ATI Maternal Newborn Focused Study guide
Maternal Child Health Nursing (Rasmussen University)
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1. Assessment and Management of Newborn Complications: findings to report Substance Withdrawal
• High-pitched cry, shrill cry; incessant crying; irritability, tremors, disturbed sleep pattern
• Hypertonicity, convulsions
• Hyperactivity with an increased moro reflex
• Increased deep-tendon reflex
• Increased muscle tone
• Nasal congestion with flaring
• Frequent yawning
• Skin mottling
• Retractions
• Apnea
• Tachypnea greater than 60/min (RR)
• Sweating
• Temperature greater than 99
• Poor feeding
• Regurgitation (projectile vomiting)
• Diarrhea
• Excessive uncoordinated constant sucking Hypoglycemia: serum glucose less than 40 mg/dl
• Hypothermia
• Flaccid muscle tone Dehydration
• Urine output less than 1 mL/kg/hr
• Urine specific gravity > 1.015
• Weight loss, dry mucous membranes, absent skin turgor, depressed fontanel
Overhydration
• Urine output greater than 4 mL/kg/hr
• Urine specific gravity less than 1.001
• Edema, increased weight gain, crackles in lungs, intake greater than output
• Nursing care and discharge teaching: car seat safety Harness should be snug and clip is at axillary level (not across neck or abdomen)
• Infections: Treatment for Gonorrhea Administer Erythromycin to all infants following delivery
• Ceftriaxone & azithromycin PO**
• Report disease to health care department
• Assessment of Fetal Well-Being: Contraindications for a Contraction Stress Test Placenta previa
• Vasa previa
• Preterm labor
• Multiple gestations (twins)
• Previous classic incision from a cesarean birth
• Reduced cervical competence
2. Nutrition During Pregnancy: Educating a Client Who has heartburn
• Eat small frequent meals (not allow tummy to get too full or too empty)
• Sit up for 30 min after meals
• Check provider prior to using OTC antacids
3. Contraception: Tubal Ligation)
• Menstrual periods? contraception
• Baby-Friendly Care: Responding to Clients Concerns About Sibling Adaptation Take sibling on a tour of the OB unit
• Encourage parents to let sibling be one of the first to see infant
• Provide a gift from the infant to give to sibling
• Arrange for one parent to spend time with the sibling while the other parent is caring for the infant
• Allow older siblings to help in providing care for the infant
• Provide preschool aged siblings with a doll to care for
• Medical Conditions: Laboratory Values to Report Hgb less than 11 mg/dl in 1st and 3rd trimester
• Hgb less than 10.5 in 2nd trimester
• Hct less than 3%
• Positive blood glucose: 130/140 mg/dl or greater
• BP greater than 140/90 or greater recorded on two different occasions at least 4 hours apart
• Report proteinuria (gestational hypertension): mild +1; severe +3 & 160/110
• Serum creatinine than 1.1 mg/dl
• Platelet less than 100,000
4. Assessment of Fetal well-being: Complications Associated with an
amniocentesis
• Amniotic fluid emboli
• Maternal or fetal hemorrhage
• Fetomaternal hemorrhage with Rh isoimmunization
• Maternal or fetal infection
• Inadvertent fetal damage or anomalies involving limbs
• Fetal death
• Inadvertent maternal intestinal or bladder damage
• Miscarriage or preterm labor
• Premature rupture of membranes
• Leakage of amniotic fluid
5. Newborn Assessment: Perform Focused Assessment of Newborn [Show Less]
