is polyhydramnios treated?
(online source)
While women with mild polyhydramnios may experience few symptoms, those who are more severely affected may have abdominal discomfort and breathing difficulties as a result of the uterus crowding the abdominal organs and lungs. Polyhydramnios also may increase the risk of pregnancy complications including preterm rupture of the membranes, preterm delivery, umbilical cord accidents, placental abruption (when the placenta partially or completely peels away from the uterine wall before delivery), poor fetal growth, stillbirth and cesarean delivery. Women with polyhydramnios may be more likely to have severe bleeding after delivery.
What causes polyhydramnios?
(online source)
In about two-thirds of cases, the cause of polyhydramnios is unknown. The most common known cause of polyhydramnios is birth defects in the fetus, especially birth defects that hinder fetal swallowing (such as birth defects involving the esophagus or gastrointestinal tract and central nervous system). Normally, swallowing by the fetus helps reduce the level of amniotic fluid, helping to balance out the input caused by fetal urination. Heart defects in the baby also can contribute to polyhydramnios.

Other fetal problems that can cause polyhydramnios include maternal-fetal blood incompatibilities (such as Rh disease) and twin-twin transfusion syndrome (a complication affecting identical twin pregnancies, in which one baby gets too much blood flow and the other too little due to connections between blood vessels in their shared placenta). Women with chronic diabetes are at increased risk of polyhydramnios, though they have fewer complications from it than women without diabetes.
What complications does polyhydramnios cause for mother and baby?
(online source)
When an ultrasound examination shows that a woman has polyhydramnios, she will probably need additional tests. Her health care provider will most likely suggest a detailed ultrasound examination to diagnose or, more likely, rule out birth defects and twin-twin transfusion syndrome. Her provider also may recommend amniocentesis (a small amount of amniotic fluid is removed through a needle inserted into the mother’s abdomen to test for certain birth defects) and a blood test for diabetes.

About half the time, polyhydramnios goes away without treatment. In other cases, it may resolve when the problem causing it is corrected. For example, treating high blood sugar levels in women with diabetes or treating certain fetal heart rhythm disturbances (by medicating the mother) often reduces amniotic fluid levels.

Health care providers usually closely monitor women with polyhydramnios with weekly (or more frequent) ultrasound examinations to check amniotic fluid levels. Tests of fetal well-being are also usually recommended to check for signs of fetal difficulties. If the pregnant woman becomes too uncomfortable, her provider may recommend a drug called indomethacin. This drug helps reduce fetal urine production and reduce amniotic fluid levels. Amniocentesis also can be used to drain off excess fluid. This procedure, which may be repeated a number of times, can reduce symptoms and may prolong pregnancy.

If tests show that mother and baby appear healthy, a woman with mild polyhydramnios near term usually does not need any treatment. While she may have an increased risk of cesarean delivery, she appears to be at low risk of other complications, and her
baby is likely to be healthy
Does discolored amniotic fluid pose a risk to the baby?
(online source)
Normal amniotic fluid is clear or tinted yellow. Abnormal coloring seen at amniocentesis or at birth can sometimes suggest problems. Green or brown-tinged fluid usually indicates that the baby has passed stool. This can be a sign of fetal stress. Pink-tinged fluid suggests bleeding, while wine-colored amniotic fluid suggests bleeding in the past. These conditions may be of little or no consequence, but tests may be suggested to find possible causes.
What does BUBBLE - HE stand for when remembering what to assess?
breasts-engorgement, sore
nipples if breastfeeding
uterus - firmness, midline,
involution...how
many cms above or
below...if above
uterus, put the
number above the
line 1/U...if it's
below the uterus,
it's U/1 which
translates to
one cm below uterus
or 2, 3, 4 etcet..
U/U is right at
umbilicus
this is for
involution
bowel
bladder
lochia..look at type which is
serosa, rubra, alba,
type, amount, and whether
clots are present or not
episiotomy - see REEDA
homan's sign - dorsiflexion
emotion
When assessing for episiotomy always remember the acronym REEDA which stands for?
Redness
edema
echymosis (bruising)
drainage - serosanguinous?
bloody? overlapped?
approximation
What position should woman be in for episiotomy assessment?
SIMS...not supine
What's the analgesic overdose antidote?
Narcan
Signs of labor?
(powerpoint)
lightening
increase in activity
Braxton Hicks contractions
ripening of the cervix
bloody show
rupture of membranes
What stage is an enema sometimes given?
first
What is the vena cava syndrome?
enlarged uterus compresses vena cava...put on left side
Sometimes, as engagement occurs, the umbilical cord may become somewhat obstructed. What lets us know this is occurring?
periodic FHR
Which stage requires the most intensive nursing support?
Stage 1
Define effacement?
lecture: the cervix..contains mucus plug...the cervix as contractions occur which makes it thin out (that's subjective)...so measured in percentages...based on your assessment...varies with each nurse and doctor...everyone has a different baseline...typicall the length of the cervix is past the second knuckle if there's no effacement taking place...so if doing an examination of the length of cervix, use your second knuckle...the only problem is if they're not in true labor, where is the cervix going to be placed with this gravid uterus...you've got this big baby...how do we stand when we're pregant...we have a tendency to compensate for the center of gravity...so that puts the baby in a long position...what happens to the cervix...posterior....so when looking at the silhouette of a person, the uterus and vagina don't line up...typically the uterus is pointed posteriorly during pregnancy and as she gets ready for labor, it becomes more anterior and more lined up with pelvis...so when she comes in with irritable uterus and she wants to be assessed whether she's in a latent phase of labor, or she's just uncomfortable...and one of the ways to tell is that the uterus is very posterior, very high, where when we do an examination, we barely tip the cervix and it's hard...the tissue is still real hard...hard, high, closed, and posterior (she's probably not in labor)...

text: with each contraction, muscles of upper uterine segment shorten and exert a longitudinal traction on cervix, causing effacement...the taking up (or drawing up) of the internal os and the cervical canal into the uterine side walls..she can still have irritable uterus and I might watch them for awhile and look for changes...but she's
not really in labor.
How does the cervix change progressively during pregnancy?
from a long thick structure to a structure that is tissue-paper thin (effacement)
In latent phase and primagravida, which comes first? effacement or dilation?____ How about multigravida?_____
effacement
effacement and dilation is
simultaneous due to a little
weak or atrophied uterine
muscles...muscles don't have
original rigidity and
resistance to change...so
the following births are
expected to go faster
So if someone comes in and the nurse subjectively decides that dilation is 0 and 30% effaced because she's lower than my second knuckle, and she's anterior, and so she's not posterior, and intact membranes...what phase of first stage is she in?____ What if she's given birth to four previous vaginal deliveries? What are her uterine muscles like?___
latent phase if first time mom
weaker and a little more atrophied, little more gravity...and they don't efface separately...they efface and dilate simultaneously
Would a multigravida walking around with a 3 cm dilation be in labor every time?
not necessarily..she doesn't have original muscle tone...she'll go fast when it's time
Do contractions hurt in the latent phase?
not normally
Emotional support is late phase first stage can be given through?
education
allow support family in room
relax to conserve labor
build trusting relationship

mom is dependent and situation is out of control so mom depends on medical staff
When water breaks, it's time to check in to a medical facility because?
now vaginal area is no longer sterile...it's a warm moist dark environment...need to assess FHR and want to induce labor if mom doesn't automatically go into delivery within 24 hours
In active first stage, the contractions are getting strong enough where the mom may not be able to talk at the peak of the contraction.
okay
she's concentrating more on her breathing
What stage is an enema sometimes given?
first
What is the vena cava syndrome?
enlarged uterus compresses vena cava...put on left side
Sometimes, as engagement occurs, the umbilical cord may become somewhat obstructed. What lets us know this is occurring?
periodic FHR
Which stage requires the most intensive nursing support?
Stage 1
Define effacement?
lecture: the cervix..contains mucus plug...the cervix as contractions occur which makes it thin out (that's subjective)...so measured in percentages...based on your assessment...varies with each nurse and doctor...everyone has a different baseline...typicall the length of the cervix is past the second knuckle if there's no effacement taking place...so if doing an examination of the length of cervix, use your second knuckle...the only problem is if they're not in true labor, where is the cervix going to be placed with this gravid uterus...you've got this big baby...how do we stand when we're pregant...we have a tendency to compensate for the center of gravity...so that puts the baby in a long position...what happens to the cervix...posterior....so when looking at the silhouette of a person, the uterus and vagina don't line up...typically the uterus is pointed posteriorly during pregnancy and as she gets ready for labor, it becomes more anterior and more lined up with pelvis...so when she comes in with irritable uterus and she wants to be assessed whether she's in a latent phase of labor, or she's just uncomfortable...and one of the ways to tell is that the uterus is very posterior, very high, where when we do an examination, we barely tip the cervix and it's hard...the tissue is still real hard...hard, high, closed, and posterior (she's probably not in labor)...

text: with each contraction, muscles of upper uterine segment shorten and exert a longitudinal traction on cervix, causing effacement...the taking up (or drawing up) of the internal os and the cervical canal into the uterine side walls..she can still have irritable uterus and I might watch them for awhile and look for changes...but she's
not really in labor.
How does the cervix change progressively during pregnancy?
from a long thick structure to a structure that is tissue-paper thin (effacement)
In latent phase and primagravida, which comes first? effacement or dilation?____ How about multigravida?_____
effacement
effacement and dilation is
simultaneous due to a little
weak or atrophied uterine
muscles...muscles don't have
original rigidity and
resistance to change...so
the following births are
expected to go faster
So if someone comes in and the nurse subjectively decides that dilation is 0 and 30% effaced because she's lower than my second knuckle, and she's anterior, and so she's not posterior, and intact membranes...what phase of first stage is she in?____ What if she's given birth to four previous vaginal deliveries? What are her uterine muscles like?___
latent phase if first time mom
weaker and a little more atrophied, little more gravity...and they don't efface separately...they efface and dilate simultaneously
Would a multigravida walking around with a 3 cm dilation be in labor every time?
not necessarily..she doesn't have original muscle tone...she'll go fast when it's time
Do contractions hurt in the latent phase?
not normally
Emotional support in latent phase first stage can be given through?
education
allow support family in room
relax to conserve labor
build trusting relationship

mom is dependent and situation is out of control so mom depends on medical staff
When water breaks, it's time to check in to a medical facility because?
now vaginal area is no longer sterile...it's a warm moist dark environment...need to assess FHR and want to induce labor if mom doesn't automatically go into delivery within 24 hours
In active first stage (3-7cm), the contractions are getting strong enough where the mom may not be able to talk at the peak of the contraction.
okay
she's concentrating more on her breathing
she may be getting a little more irritable...not much though...the idealist meets the realist...she can't back out now...feeling vulnerable...fearful...doctormay rupture membranes at this time (controversial)
What is the nurses role in first stage active phase?
Nurse may try to increase mom's movement by getting them to turn side to side...it's really best for mom to be walking around so baby will descend easier...don't allow them to lay still...she may want to lay still to slow amount of contractions but this isn't helping the labor process...educate her that gravity and movement helps baby descend faster....
intermittent (not continuous)
monitoring is good enough at this stage
What stage is best to give epidural if mom has requested anesthesia?
first stage active phase
What happens if epidural given in first stage latent phase?
stops labor...contractions aren't established or regular enough...she's not hurting enough
In obstetrics and pediatrics, how many years can pass in a lawsuit and nurse is still held responsible for her part?
up to 20 years...child has to reach full growth
An IV or hep lock would probably started in which stage?
first stage active phase
First stage latent phase, effacement is typically what percentage?
0 to 30% for primagravida

-2 to 0 in descent
Effacement of cervix in active phase first stage, is?
30 to 80 or even 100%
+1 to +2
at least to 0 in descent..
if we dont' hit a +1, the baby might be too high too deliver...due to large baby, wrong presenting part...so if my baby is still in a minus range by active phase, I'm on the phone and planning a possible c-section...baby's not in an optimal position for delivery
Transition phase first stage..what descent or station is she at?
+2 to +3
baby sitting on perineum and bulging
contractions stay at peak most of the time and abruptly drop off...more similar to Braxton Hicks...more painful...may come in couplets or waves...
might see some crowning at peak of contraction...suture lines closing in may be causing creases on baby's head which may disturb mom...
lasts about 20 to 30 minutes in primagravida...it's painful...tell patient it's almost over...talk to her about how well she's doing...she's very codependent at this time...she'll believe what you say.
What happens if mom hyperventilates during contractions in first stage transition phase?
she's gotten rid of a lot of CO2.. she's becoming alkalotic....she's not getting enough oxygen...she can cup her hands in an effort to retain CO2...the symptoms of hyperventilation are tingling of the mouth, fingers, lightheaded, sometimes nauseated, blood pressure falling...stay with her at this time...monitor and assess for contractions and FHR...tactile palpation should illicit a hard uterus during contraction (cuts off circulation to placenta and baby...at the end of her contraction, uterine muscles should be relaxing and blood flow to placenta and baby resumes...
so the baby's heart rate actually increases as blood flow to placenta decreases during a contraction...but if it stays at 90 seconds...the baby has to keep heart rate up for quite awhile especially if contraction comes in waves..say in a case where contraction extends to 45 seconds as opposed to 30 second average...or how does the baby respond if this goes on for 2 minutes?...the longer the contraction, the less time baby has to recuperate...so double check that the uterus is completely relaxing and have mom take deep breaths to really oxygenate baby
What are we looking for in FHR in transition phase?
stays in normal limits which is 110 to 160...that doesn't count accelerations.
When do you check fetal heart rate for baseline?
baseline is taken when baby is not under stress...typically not a constant number...that's why there's a wide range of 110 to 160 at rest time)...also monitor during contractions too...so chart how baby is responding to fetal heart tone during contraction, shoulders evident, meaning there's accelerations present followed by decreased heart rate of 5-10 seconds to the 100's...that's not serious, but you documented what's happened..so look at baselines and patterns.
What is the tone of the uterus at rest and during a contraction?
it should be incrementally increasing and decreasing and completely at rest between contractions....if it's not at rest during contraction and I feel some rigidity, what might be happening? there may be something else going on...maybe the placenta abupted a litle bit...bleeding...maybe someone mixed up the pitosin and put it on the wrong line...
What are accelerations?
favorable
baby raises heart rate at least 10 bpm for at least 10 to 15 seconds in response to movement or contraction
When there's a rupture of membranes for any reason, the most important assessment is?
baby's response
If spontaneous membrane rupture occurs, and baby's head comes out due to loss of fluid, there's a drop in baby's heart rate...what might happen to the cord?
prolapse...it comes out...so baby's heart rate has dropped...this is an emergency...assess color of the amniotic fluid...but more importantly the baby's life is priority...so first assess fetal response...the second priority is what is the color of the membrane
What is the expectation of what amniotic fluid should be like?
clear
odorless
flecks of vernix caseosa
Abnormal findings of amniotic fluid in SROM?
foul smell (possible infection)
yellow or green tinted or
pea soup feces
baby might aspirate this...the thicker and less transparent fluid is, the more deadly it can be for the infant...if it's yellow green or green tint, it's an old occurrence and we're more likely to have a better outcome...you'll want to have a neonatal nurse or neonatal doctor present...they'll want to intubate baby, aggressively suction down by the trach...we're dealing with what's normal for now
Is 40.5 week mom postdate or on target?
Two weeks before or minus is still on target
What is the priority if the there is SROM and mother presents herself at hospital?
risk of infection...sterile field is broken...infection depends on what time the membrane ruptured
What is Leopold's maneuver?
systematic way to evaluate the maternal abdomen ...empty bladder, lie on back with abdomen uncovered, raise shoulders slightly on pillow to relax abdominal wall, knees drawn up a little, complete procedure between contractions; used for fetal assessment
Ultrasound (use conductive gel) is for ________ _______ and toco is for ________ ______.
heart sounds
uterine contactions
The most common cause of fetal persistent tachycardia is?
infection.
Fetal bradycardia is typically due to __________.
stress

(a smooth line for a short time might indicate mother is medicated or fetus is taking a 20 minute nap, but if it's smooth for a long time, it might indicate fetal stress, so check it out)
The PNS and SNS play off of each other which accounts for the climb and drop in tracings.
okay
So, if the mom get Demerol,
the baby's FHR tracing will be ________.
This also happens in 20 minute increments when fetus sleeps..what does the line look like?
smooth
smooth...if it lasts longer than 20 minutes, and there is decreased variability, then look to see if something else is going on
Variability indirectly indicates fetal tolerance for the labor.
okay
!
The only way to get intensity is by _________ or __________ monitoring.
palpation
internal
<Meconium causes a ball-valve action which means?>
<air is allowed in but not out (exhaled)
*alveoli overdistend,
infection
*possible pneumothorax
*nursing diagnosis
*nursing intervention>
<How does physiologic jaundice differ from pathologic jaundice?>
??
<Normal fetal respiration rates?
<30-60 beats per minute
<The normal newborn chemstrip will be?
<greater than 40%
<Hypothermia in fetus may lead to?
<metabolic acidosis
hypoxia
shock
<Meconium in fetus is a problem if the fetus passes it in utero. May cause?

Physiologic response to this is?>
<asphyxia

increased peristalsis...relaxation of anal sphincter and passage of meconium into amniotic fluid>
At minus 5 station, it can't be reached.
okay
!!
After 24 hours of membrane rupture, the most important consideration is?
infection
If baby is vertex, and spine is on right side, transducer should be placed?
lower right to get FHR
(looking for spine)
She has to efface 100%.
okay
!!
If nurse can feel posterior fontanelle, that means the head is?
flexed well. (desirable)

If she feels anterior fontanelle, fetus is in more of a military stance
Left lateral is most preferred position for mother which is a (3%) difference in right side...very little difference between right and left side.
okay
!
First stage latent phase. Remind mother to urinate every 2 hours...overdistended bladder may interfere with?
fetal descent...because if the bladder is overdistended, it will go into pelvic vault...if overdistended it may become a physical obstacle

it may also cause trauma to bladder which may cause problems voiding after delivery
She's in the active stage...may want something to take the edge off...she's 5-6 cm...she's about at 0 station...nurse phones doctor for medication and gets an rx for Stadol IV push or Demerol IV push...dosage can be repeated every 1 to 1 1/2 hours until she's 8 cms. Why does the doctor stop at 8 cms?
Stadol used for conscious sedation...it's nonaddicting narcotic...Demerol addicting...Stadol crosses placenta and causes baby to be drunk and sedated...it's a CNS depressant...it takes the edge off but doesn't alleviate the pain...causes sleepiness...so give IV push...whether Stadol or Demerol, to an OB patient, you wait until an onset of a contraction to push it...less of the drug crosses over the placenta to the baby when pushed during a contraction...blood flow is inhibited across cord, so fetus doesn't get the full effect of drug...fetus won't get quite as depressed
She's in active phase, the Stadol that was IV pushed during the contraction helped her relax and that she's getting really tired, you observe that her husband is doing well...she's becoming more dependent on him and more demanding...she's fatigued...he's feeling guilty because he's been there all morning, but doesn't want to leave her.
okay
!!
An early deceleration is called such because it occurs?
in relationship with the contraction. It's a mirror image of the uterine contraction. It's caused by compression of the fetal head.

A late deceleration happens AFTER the peak of the contraction.

The fetal head is being stimulated...it's a vagal response. It's a superficial vein...many times the IV is started in the scalp...it's almost a vagal response as this fetus is being pushed down...squeezed from the sides...and they vagal down...as soon as the contraction lets up...that stimulus is no longer there. It also means the fetus is coming down more...it's good descent, probably in a plus mode.
You don't see early decelerations in fetus' that are high and floating---EVER!! You only see early decelerations when the fetus is down...makes it a good indicator. Early decelerations are not ominous...it's a good reinforcing sign.
Early decelerations are caused by?
compression of fetal head.
Decelerations noted during labor are described as?
early
late
variable
A late deceleration also resembles an upside down one, but you'll notice it starts AFTER?
the peak of the contraction.
The contraction gets up there. It's not stimulating the head, but now you have complete compression of the placenta so that no blood is getting through and the baby can no longer compensate. Late decelerations are ominous. So, the late decelerations begin when?
AFTER the contraction has peaked. It continues for a period of time between contractions. Sometimes, it'll start and it won't recover and you get these deep decelerations and fetus recovers and it only comes to a 90 baseline and it has another one and it doesn't recover. You really have to watch those because what it is saying is that there may be hypoxia secondary to poor perfusion from the placenta.
What is late deceleration activity saying?
that there may be hypoxia secondary to poor perfusion from the placenta.
If there's poor perfusion from the placenta, what type of patient's do you think would have poor perfusion?
heart mom
diabetic mom
lupus mom
smokers (placenta becomes
more necrotic)
late phase...post phase
begun to calcify.

When going into labor and delivery, look at placenta. Look at the shiny, Schultz side, the side that has the amni on it...look at the dirty Duncan side, the side that was attached to the uterus. Look at the clumping of how it's intact...look at the vessels of the umbilical cord. What you'll see when they're old is underlying vascular disease, is that the placenta is going to be gristly, like old meat...real crunchy, instead of nice and soft like liver.
It's bad, because perfusion of placenta is very hard to prove. The vagal thing...I can position her differently and get that relieve..I can decrease her contractions that she's on stimulation for stimulation for uterine contraction...I can decrease the stimulation. I can't do much about the other.
Most variable decelerations are going to look like a U or a W or a V. They happen at different times, not in relationship to the contractions. Typically, this is caused by?
cord compression
There are 3 vessels in the umbilical cord on a normal newborn. There are ______
arteries and _____ vein.
2
1
The two arteries have real _____ walls. The vein is very ____ walled.
Which way is the oxygenated blood flowing from mom to placenta to baby...through arteries or vein?
thick
thin

vein carries O2 from mom to fetus which is backwards for us...the fetus is in an anoxic environment...all of fetus oxygen comes from mom...so direction to baby from mother is the vein.
So if there is somehow a knot in the cord or a baby has no amniotic fluid now and the cord is twisted due to extra activity and there's contractions on this wonderful cord which is covered in ________.
Wharton's jelly

(It's a rubbery substance around the cord to give it elasticity, but not everyone has the same integrity. Some people have really hard nails and some people have really thin nails. Whartons jelly can be really thin on some people.
So, what would collapse first? The vein would because it's thin-walled.
If cord covered in Wharton's jelly is weak, which vessel would collapse first?
vein because it's thin-walled, obstructing flow of oxygenated blood to fetus...so there are arteries flowing deoxygenated blood and wastes back to mom and there is no oxygenated blood flowing to fetus...fetus is losing volume...causing a decrease in heart rate...eventually it'll get to a point of compressing the arteries (unox) too and there's a response...so these variable decelerations drop first and then it comes back up...they vary because they're followed by brief accelerations based on how much compression has occurred to the cord...could be a true knot...could be a prolapse cord...it's not ominous, but it's not reassuring, we typically REPOSITION the person to decrease having so many in a row
Mother's labor is progressing...besides assessingn for any pattern, mother has persistent decelerations that you monitor for changes in the baseline...we typically set the baseline of the uterine contractions around 10...the reason for this is?
if nurse didn't set it up above the line, what would happen if nurse set it too low? I wouldn't see where the start-stop of a frequency of a contraction is..so mainly we move this up enough just so we don't have any negative numbers that we couldn't see....watch baseline..if it moves up...that means the fetus is not resting well in between...that's when the nurse should be palpating and almost always as the baseline is going up, then there's a placenta abruption..that's a subtle sign...for next semester..
Doctor says mother is now 7cm, mom is getting into ______ phase. Fetus is at a plus one station, which is below ischial spine.
transition
How does molding affect station?
Look for the bony part of the head to measure station.
Mom wants an epidural block...they are neurological anesthetic blocks that cause?
decrease motor ability and block of sensation completely..just like Novocaine...almost all are "caine" drugs...so if a person is allergic to a "caine" drug at dental visits...don't give it to them in an epidural.
Fourth stage is the period after?

Mother's body begins to make <the physiological readjustment with ___ to ____hours and it may take up to _____ weeks postpartum
<delivery

1-4
6
What type of side effects do epidurals have?
headache...so mom can have a post-epidural headache...
another side effect is decrease of motor function from wherever the block was given downward...may have a prolonged second stage of labor because of it...because pushing effort is decreased...can't get synergy between uterine contractions and the mother's external efforts
The epidural space is not a real space on the body. It's between the?
subarachnoid space of the spinal cord which is where a spinal injection is given. It's right along the myelin sheath and put the patient in a position where she gets separation of the vertebrae so needle can be introduced...there's a potential space...so anesthesiologist is going to scrub the person's back...put patient is sitting or sidelying position (catlike position with arched back)....or have significant other sit in a chair facing the woman getting the anesthetic and have her lean on his shoulder and feel comforted.
Make sure she's not allergic to Betadine...scrub the back with Betadine...then doctor will do a small injection to numb it and then advance a long needle until he feels a pop...similar to what we feel when we start an IV...that is when it has passed through the dura outside the epidural space and then inject air...and make that separate and create the space to put the medication in...that's the epidural...then inject medication which may be Marcaine, Stadol, and another "caine" drug...they can put it as periodic doses where they leave it...take needle out and leave catheter in and tape it all up..and then doctor can come back and periodically add injections or he can put it on a continuous drip where the patient gets microunits over a period of time...the nurse's job for a mother receiving an epidural would be to assess for respiratory because the injection may filter into the diaphragm of whichever side the mother is laying on
When doing a spinal, it goes directly into spinal fluid...when going into a space, and added air, which way did the space go?...it's a potential space going somewhere...the injection put in there is bathing and soaking through the nerve roots...it doesn't have a direct passageway...if patient is laying supine on left side, where will most of the effect of the epidural go...to the left...due to gravity...it could even go left diaphragm..so if mother admits that it's getting hard to breathe...nurse would sit mother up so that gravity will bring injection down...it's a real potential respiratory risk to leave patient with difficulty breathing.
it's undetermined..
An epidural is a nerve block and it's going to block?
SNS and PNS below the level of the anesthetic...venous circulation is going to dilate...blood pressure drops...because circulatory bed below the block is going to hold more fluid now...so what is done pre-procedurally is give her at least 1000ml or 2000ml of fluid(typically it's D5LR or just LR, don't have to use too much dextrose or too much saline in IV, but preload them because there may be a vasodilation occurring) to patient before giving an epidural
What happens if mom becomes hypotensive, what happens to fetus?
If blood flow is decreased to mom, then it's decreased to fetus...because it's going into peripheral circulation and not central circulation...so really anticipate position, preload, and side effect of hypotension...the #1 side effect of epidurals during the epidural is hypotension...the #2 side effect during the epidural administration is the advancement of the epidural to the diaphragm...the #3 side effect of epidurals is post-epidural headache if there's a leak and there is penetration of the subarachnoid space accidentally...or even an allergic reaction to the drug
What might the anesthesiologist and nurse watch for when giving mom an epidural?
itching and rash
difficulty breathing
ringing in ears for moms
who's blood pressure drops
fast
metallic taste

so if the test dose doesn't go well, the doctor decides not to give mom anything

a mom with hypertension is not a good candidate for an epidural...it would seem the opposite, but not true