ATI MATERNAL NEWBORN REMEDIATION
1. Management of Care
a. Establishing Priorities
Requires Further Assessment (Chp 27)
tones and
... [Show More] reflex responses, and seizures. A term newborn’s blood
glucose should be 30-60mg/dL. Hypoglycemia can bring about poor
feeding, jitteriness/tremors, hypothermia, diaphoresis, weak cry, and
lethargy.
tachypnea, nasal flaring, expiratory grunting, retractions, and cyanosis.
Newborn infections like sepsis can cause an infant to have temperature
instability, suspicious drainage, poor feeding, weak suck, vomiting,
diarrhea, hypo or hyperglycemia, respiratory distress, and low BP.
membranes, observe the newborns color for yellowish tint as the skin is
blanched, and assess if there is an underlying cause that needs to be
fixed. Look for hypoxia, hypothermia, hypoglycemia, and metabolic
acidosis. Increased risk for brain damage. Congenital anomalies involve
cleft lip/palate and tracheoesophageal fistula, excessive mucous
secretions and drooling, periodic cyanotic episodes and choking,
distended abdomen. PKU can result in cognitive impairment if
untreated, not evident at birth and it’s found in newborn screening.
Hypothyroidism: hypothermia, poor feeding, lethargy, jaundice,
cretinism. Spina bifida is a protrusion of meninges and/or spinal cord,
tufts of hair on the spine. Patent ductus arteriosus is another neonate
complication that includes murmurs, abnormal heart rate or rhythm,
breathlessness, and fatigue while feeding.
has respiratory difficulties, cyanosis, tachycardia, tachypnea, and
diaphoresis. Down syndrome, also known as trisomy 21, exhibits oblique
palpebral fissures or upward slant of the eyes, epicanthal folds, flat facial
profile with a depressed nasal bridge and small nose, protruding tongue,
short broad hands with a fifth finger that has one flexion crease instead
of two, a deep crease across the center of the palm, hyperflexibility,
hypotonic muscles.
ii. Medical Conditions: Priority Finding That Requires Further Assessment (Chp 9)
● Cervical insufficiency is a painless opening of the cervix that results in delivery of the baby in the 2nd trimester of pregnancy. Some expected findings are pink stained vaginal discharge or bleeding, possible gush of fluid, and uterine contractions w/ expulsion of fetus. The nurse needs to evaluate the client’s support system and if assistance is available for them if they are prescribed activity restrictions or bed rest. Assess the
client for any vaginal discharge, monitor client reports of pressure and contractions, and check vital signs.
● For gestational HTN, some expected findings are severe continuous HA, nausea, blurring of vision, flashes of lights or dots before the eyes, HTN, proteinuria, edema, vomiting, and epigastric pain. The nurse should assess their LOC, obtain pulse oximetry, monitor urine output, and obtain a clean catch urine sample to assess for proteinuria. Also, obtain the client’s daily weight, monitor vital signs with careful attention to BP, encourage lateral positioning, perform non-stress test and daily kick counts, and instruct the parents to monitor I&Os.
2. Safety and Infection Control
a. Accident/Error/Injury/Prevention
Who Has Abstinence Syndrome (Chp 27)
exposed to drugs in the womb before birth. Babies can then go through
drug withdrawal after birth. The syndrome most often applies to opioid
medicines.
feedings, swaddle newborn with legs flexed, looser than normal, reduce
environmental stimuli (lights off, lower noise level), and educate the
mom on SIDS prevention strategies.
Safety (Chp 26)
until they reach maximum height and weight for seat. Rear facing car
seat should preferably be placed in the middle of the back seat because
they are away from the air bags and side impact. No hand me downs
should be used! Set the seat at a 45-degree angle because if the car seat
is too flat, the baby may slide out through the straps. If it is too upright,
the head may flop forwards too much and make it difficult for the baby
to breathe.
b. Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
i. Nursing Care of Newborns: Personal Protective Equipment (Chp 24)
● Before caring for a newborn, scrub arms with antibacterial soap from your elbows to your fingertips. For a newborn’s first bath, gloves need to be worn to prevent exposure to body secretions. Individual bassinets need to be equipped with diapers, T-shirts, and bathing supplies. Nurses must follow facility hygiene protocols in between caring for newborns. All nurses must know that cover gowns and special uniforms are used to prevent direct contact with clothes.
3. Health Promotion and Maintenance
conditions for up to 8 hr. It may be refrigerated in sterile bottles for use
within eight days or frozen in clean containers in a two-door
refrigerator's freezer compartment for up to 6 months. Also, mothers
may store breast milk in a deep freezer for 12 months. Thawing the milk
in the refrigerator for 24 hr preserves immunoglobulins the best. It also
can be thawed by holding the container under running lukewarm water
or placing it in a container of lukewarm water. Rotate the bottle often
but not shaken when thawing in this manner. Do not thaw breast milk in
the microwave because it can destroy immune factors and lysozymes
that is contained in the milk. Once thawed, do not refreeze, just discard
it.
fetal heart tones are auscultated the loudest on the woman's abdomen.
These tones are best heard directly over the fetal back. In vertex
presentation, PMI is either in the right- or left-lower quadrant or below
the maternal umbilicus. In breech presentation, PMI is either in the
right- or left-upper quadrant above the maternal umbilicus.
at the midline, right above the symphysis pubis, by holding the Doppler
firmly on the abdomen. FHR can be detected at early appointments by
ultrasound.
lower-extremity edema, gingivitis, nasal stuffiness, epistaxis, Braxton
Hicks contractions, and supine hypotension
iv. Postpartum Physiological Adaptions: Rh Incompatibility (Chp 17)
● Administer RhO(D) immune globulin (RhoGAM) IM around 28 weeks of gestation for Rh-negative clients. Administer RhO(D) immune globulin (RhOGAM) to the client if she is Rh-negative (standard practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization). RhO(D) immune globulin (RhoGAM) suppresses the immune response of Rh-negative clients.
● RhO(D) immune globulin (RhoGAM) is administered within 72 hr to Rh- negative mothers and gave birth to Rh-positive infants to prevent sensitization in future pregnancies. If the mother is Rh negative and the
father is Rh positive and homozygous for the Rh factor, then all the
offspring of this union will be Rh positive. The Kleihauer-Betke test determines the amount of fetal blood in maternal circulation if a large fetomaternal transfusion is suspected. If 15 mL or more of fetal blood is detected, the mother should receive an increased RhoGAM dose. Test
the client who receives both the rubella vaccine and RhoGAM after three months to determine whether immunity to rubella has been developed.
b. Health Promotion/Disease Prevention
Hemolytic Disease (Chp 27)
the fetal circulation and destroys the fetal red blood cells. A condition in
which there is an incompatibility between the Rh types of the mother
and the fetus. Less commonly may happen with incompatible blood
types between mother and fetus. Rhogam is used to prevent this
disease. Some of the signs and symptoms of hemolytic disease are
severe hyperbilirubinemia, jaundice, and Kernicterus.
Infection (Chp 20)
thrombus, history of DM, immunosuppression, anemia, malnutrition,
history of alcohol/substance use, C section, prolonged ROM, retained
placental fragments, manual extraction of placenta, catheters,
chorioamnionitis, internal fetal uterine pressure monitor, multiple
vaginal exams after ROM, PP hemorrhage, operable vaginal birth,
epidural, hematomas, and episiotomy/lacerations.
c. Health Screening
that can go above or below the range. It also depends on the
baby’s activity level.
average temperature in a newborn is 37C or 98.6F
up to a 1 year. This reflex happens by stroking the cheek or the
edge of their mouth. As a reaction, the newborn would turn
their heads to the side where they were touched and start to
suck.
happens by placing the examiner’s finger in the palm of the
newborn’s hand. The reaction should be to have the newborn
curl their fingers around the examiner’s fingers.
response happens when the examiner places their finger at the
base of the newborn’s toes. The appropriate reaction is the
newborn curls their toes downward.
months. The head and trunk of the newborn is placed in a semi
sitting position, in effort to fall backwards at a 30-degree angle.
The reaction should be that the newborn symmetrically extends,
then abduct their arms at the elbows and fingers spread to form
a “C.”
newborn is lied in supine position and the examiner turns their
head quickly to one side. The newborn’s arm and leg on that
side extend and opposing arm and leg flex. [Show Less]