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326 Cards in this Set

  • Front
  • Back
Initiation of Respirations in the Newborn
Production of lung fluid diminishes 24 to 36 hours before labor onset
80 to 100 mL remain in the passageway of a full-term newborn
During birth, fetal chest is compressed and squeezes fluid
Absorption can be delayed by C/S – no thoracic squeeze.
• Characteristics that lead to heat loss:
- Skin is thin, Blood vessels close to surface, Little SQ fat, NB’s have 3X more surface area to body mass than adults, Loose heat at rate 4X that of adults.
• Flexed position decreases ___
he surface area exposed to the environment, thereby reducing heat loss. Usually wrapped up in blankets, keeping flexed position
• NICU babies are extended, they wont flex. Risk of losing heat
is greater. Less fat than term babies.
Heat Loss Is Created by
• Evaporation (example: wet with amniotic fluid). Dry baby to dec fluid on them, stimulate baby by drying them, causes them to cry which helps w/ resp
• Convection (example: air currents such as air conditioning vents)
• Radiation (ex: cold objects near incubator; crib next to window that’s not insulated, cold outside. Cold window pulls heat from baby)
- Newborns also gain heat by radiation – radiant warmers transfer heat from the warmer to the cooler infant.
• Conduction (example: cold stethoscopes/objects)
• What happens when the infant becomes cold?
- 1. Increases the infant’s need for oxygen
- 2. Diminishes production of surfactant impedes lung expansion resulting in respiratory distress / difficulty.
- 3. Glucose needs increase d/t increased metabolic rate. Glycogen stores are depleted  hypoglycemia. (40-60 first day. 50-90 >1day). If baby has <40, feed baby! Or maybe they’re cold.
• Associate these three things together:
Cold baby, Hypoglycemia, Respiratory Distress
• Fetal Hgb carries
20-50% more O2 than adult. Enables fetal cells to receive enough O2.
• Hct – Normal is
is 43-63%.
• Polycythemia –
an abnormal increase in the # of RBC’s in the body’s circulation.
• Level > 63% -
polycythemia- increased risk of jaundice and damage to brain and other organs d/t blood stasis.
• Delayed cord clamping, holding infant lower than level of placenta, cephalohematoma, trauma causes
 inc blood vol/RBC
• Meconium –
first stool. Greenish black with thick, sticky tar like consistency, accumulates in intestines. Consists of particles from amniotic fluid (Vernix. Skin cells. Hair)

1st meconium stool w/in first 8- 24 hrs and 99% of NBs pass within 48 hours.
• Second type of stool – transitional stool.
combo of meconium and milk. Greenish brown and looser in consistency.
• Breast milk stool–
seedy, mustard color & consistency. More frequent.
• Formula stool –
pale yellow to light brown. Firmer than breast. Less frequent.
Hepatic System- Blood glucose levels (BGL):
• Term infant – normal is 40 to 60 mg/dl on first day then 50 to 90 mg/dl thereafter.
• Pregnancy – glucose supplied by
Last 4-8 weeks of pregnancy, glucose stored as
glycogen primarily in fetal liver and skeletal muscles for use after birth.
• Glucose main source of energy in first
4-6 hours after birth.
- Nurse should feed infant if glucose reading is
40 - 45 mg/dl to prevent further decrease; recheck after feeding; according to hospital policy
- Signs of hypoglycemia:
jitteriness, signs of respiratory difficulty, decrease in temp, poor feeding
- Glucose is used more rapidly in newborn than in fetus because
energy is needed during stress of delivery, breathing, heat production, etc.
Major function of liver is
conjugation of bilirubin (is the changing of bilirubin from a fat soluble (unconjugated, indirect) to a water-soluble form (conjugated, direct) in order for body to be able to excrete it)
- changing from a fat soluble to a water-soluble form so body can excrete it.
• Principle source of bilirubin is
the hemolysis (breakdown) of erythrocytes.
- Too much cause staining of tissue in brain resulting in
kernicterus or bilirubin encephalopathy – may cause severe brain damage.
• Physiologic jaundice –
nonpathologic, normal biologic response. occurs after 24 hrs of life – peaks btw days 3 to 5 of life in term infants. maybe due to cephalohematoma or trauma. Does not exceed 13–15 mg/dl. visible @ 4-6 mg/dl
- Pathologic Jaundice –
occurs during first 24 hours of birth.
- Assess for jaundice by pressing skin at
end of nose or sternum, as skin blanches it’s easier to see yellow color
- Severity can be estimated by location on body, begins
at head and moves down as bil level increases.
• Moves in progression from head to feet – bilirubin is higher for generalized jaundice than only face jaundice
- Face – 5 mg/dl. Midabd – 10 mg/dl (head and ab). Soles of feet – 15 mg/dl (completely over the body)
• Breastfeeding jaundice – Most common cause is
insufficient intake, poor feeding practices. occurs in 1st days of life
Related to milk composition. Increase in free fatty acids which inhibits bilirubin conjugation. peaks at 5 to 10 mg/dl at 2 to 3 weeks of life; may need temporary disruption of breastmilk feeding if bili reaches 20 mg/dl and to find cause.
• First voiding occurs w/in
12 hrs of birth in most and w/in 24 hr in 93% of NBs. Only 2-6 voidings may occur in first 2 days of life (urine output of 15ml/kg/day). Subsequently voids 5-25 x in 24 hr period (urine output of 25ml/kg/day).
• If newborn does not void within 36 hours, nurse should assess
adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain
• _______ of newborns will void within 48 hours.
In normal newborns, 100%
• IgG –
only immunoglobulin that crosses placenta. Provides passive acquired immunity. (protects from bacterial toxins). transferred primarily during 3rd trimester; preterms are more susceptible to infections
• IgM –
1st immunoglobulin produced by fetus. (protects against gram neg. bacteria such as E. Coli). produced by fetus beginning at 10-15 weeks gestation
• IgA –
does not cross placenta and must be produced by infant. Found in colostrum and breast milk. (important in protection of GI and respiratory systems). produced by infant at about 4 weeks after birth.
- Fever is a reliable indicator of infection T/F
– in newborn period, hypothermia more reliable indicator of inf’n
• Weight-
Cover scales with blanket, Remove clothing. Normal wt is 2500 to 4000g; (5-8 to 8-13 lbs)
• Length-
Different Methods. Mark the paper. Normal is 18 to 22 in
• Head Circumference-
Measure around the occiput and just above the eyebrows. Normal is 12.5 to 14.5 in
• Chest Circumference-
Measure around the chest at the level of the nipples. Normal is 12 to 14 in
• Abdominal Girth-
Measure just above the umbilicus. Not usually measured unless potential problem identified (unusually large or distended abdomen)
• Temperature: Initially -
rectal temp obtained on admission to nursery (avoid inserting thermometer too far, rectum turns at a sharp right angle at 3 cm). Axillary temp w/ each add’l assessment.
Axillary temps range from
97.5 to 99 F
- Heart rate measured
apically by auscultation.
Normal: Heart rate
110 to 160 bpm. an infant crying may have a HR of 180 bpm. an infant sleeping may have a HR of 100 bpm. Must listen for one full minute.
- Rhythm should be
Murmur is common until
the ductus arteriosis is functionally closed. a heart murmur is a long noise occurring between the normal heart sounds of lub-dub.
• Respirations:
30-60 breaths/min. Assess respirations by observation, auscultation, and/or palpation. Listen for one full minute. Auscultate anterior and posterior lung fields
Respirations may present:
- Periodic breathing -
- Apnea -
- Normal breath sounds
- Periodic breathing -
pauses in breathing lasting 5 to 10 secs without other changes
- Apnea -
pauses in breathing > 20 sec or accompanied by cyanosis, heart rate changes, or signs of dyspnea
- Normal breath sounds
are clear; however, may hear sounds of moisture in the lungs during first hour or two after birth. C/S babies may have coarse breath sounds
The nurse should when assessing lungs:
- Always report absent, diminished breath sounds, or abnormal breath sounds that persist
Respiratory- Signs of Respiratory Distress
• Tachypnea -
• Retractions -
• Nasal Flaring -
• Cyanosis -
• Grunting -
• Seesaw Respirations -
• Asymmetry -
• Tachypnea -
> 60 breaths per minute
• Retractions -
tissue around the bones of chest is drawn in with inspiration
• Nasal Flaring -
widening of the nostrils
• Cyanosis -
purplish blue discoloration (central involves lips, tongue, mucous membranes, trunk)
• Grunting -
noise on expiration as air moves across vocal cords
• Seesaw Respirations -
chest falls when abdomen rises
• Asymmetry -
one side of chest does not expand
• Molding -
overriding of cranial bones
•Fontanels: Anterior:
diamond shaped, closes b/w 12 to 18 mos.
Fontanels: Posterior:
triangle shaped, closes b/w 2 to 3 mos
- The nurse should assess Fontanels when?
Assess while infant is quite, elevate infant’s head during assessment; anterior fontanel should be flat
- Bulging fontanel =
intracranial pressure
Depressed fontanel =
• Caput Succedaneum -
localized edema over the vertex of the newborn’s head
• Result of newborn’s head against mother’s cervix during labor. Can result from a vacuum extractor
• Crosses suture lines. Soft. Resolves w/in 12 hours to several days after birth
• Cephalhematoma –
bleeding b/w the periosteum and the skull of newborns
• Result of pressure during birth. Does not cross suture lines
• Develops w/in 24 to 48 hours after birth. May take 2 weeks to 3 months to resolve
• Infants with cephalhematoma are at increased risk for jaundice due to breakdown of RBCs in hematoma
• Fx of clavicle more likely to occur in
large infants (shoulder dystocia).
• Signs of clavicle fx -
a lump or tenderness over the area, crepitus, swelling, or decreased movement
• Eyes
• Should be symmetric and of same size. True color by 3-12 mos. (Slanting of epicanthal folds = Down’s Syndrome)
• Transient strabismus is common in first 3-4 months. Setting sun sign = Hydrocephalus (Iris sits low in the eye)
• Focus best on objects 8-12 inches away. Should blink or close eyes in response to bright lights
• Edema of eyelids from pressure on the head (resolves in a few days)
• Subconjunctival hemorrhages from pressure on the head (resolves in 1-2 weeks)
• Yellow sclera = Jaundice Conjunctivitis = GC/CZ/Staph infections
• Ears
• Assess for placement, overall appearance, and maturity. Outer canthus of eye even w/ where upper ear joins
• Should respond to voices, noises. Hearing screen performed before discharge
• Mouth -
inspect visually and by palpation. Inspect for precocious teeth
- Epstein pearls: normal, small white inclusion cysts present on gums and hard palate
• Tongue:
inspect for size and movement. (Large tongue = Down’s Syndrome) Cleft lip or palate
- Thrush or Candidiasis may appear on palate, cheeks, or tongue (tx with nystatin)
• Bowel Sounds
Auscultate BS x 4 quadrants - before palpation. BS usually present after first hour of birth. Palpate abdomen when infant is relaxed; Abdomen should be soft and round; not distended
• Inspect anus for patency, document first stool
Umbilical Cord
• 3 vessels (2 arteries and 1 vein). Newborns with 2 vessel cord is associated with chromosomal, renal, and GI defects; nurse should assess for anomalies
• Palpate entire spine. Indention is a sign of spina bifida, may also have a tuft of hair
• Meningoceles or myelomeningoceles
(nerves, spinal cord, or both protruding through the vertebrae defect, appear as a sac on the back).
Nurse should cover area with a moist, sterile, saline dressing immediately after birth if
• Meningoceles or myelomeningoceles is present
• Moro -
• Palmar and Plantar Grasp -
• Babinski -
• Rooting -
• Sucking -
• Moro -
let infant’s head drop back 30 degrees (or elicited when infant is startled by loudnoise); arms and legs extend and abduct, fingers form C position. Reflex persistent until 6 mo
• Palmar and Plantar Grasp -
press fingers against base of fingers / toes. Fingers/toes flexes. Disappear 1 y/o
• Babinski -
stroke lateral heel to toes, toes fan
• Rooting -
stroke side of mouth to cheek, baby turns to the side and opens lips to suck
• Sucking -
place nipple or finger in mouth and infant will suck. Even when asleep- called nonnutritive sucking
• Hands & Feet-
• Hips-
• Examine creases in hand:
• Examine feet for clubfoot
• Hands & Feet-
# of digits; webbed digits; creases; clubfoot. (polydactyly and syndactyly)
• Hips-
Examine for signs of dislocation or inadequate development -gluteal folds
- Tx for hip dysplasia: immobilization, surgery, or casting
• Barlow’s maneuver - adduct the hips . Ortolani’s maneuver - abduct the hips
- If hip instability is present, may hear or feel hip click
• Examine creases in hand:
2 transverse creases normal; single crease seen in Down’s Syndrome
• Examine feet for clubfoot
(foot turns in and down) - If looks abnormal, gently manipulate
• Male Genitals -
Rugae present on the scrotum; testes should be descended into the scrotum; urinary meatus should be located at penile tip. Scrotum may be dark brown; may be edematous
• Female Genitals-
F/T newborn will have labia majora covering the labia minora and clitoris; urinary meatus and vagina should be present. May be edematous; may be darker than surrounding skin
• Lanugo:
• Milia:
• Erythema Toxicum:
• Mongolian Spots:
• Nevus Simplex:
• Nevus Flammeus:
• Nevus Vasculosus:
• Breasts:
• Hair & Nails:
• Lanugo:
fine downy hair, covers fetus in utero (thinner in F/T infants; dark skinned have more), dec w/ GA increases
• Milia:
small white spots that occur over the chin, nose, and forehead; disappear spontaneously. sebaceous glands
• Erythema Toxicum:
white or pale yellow papule of pustule with a reddish base. red blotchy rash with central papule that appears anywhere on the body during first 2-3 weeks of life (aka “fleabite” rash. “newborn rash”); No tx needed
• Mongolian Spots:
bluish black marks that resemble bruises in the sacral area; more common in dark-skinned infants
• Nevus Simplex:
(aka “stork bite”) flat pink or red marks that are found over the infant’s upper eyelids, back of the neck, and middle of forehead; disappear by age 2. common in newborns of Asian, Hispanic, and African descent.
• Nevus Flammeus:
(aka “port wine stain”) is a capillary angioma below surface of epidermis that is red or purple, size and shape varies; does not blanch or disappear; commonly seen on face, can be removed by laser surgery
• Nevus Vasculosus:
(aka “strawberry mark”) is a capillary hemangioma; raised dark red rough surfaced birthmark found on head region. Reaches fullest size by 1 to 3 mos of age then begins to shrink and resolve. Best to allow to resolve spontaneously.
• Breasts:
assess for symmetry of nipples; supernumerary nipple; breast nodule palpable - from maternal hormones, resolves in a few weeks
• Hair & Nails:
F/T should have silky soft hair; nails on each digit extending to end or beyond, post-term infant may have very long nails
New Ballard Score
infant maturity rating scale that assesses neuromuscular and physical maturity. Each parameter displays at least 6 ranges of development along a continuum. Each range of development within an assessment is assigned a number value from -1 to 5. Totals are added to give a maturity rating in weeks gestation (35 indicates 38 weeks gestation)
Growth Grids-
Plot weight, length, head circumference
• LGA (large for gestational age)
> (weight) 90th percentile
• SGA (small for gestational age)
< (weight) 10th percentile
• AGA (appropriate for gestational age) =
weight between 10th and 90th percentile
• Cardiopulmonary Support -
Suction secretions from the mouth (and then nose) with a bulb syringe; if meconium, need to suction mouth before delivery of rest of body
• Thermoregulatory Support -
Infant is placed in a radiant warmer; quickly dried off with warm towels; wrap baby in warm blanket; cap placed on baby’s head reduces heat loss; skin to skin contact with parent maintains infants temp and promotes bonding
• Assignment of Apgar Scores at
1 and 5 minutes
• Vitamin K- Newborn is Vitamin K deficient
because they cannot synthesize Vitamin K in the intestines without bacterial flora. Without Vitamin K, newborn is at risk of bleeding
- Receives .5 to 1 mg IM w/in 1 hour of birth (.5 to infants <2500 g). Administered into vastus lateralis muscle
• Eye Ointment- Prophylactic treatment to prevent
Ophthalmia Neonatorum caused by mother being infected by gonorrhea or chlamydia
- Erythromycin Opthalmic Ointment .5% is administered by applying 1-2 cm ribbon in lower conjunctival sac (from inner to outer); then close eye for 5 secs and wipe off excess
- May blur infants vision. Purulent discharge should alert nurse to possible infection; may need culture
Risk for Ineffective Thermoregulation
• Nurse should assess newborn’s temp shortly after birth then every 30 minutes until stable for 2 hours, then again at 4 hours and then every 8 hours or according to hospital policy. Nurse set radiant warmer btw 36 and 36.5 C
• Skin probe should be attached to infant’s abdomen when under warmer to monitor temp
• Warm objects that come in contact w infant (hands, stethoscope, crib) should be away from doors, windows, drafts.
Initial Bath
• Once temperature has stabilized to 98 F. Sponge bath to remove amniotic fluid, vernix, and blood; shampoo hair
• Water temp should be warm enough to prevent temperature loss (approximately 38 degrees Celsius - 100.4 F). Perform bath quickly. Put back under warmer until temp is stable. Then dress, put cap on head, and wrap in 2 blankets.Parents may want to participate
• Baths after Discharge-
Instruct parents to sponge bathe baby until the cord falls off
- Gather supplies first (baby shampoo and soap); give bath in warm room free of drafts; never leave the infant alone; before undressing, wash hair while holding him in a football position then dry well; then uncover the area one at a time as you wash. Clean diaper area last; females should be washed from front to back
- Do not use cotton-tipped swabs in the infants ears or nose
Cord Care
• Nurse should assess cord for bleeding or oozing; cord clamp should be secure until it is removed at 24 hours after birth. Base should be assessed for purulent drainage, redness, or edema
• Begins drying shortly after birth; turns brownish black within 2-3 days; falls off approximately 10-14 days
• EBP show that no previous tx used is superior to keeping the cord clean and dry and cleaning with water if soiled
• Educate parents to fold diaper below the cord to keep it dry and free from irritation and contamination
• Parents should be educated on proper positioning of their infants. Prone position increases risk for SIDS
• Back lying position best and reduces risk the most; side lying position reduces risk only slightly
• Parents should be taught to avoid soft bedding or loose bedding
• Hepatitis B vaccine given before discharge to babies of HBsAg negative mothers; educate parents on immunization schedule (0, 1-2 mos, 6 months). Injections are IM, administered in the vastus lateralis muscle
Newborn Screening Tests
• PKU (phenylketonuria - condition in which the infant cannot metabolize the amino acid phenylalanine which is common in protein foods such as milk). Accumulation can lead to severe mental retardation
• Treated with low phenylalanine diet, carefully regulated. Test more reliable after 24 hours of age
• Newborn Screening Test: Congenital Hypothyroidism - most common preventable cause of mental retardation
- Hemoglobinopathies such as sickle cell anemia and thalassemia
• Most common surgical procedure of the neonate. Removal of foreskin (fold of skin that covers the glans penis.)
• Pain relief -
pharmacologic – penile block. non-pharmacologic – pacis, oral sucrose, containment
• Before: Make sure parents sign “informed consent”. Make sure infant has received Vit. K. Infant should be at least 12 hours old. Gather equipment including bulb syringe (feedings withheld 2-4 hours before procedure to prevent regurgitation)
• During: Infant is placed on circ board, restrained, blanket under infant, diaper removed, under radiant warmer to prevent cold stress. Nurse should comfort infant during procedure (paci, sucrose, containment)
- Evaluate pain using Neonatal Inventory Pain Scale - by measuring facial expressions, crying, breathing pattern, muscles tone, state of arousal - all should be measured before, during, and after procedure.
• After: Gauze with petroleum jelly placed over circ area. Replace diaper loosely. Check area frequently for 2 hours. Important to note first urination.
• Be Aware of Signs of Complications: Bleeding more than a few drops, failure to urinate, fever, low temp, purulent or foul-smelling drainage.
• Teach parents that it will take 7 to 10 days for circumcision to heal. Keep using petroleum gauze with each diaper change until heals. Use warm water for cleaning. A crust forms during the healing process, Don’t srub off!!
Composition of Breast Milk
• The composition of breast milk changes in the different stages of lactation.
Colostrum Milk Phase
• The secretion of the breasts during the first week of lactation. It is a thick yellow substance
• It is higher in protein, fat-soluble vitamins, and minerals than mature milk but lower in calories, fat, and lactose.
• It is rich in immunoglobulin's which protect baby’s GI system from infections and has a laxative effect.
Transitional Milk Phase
• Transitional milk appears as the milk changes from colostrum to mature milk.
• Immunoglobulin's and protein dec. lactose, fat and calories inc. vitamin content is about the same as mature milk.
Mature Milk Phase
• After the first 2 weeks of lactation mature milk replaces transitional milk.
• Mature milk contains approximately 20 kcal/oz and nutrients sufficient to meet the infants needs.
• Mature milk has a blue appearance and is not as thick as colostrum
• Foremilk is produced
at the beginning of the feeding
• Hindmilk is produced
at the end and contains a high fat content and satiety and aids in the infant weight gain
Composition of Breast Milk
• While it is not likely that the newborn will be allergic to breast milk, foods that mom eats may irritate baby.

- For instance broccoli may cause gas.
• The food should be eliminated by mom as they are identified.
Advantages of Breastfeeding-
• Provides immunologic protection (colostrum)
• Infants digest and absorb components of breast milk easier (baby poops more, more easily, stool not as stinky).
• Provides more vitamin to infant if mother’s diet is adequate. Mom stay on prenatal vit during breast feeding.
• Strengthens mother-infant attachment. No additional cost. Breast milk requires no preparation
Disadvantages of Breastfeeding
• Many medications pass through to breast milk.
• Dad/family unable to equally participate in actual feeding of infant. – but mom can pump and put milk to the side.
• Mom may have difficulty being separated from infant
Bottle-Feeding Advantages
• Provides good nutrition to infant. Father / family can participate in infant feeding patterns
Bottle-Feeding Disadvantages
• May need to try different formulas before finding one that is well-tolerated by infant
• Proper preparation necessary for nutritional adequacy
Infant Feeding: Behaviors
• Infant should be awake and hungry. Feeding should begin before crying occurs
• Cues that the infant is hungry:
Licking movements, Lip smacking, Rooting, Hands to mouth, Sucking on the hands, Increased activity, Crying (a late sign)
• Breastfeeding
- Every 2-3 hours (more freq)
- Feed 8-12 times in 24 hours
- Nurse 10-15 mins on each side
- Burp after each breast
• Formula
- Every 3-4 hours
- Feed 6-8 times in 24 hours
- Burp halfway through feedings
• To burp, place infant
over the shoulder or in sitting position with the head supported while gently patting the back
Patient Teaching: Position of Mom and Baby (Breastfeeding)
• Positioning for comfort- Cradle, football, and side lying position
• Shoulders relaxed, but not hunched over- not tense. Prevent interruptions and provide privacy
• Infants head and body face breast, body aligned. Use pillows for support and elevate infant to the level of the nipple
Patient Teaching: Position of Mom’s Hands (Breastfeeding)
• Palmar or C position
- Mom places her thumb on top of the breast with fingers under the breast, supporting it/guiding it.
- Mom should not press too hard on the top of the breast making the nipple tip upward or the infant will suck improperly and nipple may become sore
- Support the breast for the first few weeks until the infant becomes more adept to breastfeeding
• In order to know if the infant is actually receiving milk from the breast, teach mom to listen for
the sound of swallowing as it occurs. It has a soft “ah” or “ka”
• Do not jiggle breast in infant’s mouth if the infant stops nursing. (Nipple not in correct position, so if baby starts sucking again, will cause rip). Teach mom to unlatch the infant from the breast, wake the infant, and start again.
Factors that Influence Breastfeeding
• Support from others- mothers may be influenced by ones close to them, such as family members.
• Culture - Muslim women breastfeed for 2 years / Certain cultures believe colostrum is bad and do not begin breastfeeding until milk comes in / Certain foods increase milk production in some cultures.
• Employment- The need to return to work soon after giving birth may cause concern about feeding methods. This is a major cause of discontinuation of breast feeding after 10-12 weeks. Need break to pump.
• Knowledge/past experiences- mom get infection in breast before. Experiences – good or bad
• Age: > 30 are more likely to breastfeed. College educated are more likely to breastfeed
• Asian 80.2. White 73.4. Hispanic 70.7. African American 53.9
• Position and clear airway; Use the simplest form of resuscitative measures initially.
- Tactile stimulation - rubbing the newborn’s back with a blanket while drying the baby.
• If no respirations or inadequate respirations (gasping or occasional respirations). Deliver 100% O2 at at least 8L/min.
• Chest should move with each inspiration; breath sounds should be audible bil. Lips and mucous membranes should become pink. You can check heart rate quickly by palpating the base of the umbilical cord stump and counting pulsations for 6 seconds and then multiplying x 10. Placing an NG tube can help control distention of the stomach.
• Endotracheal intubation may be needed for VLBW infants (<1500g). However, most newborns can be resuscitated by bag and mask ventilation.
• Once breathing is established, heart rate should increase to over 100 bpm. If heart rate is absent or the heart rate remains less than 60 bpm after 30 seconds of 100% O2, then chest compressions of 90 per minute should be started.
• Characteristics of RDS
- Increasing cyanosis, Nasal flaring ,Tachypnea (>60 resp. per minute), Apena, Grunting, Significant retractions
• All preterm newborns, and infants of DM mothers, are at risk for RDS, due to an insufficiency of surfactant which is necessary to keep the alveoli of the lungs open.
• Apneic Spells last more than 20 seconds and are accompanied by cyanosis and bradycardia. Apnea lasting a shorter time with HR or color changes are also a concern.
• Nurse must be aware of
infant’s increasing or decreasing dependence on breathing assistance and need for O2. Handling, feeding, and linen changes may require changes in settings on equipment. O2 flow should be increased with suctioning. (Suctioning decreases oxygenation during the procedure and may cause changes in heart rate, blood pressure, and cerebral blood flow)
• When O2 delivered, must be monitored. Arterial blood may be drawn for testing O2 levels. Pulse oximetry and transcutaneous monitoring also may be used which are less invasive.
• Frequent position changes help drain air passages and prevent stasis of secretions.
• Prone position not recommended for term infants but is tolerated well with preterm infants.
• Prone position allows more efficient use of respiratory muscles. Improves oxygenation and lung mechanics, decreases energy expenditure.
• Infants should be repositioned every 2 to 3 hours.
• Suctioning secretions- Suctioned as mucus becomes apparent. Mouth always suctioned before the nose to prevent aspiration of fluids if the infant gasps when the nose is suctioned.
• Performing chest physiotherapy- promotes postural drainage through percussion and vibration.
• Maintaining hydration- Dehydration results in thick secretions which can obstruct air passages. Fluid intake should be increased if dehydration signs appear.
• Retinopathy of Prematurity- immature retinal vessels sensitive to high concentrations of O2, vasoconstriction occurs and causes retina to become ischemic, hemorrhage occurs and scar tissue forms. May lead to blindness.
• Bronchiopulmonary Dysplasia (BPD)- occurs in infants dependent on O2 administration, essentially chronic lung changes occur (over inflation and atelectasis noted in lungs).
• Transient Tachypnea of Newborn (TTN): Develops rapid respirations (as high as 120) soon after birth, resolves within a few days. Caused by delay in absorption of fetal lung fluid by pulmonary capillaries and lymph vessels.
• Grunting, nasal flaring, and mild cyanosis are present. Occurs in approx 11 out of 1000 births.
• Risk factors: CS w/o labor, Intrauterine Asphyxia, Precipitous delivery, Mat’t analgesia, Mat’l Bleeding or DM.
• More prevalent in C/S births who have not had the “thoracic squeeze” to remove some of the lung fluid.
• CXR shows streaking from engorgement of pulmonary vessels and lymphatics, hyperinflation and presence of fluid in fissures between lobes and pleural space.
• Oxyhood, IV, no oral feedings
• Meconium Aspiration Syndrome (MAS): Meconium in the amniotic fluid enters the lungs during fetal life or birth.
• Often occurs when hypoxia causes increase peristalsis of the intestine and relaxation of the anal sphincter before or during labor. It may be drawn into the lungs if gasping movements occur in utero or during the first few breaths taken by the newborn.
• May be result of long labor, decreased amniotic fluid, cord compression, intrauterine asphyxia.
• Clinical manifestations: Fetal hypoxia before birth. Meconium stained amniotic fluid
- Signs of distress at birth – cyanosis, apnea, slow heart beat, low apgars.
- Yellow-green staining of fingernails, umbilical cord, and skin
• Nursing Considerations during Intrapartum: Assess / document amount of meconium present in amniotic fluid. Set up O2 and suction equipment
• After birth, nursing care is adapted to the problems presented
• Management of MAS:
• Amnioinfusion- sterile saline is injected into the uterus to dilute the meconium and minimize the severity.
• Suction after head is delivered while shoulders and chest are still in birth canal. Suction mouth and nose before shoulders and chest delivered.
• After delivery, if respiratory effort is good with good muscle tone, good color, and crying, then tracheal suctioning should not be performed.
• If poor muscle tone with little/no respiratory effort, HR <100
- Suction trachea immediately. Suction no longer than 5 seconds. No meconium retrieved do not repeat
- Meconium present and no bradycardia - repeat suction until there are no signs of meconium
• Suctioning should be performed by specially trained personnel: NNP, experienced NICU nurse, respiratory therapist, nurse anesthetist. The intensity of care depends on how the baby responds after suctioning.
• Warm humidified oxygen. Respiratory support with a ventilator. Surfactant therapy- helps to keep air sacs open
• Umbilical arterial line. Inhaled nitric oxide therapy-acts as a vasodilator
• Chest physiotherapy (percussion, vibration) to remove debris
• Prophylactic abx
- After RBC’s break down, the bilirubin binds with albumin to form indirect (unconjugated) bilirubin. To be excreted it must be converted to direct (conjugated) bilirubin. This conversion occurs in the liver.
- Complication: Kernicterus - unconjugated bilirubin levels that reach 20 mg/dl or higher and can lead to bilirubin encephalopathy. Results in permanent brain damage; can be life-threatening.
• Therapeutic Management:
- Focused on preventing the development of kernicterus.
- Determine cause: A positive Coombs’ indicates that Ab from the mother have attached to the infant’s RBCs.
• Treatment:
- Most common treatment of jaundice.
Use of special fluorescent lights.
Phototherapy S/E’s include
frequent, loose, green stools that result from increased bile flow and peristalsis.
- Exchange Transfusions are necessary when phototherapy cannot reduce dangerously high bilirubin levels quickly enough. Treatment removes antibodies, unconjugated bilirubin, and sensitized RBCs before they break down, and it corrects severe anemia. During exchange transfusion, blood is removed from the infant and replaced with an equal amount of donor blood in small portions or simultaneously. At end of transfusion, approximately 85% of the infants RBCs have been replaced.
• More significant problem in preterm than term infants. P/T infant has less time in utero so less brown fat to accumulate. This in addition to thin skin, blood vessels near the surface, and little SC fat.
• Preterm infants have larger head and more body surface area in proportion to size than term. (Extended body of preterm exposes greater surface area for heat loss)
• Complications from heat loss:
• Hypoglycemia and respiratory problems- limits glucose and O2 available to increase metabolism as a method of heat production.
• Vasoconstriction occurs when temp drops, may lead to metabolic acidosis, pulmonary vasoconstriction, interference with production of surfactant, and more respiratory difficulty.
COLD STRESS- Indications of inadequate thermoregulation:
• Lethargy, irritability, Poor feeding or intolerance to feedings, Increased respirations, Poor muscle tone, Cool skin temperature, and Mottled skin.
• Temperature instability may be early sign of infection. Assess for other evidence that infection may be present.
COLD STRESS- Nursing Interventions for Prevention:
• Maintain a neutral thermal environment. Maintaining a neutral thermal environment is important to help the infant maintain body temperature. Monitor skin temperature
• Polyethylene wrapping for VLBW. Polyethylene wrapping :A transparent plastic blanket over the infant allows heat from the warmer to pass across to the infant and decreases insensible water loss and heat loss from evaporation.
• Head coverings and blankets. Swaddling and nesting maintains flexion
• Nursing Interventions If Cold Stress occurs:
- Radiant warmers and incubators. Monitor skin temperature every 15 to 30 minutes. Check blood sugar. Warm IV fluids before infusion. Remove plastic wrap, caps, and heat shields so cool air is not trapped.
• Preterm infants lose fluid easily. Thin skin has little protective SC fat and a greater H2O content, and is more permeable than the skin of term infants.
• Radiant warmers and phototherapy lights cause fluid loss which increases their fluid needs.
• Water loss occurs through respiratory and GI tract. Rapid RR and use of O2 can cause increase fluid loss from lungs. Loose stools can lead to rapid dehydration.
• I&O by all routes carefully assessed. (parenteral, feeding tube, oral fluids, drainage tubes, urine, amount of blood for lab tests).
• Normal UO is 2 to 5 ml/kg/hr. UO <2 ml/kg/hr = inadequate fluid intake or decreased kidney function.
o UO >5 ml/kg/hr = overhydration.
• Kidneys not complete until around 35 weeks gestation. Ability of the kidneys to dilute urine is poor before that time causing a fragile balance between dehydration and overhydration.
• Collection of urinary output for measurement: Weighing diapers is more suitable for P/T infant than attaching plastic bags to skin which can cause trauma due to their fragile skin.
• Hypoglycemia is a problem because of lack of glucose and fat reserves. Brain needs steady supply of glucose.
• Need 95 to 130 kcal/kg/day
• GI tract does not absorb nutrients as well as term.
• Infants <34 weeks gestation generally have difficulty coordinating sucking, swallowing, and breathing.
- If sucking uncoordinated, infant must receive gavage or parenteral feedings.
• Adequate nutrition is critical because P/T is born before full accumulation of nutrient stores and digestive capacity is achieved.
• Oral feeding may cause increased need for O2 and glucose in weak infants.
• Nonnutritive sucking w/ pacifier is encouraged. Sucking improves oxygenation and decreases energy expenditure.
• Tape - Use little or none, cotton as backing, wait >24 hours to change
• Bathing - not necessary daily (use sterile water if skin is breaking down); No soap should be used < 32 weeks.
• Humidity regulation to prevent further drying of skin. Frequent repositioning. Handwashing
• Containment during painful procedures. Comfort measures - single dose of sucrose on pacifier
• Meds - Morphine & fentanyl tolerated well; acetaminophin may be used
• Psychosocial:

• Need to develop appropriate environment for high-risk neonate
• Coordinate care with other health care workers - cluster activities so that several tasks can be performed at 1 time.
• Reduction of detrimental stimuli (noise) - keep incubator away from heavy traffic area; no tapping on incubator; turn infants away from lights, blanket over end of incubator; provide rest periods of at least an hour
• Loss and grief occurs = “perfect” child. Grieving process needed to ensure bonding to occur.
• Intraventricular Hemorrhage-
occurs most often in infants < 34 weeks gestation or weighing <1500 grams. Bleeding in or around the ventricles of the brain. Results from rupture of fragile blood vessels to the germinal matrix, located around ventricles of the brain. Most often associated with hypoxic events such as respiratory distress, birth trauma, and birth asphyxia.
• Necrotizing Enterocolitis- NEC-
Inflammatory disease of the GI mucosa due to ischemia. Results in necrosis and perforation of the bowel. During asphyxia, blood is diverted from the GI tract to the brain, heart, and kidneys. Sepsis, polycythemia, and maternal cocaine use are other causes of decrease in intestinal blood flow.
• Risk factors include
congenital malformations, chromosomal anomalies, fetal infections, poor placental perfusion, Maternal conditions such as pre-eclampsia, maternal drug use. (mom gets infection)
• Symmetric characteristics -
body is proportionate (weight, length, and head circumference all < 10%) - caused by congenital anomalies or early infection. Small all over. IUGR started early in the pregnancy, exposed to inf early.
• Asymmetric characteristics -
caused by complications after 28 weeks (3rd trimester). Head is normal in size in comparison to a small abdomen - caused by pre-eclampsia.
• Born after 42nd week of gestation
• Placental Insufficiency may be present if pregnancy is prolonged (placental dec in fxn, dec placental diffusion). Results in decrease in amniotic fluid and compression of the umbilical cord may occur. Could result in infant not receiving enough O2 and nutrients resulting in SGA. Condition is called post-maturity syndrome.
• May pass meconium before or during labor. (trigger: stress causes meconium)
• Nurse should observe infants for hypoglycemia since glycogen stores are used so rapidly
• Infant with PMS - has little or no lanugo (hair) or vernix (cheezy subst that baby is borned w), skin wrinkled cracked and peeling, umbilical cord thin with little Wharton’s jelly. More risk for cord compression.
• Many post term infants will be normal at birth. May be large - assess for birth injury , esp shoulders.
• Monitor vital signs
• Screen for hypoglycemia and polycythemia
- lateral heel area
- Hypoglycemia (BS < 40) Even after maternal blood supply is lost, the infant continues to produce high levels of insulin which depletes the infant’s blood glucose within hours of birth.
• Observe for signs of birth trauma
TTN: progressive form of resp distress.
Cause: infant can’t clear lungs Cause: newborn cannot clear lung fluid. Presents w/in 6 hours of birth. RR > 60 breathpm (can reach 80-100 bpm)
Improves w/in a few days. S&S: grunting, flaring of the nares, subcostal retractions, desaturation, and mild cyanosis when breathing room air. Risk factors: maternal diabetes, C/S delivery, intrauterine or intrapartal asphyxia, maternal bleeding, prolapsed cord, breech presentation . Tx: oxyhood w/ O2 30-50%, IV fluids, NPO until resolved
• Mrs. Chow is Rh negative and Baby Chow is Rh positive with a positive Coombs test. Baby Chow develops pathologic jaundice during the first 24 hours. What is the cause of her jaundice?
Cause of jaundice- hemolytic dz caused by incompatibility (most common). Occurs during first 24 hrs of birth. Normally serum albumin binding sites conjugate enough bilirubin to meet the demands of newborn. BUT certain conditions dec # and/or quality of binding sites.
• What is the difference between physiologic and pathologic jaundice?
Normal process that occurs during intrauterine to extrauterine life. Occurs after 24 hours of life
• Discuss the significance of kernicterus.
Acute bilirubin encephalopathy- bilirubin does not bind to albumin which allows it to cross BB which damages the CNS cells. Brain damage that is induced by excessive bilirubi.n Unconjugated bilirubin levels > 20mg/dL. Signs and symptoms: excessive sleepiness, difficult to arouse, lethargic, high pitched cry, decreased muscle tone, arch their head and back. brain tissue gets stain, become jaundice
• Phototherapy – include nursing care that is involved.
Blue light that alters bilirubin from toxic to nontoxic form. Baby under photo light. Take baby out to feed, don’t need to keep them under there all the time. Baby wears eye patches and diapers . Baby should be taken out to feed Q2-3 hours. M vital signs Q4 hours. M I&O. Skin care!
• Exchange transfusion –used
when bilirubin levels are rising quickly (Rh incompatibility). Withdrawal and replacement of blood with donor blood. tx anemia with RBC that aren’t susceptible to maternal antibodies. Removes sensitized RBCs that would be lysed. Removes serum bilirubin and provides bilirubin-free albumin. Increases binding sites for bilirubin . Concerns: use of blood products (potential for HIV and Hepatitis)
• Head (molding, fontanels, caput, cephalohematoma)-
molding-overriding of carinal bones. Asymmetry. Fontanel- 2 soft psots. Anterior and posterior. Bulging= increased intracranial pressure, or crying. Depressed- dehydration. Caput- collection of fluid, edematous swelling. Crosses suture lines. Should reabsorb w/in 12 hrs – few days after birth. Cephalhematoma- collection of blood btw cranial bone and periosteral membrane doesn’t cross suture lines. Doesn’t increased in size w/ crying. Appears on 1st and 2nd days. Disappears after 2-3 wks.
• Eyes, Ears, Mouth- eyes:
general placement, appearance. Movement in all direction. Blink reflex w/ bright light. Ears- eternal ears w/o lesions, cysts, nodules. Attends to sounds, sudden. Loud noises. Mouth: Adequate salivation. Presence of gag reflex and sucking. Soft and hard palate intact. Tongue is free moving, Pink in color
• Neck/Clavicles –
neck short, straight, creased w/ skin folds. Posterior neck lacks loose extra folds of skin. Palpate lymph nodes. Clavicles- evaluated for evidence of fractures by feeling for crepitus normal clavicle is straight.
• Trunk/Abdomen (nipples, umbilical cord)- trunk:
bilateral chest expansion. Breath sounds. Flat breasts w/ symmetric nipples. Breast tissue diameter 5 cm or more @ term. Ave distance btw nipples 8 cm. Ab: cynlindrical, larger to pelvis. No cyanosis, no protusion of umbilicus. Bowels sound heard. Femoral pulses palpable, equal, bilateral. No inguinal lymph nodes.
• Genitourinary (male and female)-
F: labia majora, labia minora, clitoris, noting size. 1st wk. may have vaginal d/c, thick whitish mucus. M: penis (size, opening). Scrotum- size, symm. Palpate both testes. Rule out cryptorchidism, failure of testes to descend Both should void @ least once in 1st 24 hrs. 2x in 2nd 24 hr. By 5th day of life and thereafter, the newborn can be expected to have at least 5 or more wet diapers/day
• Extremities (hips, hands, feet, nails, pulses)-
hips: flat/straight when prone. Dislocation. Gluteal folds. Barlow’s maneuver-adduct hips. Ortolani’s maneuver- abduct the hips (@ least 60 degrees) Listen/ feel for clicking sound in hip joints. Hands/feet: # of digits. Webbing of digits. Creases on palms of hands/soles of feet. Foot clubbing. Nails: extend beyond the fingertips in term newborns. May adhere to skin of fingers, so cutting contraindicated
• Back/Spine-
palpate the entire spine. Assess for indention. Patch of hair (spina bifida). Meningoceles or myelomeningoceles (sac of nerves and/or spinal cord protruding from the spinal cord.
• Skin (lanuga, milia, erythema toxicum , Mongolian spots, nevus simplex, nevus flammeus, nevus vasculosus,)- notes above!
Jaundice- yellowing of the skin 1st detectable on the face. Eval by blanching the tip of the nose, forehead, sternum, or the gum line. If jaundice is present the area will appear yellowish immediately after blanching
• Discuss how MAS can be managed during intrapartum.
Amnioinfusion - dilute the meconium. Suctioning mouth/nose at delivery- take out meconium from respiratory system
• Discuss the management options of MAS after delivery.
Suctioning nasal and oral, trachel prn. O2/ Ventilator (high pressure). Umbilical arterial line- BP, blood sample for pH, blood gas. Nitric oxide therapy- vasodilate. Chest physiotherapy- percuss/vibrate to remove debris. Prophylactic abx- prevent pneumonia. Surfactant therapy- natural surfactant is inactivated, prophylactic measure to keep alveoli open.
• Baby Shaiqk was delivered by forceps delivery and weighed 9-7 (LGA). What nursing considerations are important in the care of Baby Shaiqk and why?
Cephalohematoma. Injury to baby shaiqk (shoulders). Monitor Vs, screen for hypoglycemia and polythemia
• Describe nursing considerations specific for caring for the preterm infant.
Tape (skin is thin, so putt cotton backing on tape. If need tape, then leave it for 24 hrs since you don’t want to take it on and off), Bathing (once temp is 98F, Sponge to remove fluid, vernix, blood. Warm water to prevent temp loss. Quickly done! If baby has any skin breakdown, use sterile water! Bath not needed everyday since soap dries out skin), Positioning (place baby on stomach w/ arms flexed. If not flexed, prone position inc risk for SIDS, back lying reduces risk. Full term position- back. Preterm- tummy since keeps them flexed and reduce temp loss, doesn’t inc risk for SIDS), Handwashing (prevent infection), Comfort measures (Containment, meds, sucrose)
• Discuss how cold stress is prevented and managed in the preterm infant.
Warm baby w/ radiation warmers and incubator. Skin temp M q15-30 min. M BG. Infuse warm IV fluids. Remove things that trap cool air (plastic stuff). Weigh diapers for preterm babies! Don’t want to over hydrate or underhydrate baby. Calculate blood that comes out too. Group babies care activities, that way you don’t wake the baby up. They’re using a lot of energy anyway.
• How is fluid/electrolyte/nutritional balance managed in the preterm infant? ).
F/E 140-160 ml/kg/day (increases if fever or warmer environment). Calories 100-115 kcal/kg/day. Fats- 98% in human milk, vit, minerals. Carbs 40% of calories. Protein 0.8-0.9% g/dL. Wt gain first 2 wks 1oz/day or 0.5 lb/wk.
• Two complications for preterms who are on 02 therapy are
Retinopathy of Prematurity- formation of fibrotic tissue behind lense. Optimal detachment, arrested eye growth, seen w/ hypoxemia in preterm.

Bronchiopulmonary Dysplasia- chronic pulm dz of multifactorial etiology. Alveolar and bronchial necrosis.
• Two other complications associated with prematurity are Intraventricular Hemorrhage and Necrotizing Enterocolitis (NEC).
Intraventricular hemorrhage: Bleeding w/ ventricles or fluid filled areas of brain. Immature vessels. Infants born before 30 wks. Spinal tap may be done to relieve pressure.

Necrotizing enterocolities Death of intestinal tissue. Occurs when lining of intestinal tissue dies.
• Involution
used to describe rapid reduction in size of uterus and return to prepregnant state.
• Exfoliation allows for
healing of placenta site; is important part of involution; placental site takes up to 6 wks to heal.
Involution of the Uterus
• Enhanced by uncomplicated labor and birth – complete expulsion of placenta or membranes, breastfeeding, and early ambulation
Factors that retard involution
Prolonged labor
Difficult birth
Grand Multiparity
Full bladder
Incomplete expulsion of placenta
Over distention of uterus
 Lochia changes:
Bright red at birth
Lochia Rubra – dark red (first 2 to 3 days)
Lochia Serosa – pink (day 4 to 10)
Lochia Alba – white (day 11 to around 3rd week)
 (uterine atony)
If blood collects and forms clots within uterus, fundus arises and becomes boggy
Uterus / Afterpains
More acute for multiparas due to repeated stretching of muscle fibers – loss of tone.
 Worse with breastfeeding – Oxytocin release. Pains decrease rapidly after 48 hours. Analgesics used.
Cervical Changes
Immediately after delivery – formless, flabby and open wide enough to admit entire hand!
 Rapid healing takes place – by end of 1st week becomes firm and ext. os width of pencil (fingertip).
 Os changes in appearance permanently. W/I first few days of delivery, cervix may admit 2 fingers
Vaginal Changes
 Stretched during birth. After delivery – edematous, gaping, bruised.
 Rugae begin to return and size of vagina decreased w/in 3 wks. appears normal by 6 weeks in non-lactating women.
 Lactating women - hypoestrogen state; thin vaginal walls, dryness, dyspareunia.
 During pp period, vaginal mucosa becomes very thin/atrophic – vaginal walls do not regain thickness until estrogen is re-established by the ovaries. Breastfeeding mothers may be affected more; tend to have vaginal dryness and dyspareunia (painful intercourse).
 Changes permanently; labia majora and minora are looser in women who have borne a child.
Perineum- Evaluate episiotomies and lacerations with REEDA
 1st degree – involves superficial vaginal mucosa or perineal skin.
 2nd degree – involves vaginal mucosa, perineal skin, and deeper tissue (may include muscles of the perineum).
 3rd degree – Same as 2nd degree but involves anal sphincter.
 4th degree – Extends through the anal sphincter into the rectal mucosa.
 1st degree –
involves superficial vaginal mucosa or perineal skin.
2nd degree –
involves vaginal mucosa, perineal skin, and deeper tissue (may include muscles of the perineum).
3rd degree –
Same as 2nd degree but involves anal sphincter.
4th degree –
Extends through the anal sphincter into the rectal mucosa.
Cardiovascular System
- Cardiac output decreased for first few weeks. Cardiac output reaches normal by 6-12 weeks pp.
- Decreased blood volume – bradycardia rates of 50 to 70 beats per minute occur during first 6 to 10 days. Vaginal delivery – average blood loss is 200-500 ml; C/S delivery – average blood loss is 1000 ml
 Body rids itself of excess plasma volume by two methods:
1. Diuresis - increased urine excretion; urinary output of 3000 ml per day is common days 2-5 pp.

2. Diaphoresis - profuse perspiration
 Coagulation:
Fibrinogen changes during pregnancy. Elevations in clotting factors continue for several days or longer in pp period. It takes 3-4 weeks before hemostasis returns to normal pre-pregnant levels.
Syphilis - Stages
Primary Phase:
Secondary Phase:
Latent Phase:
Tertiary Phase:
Syphilis -
The causative organism in Syphilis is the “Spirochete Treponema Pallidum”
Several phases occur - and the symptoms are different with each phase.
Primary Phase:
Painless sores or open, wet ulcers known as chancres appear
Last 3 to 6 weeks
Appear on the genitals, in the vagina, on the cervix, lips, mouth, or anus
Swollen glands may also occur during the primary phase.
Secondary Phase:
About 2 months after initial infection, other symptoms appear. Symptoms may come and go for up to two years.
Symptoms include body rashes that last from two to six weeks—often on the palms of the hands and the soles of the feet.
Other symptoms include mild fever, fatigue, sore throat, hair loss, weight loss, swollen glands, headache, and muscle pains. Condylomata lata may develop on genitalia (resembles warts)
Latent Phase:
If untreated, enters latent phase. No symptoms. May last for several years.
Tertiary Phase:
One-third of untreated people with syphilis experience serious damage to the nervous system, heart, brain, or other organs, and death may result.
Screening tests: VDRL and RPR.
Tx: PCN preferred; others meds include ceftriaxone, doxycycline, tetracycline.
Must be reported to CDC.
Things that could happen if Syphilis is untreated.
If untreated may cross placenta. Could result in:
Spontaneous abortion,
Premature labor and/or birth,
Congenital syphilis.
Symptoms of congenital syphilis are:
Enlarged liver and spleen,
Skin lesions,
Pneumonia and hepatitis.
PCN is primary treatment for mother and fetus.
Gonorrhea – causative organism –
Neisseria gonorrhoeae
Gonorrhea, often called
the clap, dose, or drip, is one of the most common infectious diseases in the world.
In women, gonorrhea can cause pelvic inflammatory disease (PID), which can result in ectopic pregnancy or infertility.
Usually asymptomatic; symptoms may develop as infection spreads (abnormal vaginal discharge, dysuria, dyspareunia, bleeding with intercourse)
During pregnancy, gonorrhea infections can cause premature labor and stillbirth.
More than one million cases of gonorrhea are reported every year in the U.S.
How gonorrhea is spread:
vaginal, anal, and oral intercourse.
Protection: Condoms offer very good protection against gonorrhea.
To prevent serious eye infections – ophthalmia neonatorum -
that can be caused by gonorrhea, antibiotics drops are put into the eyes of newborn babies after delivery.
20-50% of women with gonorrhea test positive for chlamydia.
Treatment –
Rocephin or Cipro
Must be reported to CDC
Chlamydia is
a common sexually transmitted disease (STD) caused by the bacterium, Chlamydia trachomatis.
Symptoms of chlamydia are usually mild or absent; may develop an abnormal vaginal discharge, dysuria, dyspareunia, bleeding with intercourse. Chlamydia may cause discharge from the penis of an infected man.
Infection may spread to upper reproductive tract (PID) and result in infertility.
How Chlamydia is spread:
- vaginal, anal, and oral intercourse
- may be found in throats of women and men having oral sex with an infected partner
- Condoms offer good protection against Chlamydia.
Chlamydia is a leading cause of early infant pneumonia and conjunctivitis (pink eye) in newborns. T/F
Chlamydia can be easily treated and cured with
antibiotics. A single dose of azithromycin or a week of doxycycline (twice daily) are the most commonly used treatments.
WBC’s -
25,000 to 30,000 (average 14,000 to 16,000); should fall to normal by end of first week.
- difficult to interpret first 2 days; returns to normal within 4 to 6 weeks.
Intestines sluggish because of lingering effects of progesterone and decreased muscle tone.
 Spontaneous bowel movement may not occur for 2 to 3 days after childbirth.
 Mom may have discomfort because of perineal tenderness, fear of episiotomy tearing, or hemorrhoids.
 Urinary Tract
Urinary retention and overdistention may occur.
 2 complications may result from retention and overdistention
 1. UTI (not emptying the bladder completely) and 2. PP hemorrhage
 If fundus is higher than expected on palpation and is not in midline, nurse should suspect
bladder distension
Taking in phase–
1 to 2 days after delivery
 Mother is passive and somewhat dependent as she sorts reality from fantasy in birth experience
 Food and sleep are major needs
Taking hold phase–
2 to 3 days after delivery
 Mother ready to resume control over her life, her body, her mothering
 She is focused on baby and may need reassurance
 En Face position-
baby and mother has faces close together.
 Verbal behaviors -
Important indicators of maternal attachment. Some mom start by calling baby “it”“he or she” name. The pitch of the voice is another verbal characteristic – most mothers will use a soft, high pitch.
 Fingertipping exploration-
occurs during the early minutes after delivery, mother gently explores infant’s face, fingers, and toes with her fingertips only
 Palming-
After fingertipping – mother strokes infant with palm. Next she uses entire hand to enfold infant and bring close to her body. Holds close, presses cheek to infant
 Enfolding with whole hand and arms-
Then will look and ID specific features of infant- will relate infant’s features to family members. Termed claiming or binding-in.
Vital signs: Temperature elevations from baseline, last for only 24 hrs. Temp of >100.4 after 24 hrs infection.
 Blood pressure is stable and pulse is initially slow, breath sound should be clear.
 Easy way to remember sequence: BUBBLEHER
Breast Assessment
Assess if mother is breast or bottle-feeding – inspect nipples and palpate for engorgement or tenderness.
 Assess fit / support of woman’s bra.
Uterine Assessment
 Determine firmness of fundus and ascertain position.
 Correlate position with approximate descent of 1 cm per day
 Correct documentation - VERY IMPORTANT!
 Consistency (firm or boggy); Position (midline, right, or left); Location (@U, U-1, U+1)
 Assess q15 min for 1 hr then q30 min for 2nd hr then q1hr for 2 + hrs.
Bowel, Bladder Assessment
Assess frequency, burning, or urgency – palpate for bladder distention
 Bowel: Assess bowel sounds, flatus, and distention
Lochia Assessment
Note color, odor, presence of clots.
 Amount of Lochia: Scant - < 2.5 cm (1 inch) Moderate – 10 to 15 cm (4-6 inch)
 Light – 2.5 to 10 cm (1-4 inch) Heavy – saturated in 1 hour
 Note: A constant trickle or dribble of lochia indicates excessive bleeding and requires immediate attention!
 Measure the amount of lochia on the pad. Lochia should not exceed moderate amount (4 to 8 pads per day).
Episiotomy or Incision Assessment
Inspect the perineum for REEDA and for hemorrhoids.
 Inspect abdominal incision for REEDA
 ** REEDA = Redness. Edema (swelling). Ecchymosis (bruising). Discharge. Approximation (how well the edges of an incision or laceration are holding together)
Homan’s Sign, Edema, Reflexes Assessment-
 Extremities- Assess for edema, redness, and warmth. Check pedal pulses. Check Homan’s sign
 Reflexes (if hx of severe-pre-eclampsia / eclampsia) – 2+ is normal
Maternal Comfort
 Relief of perineal discomfort-
Ice packs, Topical agents (Dermaplast), Peri care, Sitz baths (cool or warm)
Relief of hemorrhoidal pain
Topical anesthetic ointments, Witch hazel pads (Tucks), Increase in fiber and fluids; stool softeners
 Topic hydrocortisone or suppositories - No rectal suppositories for 4th degree lacerations.
Afterpains- Relief of afterpains **first 48 hrs
Positioning (prone position) with pillow. Analgesia (Motrin or Ibuprofen)
 Encourage early ambulation – monitor for dizziness and weakness
 Postpartum client may need medications to promote
comfort, treat anemia, promote rubella, prevent development of antigens (in nonsensitized Rh-negative woman), prevent pertussis
 Rubella injection if rubella non-immune
 Rhogam injection if mom is Rh – and baby is Rh + (also Rhophylac)
 Adacel (tetanus) if not current, includes pertussis
 Epic has Immunization questions now.
Postpartum clients should be informed about
name of medication, expected action, possible side effects
 Nurse must review safety measures with medications
Cesarean Section Needs
Assess location and firmness of fundus, lochia, and incision site. Administer analgesia. Proper positioning.
 Splint incision with turning, coughing.. Adequate rest. Early ambulation. Advance diet when awake awake and alert.
 Foot pumps; foley; monitor dressing. Page 1043
Suppressing Lactation - In non-breastfeeding woman. Will take
a few days.
 Suppressing Lactation
Sports bra - 24 hours. Avoid breast stimulation. Cabbage leaves / cold compresses. Analgesics.
Preparation for Discharge
 Preparation for discharge should begin when expectant mother enters birthing unit.
 Mother needs to be aware of signs of postpartum complications and should be aware of her self-care needs.
 Nurses should begin first by assessing knowledge and expectations of new mother and family.
 Nurse should be available to answer questions and provide support to parents.
Sexual Activity
Sleep deprivation, vaginal dryness, and lack of time together may impact resumption of sexual activity.
 Usually sexual intercourse should not be resumed until client has been evaluated at her pp f/u appt (6 weeks).
 Breastfeeding mother may have leakage of milk from nipples with sexual arousal.
Information on contraception should be part of discharge planning.
 Nursing staff need to identify advantages, disadvantages, risk factors, and any contraindications.
 Breastfeeding mothers concerned that contraceptive method will interfere with ability to breastfeed – they should be given available options (no estrogen).
puerperal infection: bacterial inf of reproductive tract assoc. w/ childbirth that occurs any time up to 6 wks pp.
 Fever of 100.4 or higher after first 24 hours and occurring on at least 2 days during the 1st 10 days after childbirth.
 Most common are: Endometritis (infection of the uterus), Wound infections (C/S and Perineal), UTI, Mastitis
 Risk Factors for Uterine Infection:
 CS, Prolonged labor, Instrument assisted childbirth
 Catheterization, Multiple vaginal exams, Chorioamnionitis, Use of internal monitoring during labor,
 Prolonged ROM or PPROM, Retained placental fragments, Uterine exploration or manual placental removal
 Compromised health status ((poor general health, poor nutrition, illicit drug use, low socioeconomic status) Diabetes, Pre-existing BV or CZ infection
S&SXs of Endometritis:
Foul smelling lochia is classic sign!!!
 Mild Endometritis: bloody vaginal d/c, foul smelling, scant or profuse.
 Severe Endometritis: mild endometritis sxs + uterine tenderness, high T 101-104F, tachycardia, chills, subinvolution.
 Most often occur within the first 24 to 36 hours
 Dx within 24 TO 36 hrs is early onset and is usually related to GBS. > 36 HOURS is late onset; usually r/t chlamydia.
 Therapeutic Management of Endometritis:
 Broad spectrum abx - combination of clindamycin + gentamicin; or ampicillin, cephalosporins, and metronidazole may be necessary. Route / dosage of abx is dependent on severity of infection. Usually improvement within 48 - 72 hours. Abx continued until afebrile for 24-48 hours.
 Other drugs – Antipyretics for fever, Oxytocics (increase drainage of lochia and promote involution. Place in Fowlers position to promote drainage of lochia.
 Complications of Endometritis: If spreads outside of uterus:
Salpingitis or oophoritis may occur. Peritonitis may occur and lead to pelvic abscess –inf of peritoneal cavity.
 Risk of pelvic thrombophlebitis is increased -clot in ovarian vein that becomes infected and the wall of the vein breaks down from necrosis spilling infection into the connective tissue of the pelvis.
 S&SXs of spreading may be similar to endometritis, but patient is more acutely ill. ACUTELY ILL - Severe pain, marked anxiety, high fever, rapid/shallow respirations, pronounced tachy, abd. Distention, N&V.
Therapeutic Management of Wound Infection:
Wounds with pus or serosanguinous drainage - remove stitch, allow to drain, pack 2-3 x per day.
 Broad-spectrum antibiotics. Analgesics. Warm compresses or sitz baths.
 Wound Infections:
 Any break in the skin or mucous membrane provides a portal of entry for bacteria.
 25 – 30% caused by STAPH.
 S&SXs: Edema, warmth, redness, tenderness, and pain. General signs may develop as well- fever, malaise.
 S&S of UTI:
Typically begin on 1st or 2nd day PP.
 Include dysuria, urgency, and frequency. Low-grade temp is sometimes only sxs.
 Sometimes upper urinary tract infection, may develop the 3rd or 4th day with chills, spiking fever, CVA tenderness, flank pain, and N&V.
 TX: of UTI depends on
location of infection and organism. Pyelonephritis is usually tx’d w/ IV ABx.
 UTI’s:
Bladder and urethra are traumatized by pressure from descending fetus during childbirth.
Overdistended from trauma / anesthesia.
Insertion of catheters increases risk.
 After birth, bladder and urethra are hypotonic. Residual urine and reflux of urine may occur.
 S&SXs of Mastitis:
At first may feel like flu due to fatigue and aching muscles. Progress to include high fever, chills, malaise, and HA.
 Characterized by localized area of redness and inflammation. Untreated may lead to abscess.
 Mastitis= Infection of the lactating breast. Occurs most often during the 2nd to 8th weeks after birth. More common in mothers nursing for the 1st time and usually affects only one breast. Generally caused by S. aureus, E. coli, Streptococcus. Organism can enter breast through an injured area such as a crack or blister.
 Engorgement and stasis of milk frequently precede mastitis.
 Blocked duct is a significant predictor of mastitis. (Too tight clothing may interfere with emptying of all the ducts and may lead to infection)
 Avoid bras with underwire.
Erythema,swelling in the upper outer quadrant of breast. Axillary lymph nodes are enlarged and tender. The segmental anatomy of breast accounts for demarcated, V-shaped wedge of inflammation.
 Measures to Prevent Mastitis:
Correct positioning of the infant, Avoid trauma to nipples and milk stasis,
 Breastfeed every 2-3 hours, Avoid formula supplements and nipple shields,
 Change nursing pads when they are wet, Avoid continuous pressure on the breast.
 Therapeutic Management of Mastitis:
Abx therapy (7-10 days) + continued decompression of breast by breastfeeding or breast pump constitute 1st line of tx. Regular emptying of breast is imp to prevent abscess formation. (Empty breast q1.5-2 hrs)
 Moist heat compresses, breast support, bed rest and analgesic. NSAID to treat fever and inflammation
 Candidal infections will be treated with anti-fungal
 Mother should stay in bed during acute phase. Fluid intake 2000 to 2500 ml/day.
 Diagnosis by history and exam; culture and sensitivity of breast milk can also be done.
 Early PPH:
Major causes are uterine atony and trauma.
Uterine atony:
lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around blood vessels when the placenta separates. Causes 75-80% of cases of early PPH.
 Trauma: Lacerations. Hematomas.
 Factors Associated with Uterine Atony:
Overdistention of uterus. Grandmultiparity
 Dysfunctional labor - prolonged labor. Prolonged 3rd stage - >30 mins. Oxytocin augmentation or induction.
 Operative births. Anesthesia relaxing effects. Retained placental fragments
 S&S of Uterine Atony:
Uterine fundus difficult to locate. Soft or “boggy” uterus. Uterus that becomes firm as it is massaged but loses its tone when massage is stopped. Uterus located above the expected level. Excessive lochia. Excessive clots expelled.
 Therapeutic Management of Uterine Atony:
If not firm, first intervention is fundal massage. Bimanual Massage. Relieve bladder distention.
 Pharmacological measures may include,
rapid infusion of Oxytocin (Pitocin)- 10 to 40 units in 500 to 1000 ml of LR or NS (over 1 hour); or Methergine; or Prostaglandins.
 If bleeding and atony continues, Methergine may be given IM x 5 doses, then to po dose, rarely IV. (S/Es- May elevate BP and should not be used in woman with HTN or CV disease. N&V, uterine cramping, dizziness, H/A, dyspnea, chest pain, or palpitations) Check blood pressure before giving. Caution against smoking.
 If unable to receive Methergine, prostaglandin injections may be given IM.
 If massage and pharmacological methods do not work: HCP may need to do bimanual compression of the uterus to stop the bleeding-
 Fluid replacement is necessary. LR or other plasma extenders, whole blood, or packed cells may be used. Fluid should be given to maintain UO of at least 30 ml/hr.
 Operative procedure- last resort.
Manual compression of uterus and removal of placenta.
A, Manual compression of the uterus and massage with the abdominal hand usually will effectively control hemorrhage from uterine atony.
 Second most common cause of early PPH.
lacerations. (most common sites- perineum, vagina, cervix, area around urethral meatus)
 Factors: Nulliparity, Epidural, Precipitous childbirth, macrosomia, operative vaginal delivery, Oxytocin
 S&SXs- Lacerations
excessive bright red bleeding with firm uterus.
Occur when bleeding occurs into loose connective tissue while overlying tissue remains intact.
 Vulvar hematoma may have discolored bluish bulging mass that is sensitive to touch.
 Vaginal or retroperitoneal hematomas may not be visible
 S&SXs- deep, severe, unrelieved rectal/perineal pain or feeling of pressure.
 Therapeutic Management for Trauma:
acerations require immediate repair.
 If hematoma is small and not enlarging- apply ice packs. If large - evacuate hematoma and ligate the blood vessels.
 Late Postpartum Hemorrhage:
Usually occurs 7 to 14 days postpartum.
 Most common causes are subinvolution and retained placental fragments.
 SUBINVOLUTION - delayed return of the uterus to its nonpregnant size and consistency.
 D&C for retained placental fragments
 S&SXs-Late Postpartum Hemorrhage
pelvic or back pain, bleeding, boggy and tender uterus.
TX: Late Postpartum Hemorrhage
control excessive bleeding - administer Methergine .2 mg every 3-4 hours for 24-48 hours; antibiotics; D&C.
Three most common Thromboembolic Disorders
1. Superficial Venous Thrombosis
a. SVTs are usually associated with varicose veins and limited to calf area.
b. S&S: swelling of involved extremity, redness, tenderness, warmth, cord-like vein may be palpable.
c. Management: Analgesics, rest, elastic support hose, elevation of extremity, warm heat.
2. Deep Venous Thrombosis
a. S&S: Swelling (>2cm than opposite leg), redness, heat, tenderness, pedal edema, + Homan’s sign, weak pedal pulse, low fever followed by high temp and chills.
b. Initial Tx: Analgesics, ABX therapy, continuous moist heat (for pain relief and increased circulation), bedrest, gradual ambulation, IV heparin, maintenance - coumadin 3-6 months.
3. Pulmonary Embolism
a. S&S: Dyspnea, sudden sharp chest pain, tachycardia, tachypnea, syncope, cough, hemoptysis, cyanosis.
b. Management: O2, Bedrest, HOB elevated, Narcotic analgesics, (IV heparin) anticoagulant therapy, embolectomy if no time exists to allow clot to dissolve.
Trichomoniasis -
caused by Trichomonas vaginalis (single cell protozoan parasite)
Trichomoniasis S&S –
frothy yellow-green discharge with foul odor, dyspareunia. Pain w/ urination. irritation and itching of the female genital area. lower abdominal pain (rare). strawberry appearance to cervix
 for both men and women, a health care provider must perform a physical examination and laboratory test to dx trichomoniasis. The parasite is harder to detect in men than in women. In women, a pelvic examination can reveal small red lesions on the vaginal wall or cervix
Trichomoniasis Tx
– Metronidazole (Flagyl). 500 mg I po BID x 7 days; must be systemic treatment; no ETOH during treatment
Most common site of infection in women and men (Trichomoniasis)
vagina and urethra (urine canal) is the most common site of infection in women, and the urethra is the most common site of infection in men. The parasite is sexually transmitted.
Genital Warts – (aka condyloma, condylomata accuminata,venereal warts)
 Caused by HPV virus – types 6 and 11 most commonly assoc w/ warts; 16 and 18 assoc w/ cervical CA

highly contagious STI. Spread through direct skin-to-skin contact during oral, genital, or anal sex with an infected partner.
• Characteristics of contemporary childbirth
• Characteristics of contemporary childbirth
o Choices of childbirth
o Family centered
o Recognizes needs of siblings and other family members
o It allows the pt to labor, deliver, and recover in one room before moving to postpartum unit.
 These rooms are often decorative and homelike with entertainment media, furniture, and soothing lights.
• Traditional hospital setting
o The pt is labored in a labor room and then moved to a delivery room (similar to OR) for birth.
o After delivery pt was moved to recovery room for 1-2hrs and the moved to the postpartum unit.
 Disadvantages were multiple moves that made the pt uncomfortable and the setting was impersonal.
 Each move disrupted the family
• A family is two or more individuals joined together by:
o Marriage
o Blood
o Adoption
o Residence in the same household
o 2 or more persons joined together to share resources and emotional closeness.
o Lay midwife (aka granny midwife) –
no formal education, received through apprenticeship.
o Certified nurse midwife –
masters or doctorate degree, focuses on antepartum, intrapartum, and postpartum care of women and newborn care.
o Acute care clinical nurse specialist –
masters or doctorate, usually work more in hospital setting, leader in improving quality pt care.
o Women’s healthcare nurse practitioner –
masters or doctorate degree, gyn and ob focused, preventative, primary care of women, prenatal and postpartum but not intrapartum.
o Traditional nuclear –
a husband provider, wife who stays home, and children.
o Binuclear (joint custody) –
post divorced family in which the biologic children are members of two nuclear households, both that of the father and that of the mother. Both parents have equal responsibility and legal rights, regardless where the children live.
o Dual career/dual earner –
both parents are working
o Childless –
couples who remain childless
o Extended –
a couple who share house hold responsibilities, chores, and expenses with parents, siblings, or other relatives
o Extended kin network –
two nuclear families of primary or unmarried kin live in close proximity to each other. The family shares a social support network, chores, goods, and services.
o Single parent
– headed by only one parent.
o Blended (stepparent) –
include a biologic parent with children and a new spouse who may or may not have children.
o Nonmaritial heterosexual co-habitating –
a heterosexual couple who may or may not have children and live together outside of marriage.
o Gay and lesbian –
those in which two or more people who share a same sex orientation live together as well as families consisting of a gay or lesbian single parent rearing a child.
• Transverse diameter
is largest diameter of the inlet
• Relaxin
helps loosen the joints
o Gynecoid –
most common and favorable
 50% of women have this shape. Inlet is rounded and favorable for vaginal birth
o Android –
male pelvis, sometimes found in females; inlet is heart shaped. Not favorable for vaginal birth.
 25% white, 50% non white women have this shape. Inlet is oval and favorable for vaginal birth
o Anthropoid –
inlet is oval, favorable for vaginal birth
 30% of women have this shape. Inlet is heart or triangular shaped, narrow diameters and arch. Poor pelvis for vaginal delivery.
o Platypelloid –
flat female pelvis, not favorable for vaginal birth.
 5% of women have this shape. Inlet is flattened wide, oval, short. Poor prognosis for vaginal delivery.
• Female reproductive cycle involves 2 stimultaneous cycles
o Ovarian cycle: 2 phases
o Endometrial cycle: 4 phases
o Ovarian cycle: 2 phases
Follicular phase – secretion of FSH and LH from the anterior pituitary causes graafian follicle to develop and rupture (day 1-14)

Luteal phase – (day 15-28) ovulation marks the beginning of the luteal phase. Ovum is susceptible to fertilization for the first 24hrs after ovulation. If fertilization does not occur, menstruation begins about 14 days later.
o Endometrial cycle: 4 phases
Menstrual: begins day 1-6 of menses, endometrium sheds, estrogen and progesterone is low.

Proliferative: day 7-14, endometrium thickens as estrogen increasese

Secretory: day 15-26, estrogen drops and progesterone dominates, endometrium thickens to 5-6mm, becomes rich in glycogen and nutrients in prep for the fertilized ovum.

Ischemic: day 27-28, if fertilization does not occur, progesterone and estrogen falls, endometrium becomes ischemic from lack of blood supply; endometrium begins to slough off, thus the beginning of the menstrual phase. hCG which is produced by the fertilized ovum, maintains the corpus luteum. Corpus luteum produces progesterone for the pregnancy until the placenta can take over. If no pregnancy occurs, then corpus luteum degenerates.
begins day 1-6 of menses, endometrium sheds, estrogen and progesterone is low.
day 7-14, endometrium thickens as estrogen increasese
day 15-26, estrogen drops and progesterone dominates, endometrium thickens to 5-6mm, becomes rich in glycogen and nutrients in prep for the fertilized ovum.
day 27-28, if fertilization does not occur, progesterone and estrogen falls, endometrium becomes ischemic from lack of blood supply; endometrium begins to slough off, thus the beginning of the menstrual phase. hCG which is produced by the fertilized ovum, maintains the corpus luteum. Corpus luteum produces progesterone for the pregnancy until the placenta can take over. If no pregnancy occurs, then corpus luteum degenerates.