ATI Maternal Newborn Study Guide
ATI Maternal Newborn Study Guide
Chapter 1- contraception
• Contraception refers to strategies or device
... [Show More] used to reduce the risk of fertilization or implantation in an attempt to prevent pregnancy
• Natural family planning: behavioral methods
o Abstinence – no gentialia contact o Withdrawal (coitus interruptus)
Choice for monogamous couple
Least effective methods
Risk for pregnancy o Calendar methods
ovulation occurs about 14 days before the onset of her next menstrual cycle, and avoid intercourse during that period
count at least 6 cycles o basal body temperature
body temperature can drop slightly at the time of ovulation
measure oral temperature prior to getting out of bed each morning to monitor ovulation
inexpensive, convenient, and no adverse effects
Basal body temperature and the symptothermal method are fertility awareness methods.
o Lactational amenorrhea method
• Barrier o Condoms
Only water-soluble lubricants should be used with latex condoms to avoid condom breakage o Diaphragm
Dome-shaped cup with a flexible rim made of silicon that fits snugly over the cervix with spermicidal cream or gel placed into the dome and around the rim
Client should be properly fitted with a diaphragm by a provider
Replaced every 2 years and refitted for a 20% weight fluctuation, after abdominal or pelvic surgery and after every pregnancy
Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim
The diaphragm can be inserted up to 6 hours before intercourse and must stay in place 6 hour after intercourse but for no more than 24 hrs.
Spermicide must be reapplied with each act of coitus
Patient should empty bladder before insertion
Wash with soap and water after use o Cervical cap o Contraceptive sponge o Question
Which method would the nurse identify as a barrier method of contraception?
a. Basal body temperature
b. Transdermal patch
c. Diaphragm
d. Symptothermal method
• Hormonal o Oral contraceptives
Adverse effect
• Chest pain, shortness of breath, leg pain from a possible clot, headache, eye problems form a stroke, and hypertensive, breast tenderness, nausea, breakthrough bleeding
(common adverse effects of estrogen component and progestin component)
Can increase the risk of thromboembolism, stroke, heart attack, hypertension, gallbladder disease, liver tumor
Effectiveness decrease when taking medications that affect liver enzymes, such as anticonvulsants and some antibiotics
o Injectable contraceptives
Medroxyprogesterone is an IM or SQ injection given to a female client every 11 to 13 weeks
• First injection should be during the first 5 days of period
• In postpartum, 5 days after delivery
Maintain adequate intake of calcium and vitamin D
Very effective and require only 4 injections per year
Adverse effects
• Decrease in bone mineral density, weight gain, increase depression and irregular vaginal spotting or bleeding
Contraindicated for osteoporosis patient
Return to fertility can be a long as 18 months after discontinuation o Transdermal patches o Vaginal rings o Implantable progestin
Minor surgical procedure to subdermally implant and remove a single rod contain etonogestrel on the inner side of the upper arm
Disadvantage
• Etonogestrel can cause irregular menstrual bleeding
Adverse effects
• Irregular and unpredictable menstruation (most common)
• Mood changes, headache, acne, depression, decreased bone density and weight gain
o Intrauterine contraceptives (IUD)
A chemically active T-shaped device that is inserted through the cervix and placed in the uterus by the provider
Device must be monitored monthly by clients after menstruation to ensure the presence of small string that hangs form the device into the upper part of the vagina to rule out migration or expulsion of the device
IUD can maintain effectiveness for 1 to 10 years
Contraception can be reversed
Can increase the risk of pelvic inflammatory disease, uterine perforation, or ectopic pregnancy and can be expelled
A client should report to the provider later or abnormal spotting or bleeding, abdominal pain or pain with intercourse, abnormal of foul-smelling vaginal discharge, fever, chills, a change in string length or if IUD cannot be located
IUD can cause irregular menstrual bleeding
Must be removed in the event of pregnancy o Emergency contraception
Morning-after pill that prevents fertilization from taking place
Pill is taken within 72 hr after unprotected coitus
• Surgical methods o Tubal ligation
Sterilization for women
A laprascope is inserted; fallopian tubes are grasped and sealed
o Vasectomy
Sterilization for men
Usually performed under local anesthesia
Involves cutting the vas deferens, which carries the sperm
Chapter 3 – Expected physiological changes during pregnancy
• Signs of pregnancy o Presumptive, probable, positive
• Presumptive: those changes felt by the woman o e.g., breast changes (darkened areolae, enlarged Montgomery’s glands), uterine enlarged, quickening
(slight fluttering movements of the fetus feld by a woman, usually between 16 to 20 seeks of gestation) o Skipping period is not reliable sign of pregnancy by itself but if it accompanied by nausea, fatigue, breast tenderness, and urinary frequency, pregnancy would see very likely
• Probable: those changes observed by an examiner o Hegar’s sign – softening and compressibility of lower uterine segment or isthmus o Ballottement
examiner pushes against the women's cervix during a pelvic exam and feels a rebound from the floating fetus
rebound of unengaged fetus o abdominal enlargement o Chadwick’s sign – deepened violet-bluish color of cervix and vaginal mucosa o Broxton Hicks contractions – falls contractions that are painless, irregular, and usually relieved by walking o Positive pregnancy test
Human chorionic gonadotropin (HcG) is earliest biochemical marker for pregnancy
Production begins as early as day of implantation
Can be detected in maternal serum or urine as soon as 7 to 8 days before the expected menses
Urine sample should be first-voided morning specimens and follow the direction for accuracy o Fetal outline felt by examiner
• Positive: those signs attributed only to the presence of the fetus o Confirm that fetus is growing in the uterus o Fetal heart sound - hearing fetal heart tones (via Doppler) o visualizing the fetus by ultrasound o palpating fetal movements (20 weeks) by examiner o Pulse sock on mom to get mom’s HR to ensure it’s not baby’s heart sound
• Calculating delivery date and determine number of pregnancies for pregnant client o Nagele’s rule
Date of last menstrual period (LMP)
Calculation of estimated or expected date of birth (EDB) or delivery (EDD)
• Nagele’s rule
• Use first day of LNMP 11/21/07
• Subtract 3 months 8/21/07
• Add 7 days 8/28/07
• Adjust year 8/28/08 = EDB
Ultrasound is the best method of dating a pregnancy o Kathy’s rule
Add 9 months and 7 days o Measurement of fundal height
In centimeters form the symphysis pubis to the top of the uterine fundus (between 18 and 32 weeks of gestation)
Approximates the gestational age o Gravidity – number of pregnancies
Nulligravid – never been pregnant
Primigravida – first pregnant
Multigravida – two or more pregnant o Parity – number of pregnancies in which the fetus or fetuses reach 20 weeks of pregnancy
Nullipara – no pregnancy beyond the stage of viability
Primipara – has completed one pregnancy to stage of viability
Multi para o Viability – infant has capacity to survive outside of uterus (22 to 25 weeks) o GTPAL acronym
Gravidity
Term birth (38 weeks or more)
Preterm birth (from viability up to 37 weeks)
Abortions/miscarriages (prior to viability)
Living children
• Blood pressure o Position of pregnant woman affect blood pressure o In Supine position, blood pressure might appear to be lower due to the weight and pressure of the gravid uterus on the vena cava, which pressures venous blood flow to the heart
o Maternal hypotension and fetal hypoxia might occur, which is referred to as supine hypotensive syndrome or supine vena cava syndrome
o Signs and symptoms include
Dizziness, lightheadness, and pale, clammy skin o Encourage client to engage in maternal positioning on the left-lateral side, semi-fowler’s position o if supine, with a wedge placed under one hip to alleviate pressure of the vena cava
• fetal heart tone o 110 to 160/min with reassuring FHR accelerations noted, which indicates an intact fetal CNS
• By 36 weeks gestation, the top of uterus and the fundus will reach the xiphoid process o This cause pregnant woman to experience shortness of breath as the uterus pushes against the diaphragm
• Skin changes o Chloasma – increase of pigmentation on the face o Linea nigra – dark line of pigmentation from the umbilicus extending to the pubic area o Striae gravidarum – stretch marks most notably found on the abdomen and thighs
• Client is encouraged to keep all follow-up appointments and to contact the provider immediately if there is any bleeding, leakage of fluid, or contractions at any time during the pregnancy
Chapter 5
• Recommended weight gain during pregnancy o Healthy weight BMI: 25 to 35 lb
First trimester: 3.5 to 5 lb
Second and third trimesters: 1 lb/wk o BMI <19.8: 28 to 40 lb
First trimester: 5 lb
Second and third trimesters: 1+ lb/wk o BMI >25: 15 to 25 lb
First trimester: 2 lb
Second and third trimesters: 2/3 lb/wk
• Client education o Increase calories
Second trimester – increase 340 cal/day
Third trimester – increase to 450 cal/day
During breastfeeding women should well nourished should be added 450 to 500 cal/day to a balanced diet
o Increasing protein intake
High in folic acid is important for neurological development and prevent fetal neural tube defects
Foods – green leafy vegetables, dried peas and beans, seeds, orange juice
Women who wish to become pregnant of childbearing age take 400 mcg of folic acid
Women who become pregnant take 600 mcg of folic acid to prevent fetal neural tube defects o Iron supplements
Best absorbed between meals and when given with a source of vitamin C (orange juice) Foods – beef liver, red meat, fish, poultry, dried peas and beans and fortified cereals
Stool softener might need to be added to decrease constipation with iron supplement o Calcium
Foods – milk, nuts, legumes and dark green leafy vegetables
Postpartum women who are breastfeeding should continue taking calcium supplement during lactation
o Fluid
8 to 10 glasses (2.3 L) of fluids are recommended daily o Limit caffeine
Recommend daily intake of no more than 200 mg of caffeine
It is recommended that women abstain form alcohol consumption during pregnancy
Chapter 6 – Assessment of fetal well-being
• Ultrasound o client should have full bladder for the procedure o fetal and maternal structures can be pointed out to the client as the US procedure is performed
• Biophysical profile o Uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli
o Client presentation
Premature rupture of membranes
Maternal infection
Decreased fetal movement
Intrauterine growth restriction o Variables
FHR
Fetal breathing movements
Gross body movements
Fetal tone
Qualitative amniotic fluid volume o Total score findings
8 to 10 is normal – low risk of chronic fetal asphyxia
4 to 6 is abnormal – suspect chronic fetal asphyxia
Less than 4 is abnormal – strongly suspect chronic fetal asphyxia
• Nonstress test o Most widely used technique for antepartum evaluation of fetal well-being performed during the 3rd trimester
o Noninvasive procedure that monitors response of the FHR to fetal movement o Disadvantage of an NST include a high rate of false nonreactive results with the fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications and nicotine use disorder
The acoustic vibration device is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus
• Contraction stress test
o Nipple-stimulated contraction test
Consists of a woman lightly brushing her palm across her nipple for 2 min, which cause the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins
o Oxytocin-stimulated contraction test
IV administration of oxytocin to induce uterine contractions
Oxytocin is used to induce uterine contraction
Contraindicated for placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incisions for C-section, reduced cervical competence
Can be difficult to stop and may lead to preterm labor
Negative results are a normal finding
Positive result is an abnormal finding o Indication for contraction stress test (CST)
Decreased fetal movement
Intrauterine growth restriction (IUGR)
Postmaturity
• Amniocentesis o Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client’s uterus and amniotic sac under ultrasound guidance locating the placenta and determining the position of the fetus
o It may be performed after 14 weeks of gestation o Indications
Prenatal diagnosis of genetic disorder or congenital anomaly of the fetus
Alpha-fetoprotein (AFP) level for fetal abnormalities
• High AFP – neural tube defect
• Low AFP – down syndrome
Lung maturity assessment o Instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture
o Post procedure
Administer Rho(D) immune globulin to the client if she is Rh-negative (standing practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization)
RhoGAM is giving to Rh- moms at 28 weeks gestation after amniocentesis and after delivery to protect mon against baby’s blood of bay is Rh+
o Complications
Amniotic fluid emboli
Maternal or fetal hemorrhage
Maternal or fetal infection
Miscarriage or preterm labor
Premature rupture of membrane
Leakage of amniotic fluid o A test of the L/S ratio is done as part of amniocentesis to determine fetal lung maturity
• High-risk pregnancy; chorionic villus sampling o CVS is ideally performed at 10 to 23 weeks of gestation o Indications
Risk for giving birth to a neonate who has a genetic chromosomal abnormality
• Monitoring for adverse effects of substance use disorders o Substance use is a risk factor that can leads to spontaneous abortion and abruptio placentae o Teach patient to watch for
Vaginal bleeding uterine craping, partial/complete expulsion of products of conception sharp abdominal pain, and tender rigid uterus
Chapter 7 – Bleeding During Pregnancy
• Ectopic pregnancy
o Ectopic pregnancy is abnormal implantation of a fertilization ovum outside of the uterine cavity usually in the fallopian tube, which can result in a tubal rupture causing a fetal hemorrhage
o Unilateral stabbing pain and tenderness in the lower-abdominal quadrant o Instruct client who is taking methotrexate to avoid alcohol consumption and vitamins containing folic acid to prevent a toxic response to the medication
• Molar growth o Bleeding is often dark brown resembling prune juice o Bright red that is either scant or profuse and continues for few days or intermittently for a few weeks and can be accompanied by passage of vesicles
• Placenta previa o Placenta a previa occurs when the placenta abnormally implants in the lower segment of the uterus near of over the cervical os instead of attaching to the fundus
Complete or total – cervical os is completely covered by the placental attachment
Incomplete or partial – cervical os is only partially covered by the placental attachment o Painless, bright red vaginal bleeding during the 2nd and 3rd trimester o Refrain from performing vaginal exams – can exacerbate bleeding o Administer IV fluids blood products, and medications as prescribed
Corticosteroids, such as betamethasone, promote fetal lung maturation if early delivery is anticipated (cesarean birth)
• Abruptio placentae o Abruptio placentae is the premature separation of the placenta from the uterus o It has significant material and fetal morbidity and mortality and is a leading cause of maternal death o Sudden onset of intense localized uterine pain with dark red vaginal bleeding o Risk factors
Blunt external abdominal trauma (motor-vehicle crash, maternal battering)
Cocaine use resulting in vasoconstriction
Smoking cigarette
Maternal hypertension (chronic or gestational)
Previous incidence of abruptio placentae
Premature rupture of membrane
Multifetal pregnancy
Chapter 9 – Medical conditions
• Cervical insufficiency (premature cervical dilation) o The client can require cervical cerclage (indicated for women who have singleton pregnancy) o Often placed at 12 to 14 weeks gestation and removed at 37 weeks gestation o Provide education about clinical findings to report to the provider for preterm labor rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push
• Hyperemesis gravidarum o hyperemesis gravidarum is excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks gestation and results in 5% weight loss from pre-pregnancy weight, electrolyte imbalance, acetonuria and ketosis
o Risk factors
maternal age younger than 30, history or migraines, obesity, first pregnancy, diabetes, multigestation, GI disorders, or family history of hyperemesis monitor patient I&O, assess skin turgor, weight and vital signs
o laboratory test
Urinalysis for ketones and acetones (breakdown of PR and fat) is the most important lab test
- Elevated urine specific gravity, urine ketone present
Chemistry profile
Thyroid test – indicate hyperthyroidism
CBC (complete blood count) – elevated Hct
o Nursing care
Monitor I&O
Assess skin turgor and mucous membranes
Monitor vital signs
Monitor weight
Have the client remain NPO for 24 to 48 hours
Clear liquid after 24 if no vomiting and increase diet if tolerated o Medications
Give the client IV lactated ringer’s for hydration
Give pyridoxine (vitamin B6) and another vitamin supplement s as tolerated
Use antiemetic medications (ondansetron, metoclopramide) cautiously for uncontrollable nausea and vomiting
Use corticosteroid to treat refractory hyperemesis gravidarum o Advance the client’s diet as tolerated, with frequent small meals – start with dry toast, crackers, or cereal; then move to a soft diet; and finally, to a normal diet as tolerated
• Iron-deficiency anemia o Occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron
o Foods – legumes, fruits, green leafy veggies, and meat o Medications
Ferrous sulfate iron supplements
• Instruct the client to take the supplement on an empty stomach and take with orange juice to increase absorption
• Encourage a diet rich in vitamin C- containing foods to increase absorption
• Gestational diabetes mellitus o Gestational diabetes mellitus (GDM) is an impaired tolerance to glucose with the first onset or recognition during pregnancy
Normal glucose during pregnancy – 70 to 110 mg/dL
Women will develop type II diabetes mellitus within 5 years of delivery o Laboratory tests
Glucola screening test/1-hr glucose tolerance test
• 50 g oral glucose load, followed by plasma glucose analysis 1 hour later perforated 24 to 28 weeks of gestation
• Fasting is not necessary
• Positive blood glucose screening is 130 to 140 mg/dL or greater
• Additional testing with a 3-hr oral glucose tolerance test (OGTT) is indicated
Oral glucose tolerance test (OGTT)
• Following overnight fasting
• Avoid caffeine and abstinence from smoking for 12 hr prior to testing
• Fasting glucose is obtained, a 100g glucose load is given and serum glucose levels are determined at 1,2, and 3 hr following glucose ingestion
o Diagnostic procedures
Biophysical profile to ascertain fetal well-being
Nonstress test to assess fetal well-being o Medication
Oral hypoglycemic therapy is an alternation to insulin in women who have GDM who require medication in addition to diet for blood glucose control
Most oral hypoglycemic agents are contraindicated for gestational diabetes mellitus, but there is limited use of glyburide.
• Gestational hypertension o Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the manifestations of pregnancy hyper tensive disorders o Gestational hypertension (GH)
After 20th weeks of pregnancy
Elevated BP at 140/90 mmHg or greater recorded on 2 different occasions at least 4 hr apart
Not proteinuria o Mild preeclampsia
GH with addition of
Proteinuria of greater than or equal to 1+ o Severe preeclampsia
Bp 160/110 mmHg or greater
Proteinuria greater than 3+
Elevated serum creatinine greater than 1.1 gm/dL
Cerebral visual disturbances (headache and blurred vision)
Hyperreflexia with possible ankle clonus
Pulmonary or cardiac involvement
Extensive peripheral edema
Hepatic dysfunction
Epigastric and right upper-quadrant pain and thrombocytopenia o Eclampsia
Severe preeclampsia manifestation with the onset of seizure activity or coma o Help syndrome
H: Hemolysis – resulting in anemia and jaundice
EL: Elevated liver enzyme – ALT, AST
LP: Low platelet (less than 100,000) o Laboratory
Liver enzyme – elevated AST, LDH
Serum creatinine, BUN, uric acid, magnesium increases as renal function decreases
CBC
Clotting studies – thrombocytopenia
Chemistry profile – decreased Hgb, hyperbilirubinemia o Medication
Anti-hypertensive medication
• Methyldopa
• Nifedipine
• Hydralazine
• Labetalol
Avoid ACE inhibitors and angiotensin II receptor blockers
Anticonvulsant
• Magnesium sulfate
• Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS
• Monitor for signs of magnesium sulfate toxicity o Absence of patella deep tendon reflexes o Urine output less than 30 mg/hr o RR less than 12/min o Decrease level of consciousness o Cardiac dysrhythmias
• Antidote – calcium gluconate or calcium chloride
o Client education
Maintain bed rest and encourage side-lying position
Promote diversional activities (TV, visits form family or friends, gentle exercise)
Avoid foods that are high in sodium
Avoid tobacco and alcohol and limit caffeine intake
Drink 6 to 8 oz glasses of water a day
Maintain dark, quiet environment to avoid inducing a seizure
Maintain a patent airway in the event of seizure
Administer antihypertensive medications as prescribed
Chapter 10 – Early Onset of Labor
• Preterm labor o Preterm labor is uterine contraction and cervical changes that occur between 20 and 37 weeks of gestation
o Assessment of preterm labor
Previous preterm birth
Multifetal pregnancy
Substance use
History of multiple miscarriages or abortions
Diabetes mellitus
Chronic hypertension
Second trimester bleeding
History of UTI
o
o Expected findings – uterine contraction o Diagnostic procedures
Obtain swab of vaginal secretions for fetal fibronectin between 24 and 34 weeks of gestation
This protein can be found in vaginal secretions and can be related to inflammation of the placenta and that can lead to preterm birth
This test is used to determine preterm labor o Nursing care
Focusing on stopping uterine contraction
Activity restriction
• Strict bed rest can have adverse effects
• Encourage the client to rest in the left lateral position to increase blood flow to the uterus and decrease uterine activity
Ensuring hydration
• Dehydration stimulate the pituitary gland to secret and antidiuretic hormone and oxytocin
o Medication
Nifedipine
• Calcium channel blocker
• Used to suppress contractions by in habiting calcium form entering smooth muscles
• Nursing consideration o Monitor for headache, flushing, dizziness and nausea o These usually are related to orthostatic hypotension that occurs with administration
Magnesium sulfate
• Commonly used tocolytic that relaxes the smooth muscle of the uterus and thus inhibits uterine activity by suppressing contraction
• Nursing consideration o Contraindications for tocolysis include active vaginal bleeding, dilation of the cervix greater than 6 cm, chorioamnionitis, greater then 34 weeks gestation and acute fetal distress
o Monitor for client for magnesium toxicity and discontinue for any of the following adverse effects
Loss of deep tendon reflexes
Urinary output less than 30 ml/hr
Respiratory depression (less than 12/min)
Pulmonary edema and chest pain
o Administer gluconate of calcium chloride as and antidote for magnesium sulfate toxicity
• Notify provider – blurred vision, headache, nausea, vomiting, or difficulty breathing
Indomethacin
• Non-steroidal anti-inflammation drug (NSAID)
• Suppress preterm labor by blocking the production of prostaglandins
• This inhibition of the prostaglandins suppresses uterine contraction
Betamethasone
• Enhance fetal lung maturity and surfactant production in fetuses between 24 to 34 weeks gestation • Premature rupture of membranes
o Client reports a gush or leakage of clear fluids from the vagina
Temperature elevation
Increased maternal hear rate or FHR
Foul-smelling fluid or vaginal discharge
Abdominal tenderness o Positive nitrazine paper test (blue, pH 6.5 to 7.5) or positive forming test is conducted on amniotic fluid to verify rupture of membranes
o Medications
Ampicillin is an antibiotic uses to treat infection
Betamethasone
• Glucocorticoid administered IM in 2 injections • Enhance fetal lung maturity and surfactant production
o Tell the client to record daily kick counts for fetal movement
Chapter 11 – Labor and Delivery Process
• Stages of labor o First stage (onset of labor to complete dilation)
Latent phase (0 to 3 cm)
• Onset of labor – contractions irregular and mild to moderate
• Woman is talkative and eager
Active phase (4 cm to 7 cm)
• Contractions – regular moderate to strong
• Woman feeling of helplessness
• Anxiety and restlessness increase as contraction become stronger
Transition phase (8cm to 10 cm)
• Complete dilation
• Feeling out of control, client often states “cannot continue”
• Urge to push increased rectal pressure and feelings of needing to have a bowel movement
o Second stage
Full dilation to birth o Third stage
Delivery of the neonate to delivery of placenta o Fourth stage
Delivery of placenta to maternal stabilization of vital signs
• Physiologic changes preceding labor (premonitoring sign) o Backache, weight loss o Lightening
fetal head descends into true pelvis about 14 days before labor
feeling that the fetus has “dropped”
easier breathing but more pressure on bladder resulting urinary frequency o contraction – begin with irregular uterine contractions (Braxton Hicks)
o increased vaginal discharge or bloody show o energy burst o gastrointestinal changes – nausea, vomiting and indigestion o Cervical ripening- cervix become soft (opens) and partially effaced and can begin to dilate o Rupture of membrane
Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse
o Assessment of amniotic fluid
Amniotic fluid is alkaline – Nitrazine paper is deep blue, indicting pH of 6.5 to 7.5
• Laboratory analysis o Group B streptococcus
Screening at 35 to 37 weeks
If positive, IV prophylactic antibiotic is prescribed, exceptions are planned cesarean birth and membranes intact
o Urinalysis
Proteinuria, UTI (common diabetic pregnancy)
• Characteristics of False Labor o Contraction
-Painless, irregular frequency, and intermittent contractions
-Contractions decrease in frequency, duration, and intensity with walking or position changes
-Contractions are felt in lower back or abdomen above umbilicus
-Contractions often stop with sleep or comfort measures such as oral hydration or emptying of the bladder
o Cervix (assessed by vaginal exam)
-The cervix has no significant changes in dilation or effacement
-The cervix often remains in posterior position
-The cervix has no bloody show
o Fetus -The presenting part of the fetus is not engaged in the pelvis.
• Nursing Care During Stages of Labor: Identifying the Need for Reassessment o If there are late declarations o if baby is tachycardic or bradycardia Chapter 12 – pain management
• nonpharmacological o Reduce anxiety, fear and tension which are major contributing factors to pain in labor o Hypnosis, biofeedback, music therapy o Cutaneous stimulation strategies
Effleurage – light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions
o Sacral counterpressure
using the heel of the hand or fist against the client’s sacral area to counteract pain in the lower back
o hydrotherapy (whirlpool or shower) increases maternal endorphin levels o frequent maternal position changes to promote relaxation and pain relief
supine position only with the placement of a wedge under one of the client’s hip to tilt the uterus and avoid supine hypotension syndrome
• pharmacological o To avoid slowing the progress of labor, prior to administering analgesic medications, the nurse should verify that labor is well established by performing a vaginal exam and evaluating uterine contraction pattern
o Analgesia
Sedatives (barbiturates)
Secobarbital pentobarbital and phenobarbital can be used during the early or latent phase of labor to relieve anxiety and induce sleep
Side effect - Neonate respiratory depression secondary to the medication crossing the placenta and affecting the fetus. This medication should not be administered if birth is anticipated within 12 to 24 hours
Nursing action
• Assist the mother to cope with labor
• Assess the neonate for respiratory depression
Opioid analgesics
• Meperidine hydrochloride, fentanyl, butorphanol, nalbuphine act in CNS to decrease the perception of pain without the loss of consciousness
• Client can receive opioid analgesics IM or IV but the IV route is recommended during labor because the action is quicker
• these given early part of active labor
• Butorphanol and nalbuphine o Adverse effect
Opioid analgesics can cause respiratory depression in the neonate
Sedation
Hypotension
Decreased FHR variability o Nursing action
Performing a vaginal exam that reveals cervical dilation of at least
4 cm with a fetus that is engaged
Administer antiemetics as prescribed
Prepare administer antidotes
• Naloxone, an opioid antagonist, should be readily available for reversal of opioid-induced respiratory depression • Epidural and spinal regional analgesia o Fentanyl and sufentanil o Adverse effect
Bradycardia or tachycardia
Hypotension
Respiratory depression o Nursing action
Putting side rails up on the client’s bed – client can experience dizziness and sedation, which increases maternal risk for injury
Administer Antiemetics as prescribed Continue FHR pattern monitoring
o Pharmacological anesthesia
Epidural block
• Injected into the epidural space at the level of 4th or 5th vertebrae
• This eliminates all sensation from the level of umbilicus to the thighs, relieving the discomfort of uterine contractions, fetal descent and pressure and stretching of the perineum
• It is administered when the client is active labor and dilated to at least 4 cm
• It is suitable for all stages of labor and types of birth and for repair of episiotomy and laceration
• Adverse effect o Maternal hypotension o Fetal bradycardia
o Loss of the bearing down reflex
• Nursing action o Administer a bolus of IV fluids to help offset maternal hypotension as prescribed o Side-lying modified Sim’s position
o Encourage the client to remain in the side-lying position after insertion of the epidural catheter to avoid supine hypotension syndrome with compression of the vena cava
o Monitor maternal blood pressure and pulse, and observe for hypotension, respiratory depression and decreased oxygen saturation
o Assess for orthostatic hypotension. If present, be prepared to administer an IV vasopressor such as ephedrine, position client laterally, increase rate of IV fluid administration and initiate oxygen o Do not allow the client to ambulate unassisted
Spinal anesthesia (block)
• Injected into the subarachnoid space into the spinal fluid at the 3rd 4th and 5th lumbar interspace
• Spinal block eliminates all sensation form the level of the nipples to the feet
• Spinal block is administered in the late second stage or before cesarean birth
• Adverse effect o Maternal hypotension o Fetal bradycardia o Potential headache form leakage of cerebrospinal fluid at the puncture site o Higher incidence of maternal bladder and uterine atony following birth
• Nursing action o Assess maternal vital signs every 10 min o Manage maternal hypotension by administering an IV fluid bolus as prescribed, position the mother laterally, increasing the rate of IV fluid administration and initiating oxygen
o To relieve postpartum headache resulting from cerebrospinal fluid leak, placing the client in a supine position, promoting bed rest in a dark room, and administering oral analgesics, caffeine and fluids. An autologous blood patch is the most beneficial and reliable relief measure for cerebrospinal fluid leaks
General anesthesia
• Delivery complication or emergency
• General anesthesia produces unconsciousness
• Nursing action
o NPO
o Apply antiembolic stockings or sequential compression devices o Administer histamine-receptor antagonist – ranitidine to decrease gastric acid production
o Administer metoclopramide to increase gastric emptying as prescribed o Assess the client postpartum for decreased uterine tone, which can lead to hemorrhage and be produced by pharmacological agents used in general anesthesia
Chapter 13 – Fetal Assessment during labor
• Leopold maneuvers o Leopold maneuvers consist of performing external palpations external palpations of the maternal uterus through the abdominal wall to determine the following
o Place a small, rolled towel under the client’s right or left hip to displace the uterus off the major blood vessels to prevent supine hypotensive syndrome
• Continuous electronic fetal monitoring o A normal fetal heart rate breathing at term is 110 to 160/min excluding accelerations, decelerations and periods of marked variability within a 10 min window.
o Fetal heart rate baseline variability is described as fluctuations in the FHR baseline that that irregular in frequency and amplitude
• FHR patterns o Accelerations o Fetal bradycardia
FHR less than 110/min or 10 min or more
Causes/complications
• Uteroplacental insufficiency
• Umbilical cord prolapses
• Anesthetic medications
Nursing intervention
• Discontinue oxytocin if being administered
• Assists the client to a side-lying position
• Administer oxygen by mask at 10 L/min via nonrebreather face mask
• Notify the provider
o Fetal tachycardia
FHR greater than 160 /min for 10 min or more Causes/complication
• Maternal infection, chorioamnionitis
Nursing interventions
• Administer prescribed antipyretics for maternal fever
• Administer oxygen by nonrebreather face mask
o Early deceleration of FHR
Causes/complication
• Compression of the fetal had resulting form uterine contraction
o Later decelerations of FHR
Uteroplacental insufficiency causing inadequate fetal oxygenation
Nursing intervention
• Place client in side-lying position
• IV fluid administration
• Discontinue oxytocin if being infused
• Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask
• Elevate the client’s leg
• Notify the provider
o Variable deceleration of FHR
Umbilical cord compression
Nursing interventions
• Reposition client form side to side or into knee-chest
• Discontinue oxytocin if being infused
• Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask
Chapter 14 – Nursing care during stages of labor
• Identifying the needs for reassessment each different stage of labor calls for different assessments of the mom
• stage one should focus on rupture of membranes, bladder distention, temperature, and FHR
• stage two should focus on BP, HR, and RR every 5-30 minutes, uterine contractions, pushing efforts by client, increase in bloody show, shaking of extremities
• stage three is focused on BP, HR, and RR every 15 min, clinical findings of separation of placenta, vaginal fullness exam
• stage four should focus on assessing maternal vital signs to a steady state
Chapter 15 – Therapeutic procedures to assist with labor and delivery
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Chapter 16 – Complications related to the labor process
• Prolapsed umbilical cord o A prolapse umbilical cord occurs with the umbilical cord is displaced, preceding the presentation part of the fetus, or protruding through the cervix
o Nursing care
Notify the provider
Use a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord
Reposition the client in a knee-chest, Trendelenburg or side-lying position with a rolled towel under the client’s right or left hip to relieve pressure on the cord
Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow
Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation
Chapter 17 – Postpartum physiological adaptations
• Fundus o Immediately after delivery, the fundus should be firm, midline with the umbilicus, and approximately at the level of the umbilicus
o At 12 hr postpartum, the fundus may be palpated at 1 cm above the umbilicus o Every 24 hours, the fundus should descend approximately, 1 to 2 cm o It should be halfway between the symphysis pubis and the umbilicus by the 6th postpartum day o After 2 weeks, the uterus should lie within the true pelvis and should not be palpated
• Lochia o Lochia is post-birth uterine discharge that contains blood, mucus and uterine tissue o 3 stage of lochia
Lochia rubra – bright red color, bloody consistency, fleshy odor, last 1 to 3 days after delivery
Lochia serosa – pinkish brown color and serosanguineous, consistency. Last from 4 to 10 days after delivery
Lochia alba – yellowish white creamy color, flesh odor. Last 11 days up to 4 to 8 weeks postpartum
o Assessment of lochia
Excessive blood loss: one pad saturated in 15 min or less, or pooling of blood under buttocks o Manifestation of abnormal lochia
Excessive spurting of bright red blood form the vagina
Numerous large clots and excessive blood loss (saturation of one pad in 15 min or less) which can indicate hemorrhage
Persistent lochia rubra in the early postpartum period beyond day 3, which can indicate retained placental fragments
• Breasts o Physical changes of the breasts include the secretion of colostrum – 2 to 3 days immediately after birth o Assessment
Colostrum (early milk) transitions to mature milk by about 72 to 96 hr after birth and is referred to as the milk coming in
• Cardiovascular system and fluid and hematologic status o Blood loss during childbirth (average blood loss is 300 to 500 mL in an uncomplicated vaginal delivery and 500 to 1000 mL for cesarean birth
• Urinary system and bladder function o Urinary retention secondary to loss of bladder elasticity and tone and/or loss of bladder sensation resulting from trauma, medications, or anesthesia
o Distended bladder as a result of urinary retention can cause uterine atony and displacement to one side, usually to the right
o The ability of the uterus to contract is also lessened o Assessment
Assess the client’s ability to void every 2 to 3 hours
Assess bladder elimination pattern (client should be voiding every 2 to 3 hr). excessive urine diuresis (more than 3,000 mL/day) is normal within the first 2 ot 3 days after delivery
Assess for evidence of a distended bladder o Patient-centered care
Encourage the client to empty her bladder frequently (every 2 to 3 hr) to prevent possible displacement of the uterus and atony
Chapter 18 – Baby-friendly care
• Phase of maternal postpartum adjustment o Dependent – taking-in phase
First 24 to 48 hours
Rely on others for assistance
Focused on meeting personal needs rely on others for assistance
Excited, talkative
Need to review birth experience with others o Dependent-independent – taking-hold phase
Begins on day 2 to 3
Last 10 days to several weeks
Focus on baby care and improving caregiving competency o Interdependent – letting-go phase
Focus on family as a unit
Resumption on role (intimate partner, individual)
Chapter 19 - Client education and discharge teaching
• Breast care o Lactating client
Initiate breastfeeding within the first 1 to 2 hr after birth unless contraindicated
To relieve breast engorgement, have client completely empty her breast at each feeding
For breast engorgement, apply cool compresses after feedings and apply warm compresses, or take a warm shower prior to breastfeeding. These actions will increase milk flow and promote the letdown reflex
o Nonlactating client
Wear a well-fitting, supportive bra continuously for the first 72 hr
Suppression of lactation is necessary for clients who are not breastfeeding. Avoid breast stimulation and running warm water over the breast stimulation and running warm water over the breast for prolonged period until no longer lactating
For breast engorgement, which can occur on the third or firth postpartum day, apply cold compresses 15 min on and 45 min off. Fresh, cold cabbage leaves can be placed inside the bra. Mild analgesics or anti-inflammatory medication can be taken for pain and discomfort of breast engorgement
Chapter 20 – postpartum disorders
• Deep-vein thrombosis o Greatest risk for a deep-vein thrombosis (DVT) that can lead to a pulmonary embolism o Expected findings
Unilateral area of swelling, warmth, and redness
Hardened vein over the thrombosis
Calf tenderness
• Pulmonary embolus
o A pulmonary embolism is a complication of DVT that occurs if the embolus moves into the pulmonary artery or one of its branches and lodges in a lung, occluding the vessel and obstructing blood flow to the lungs
o Acute pulmonary embolus is an emergent situation o Expected findings
Pleuritic chest pain
Dyspnea
• Postpartum hemorrhage o Postpartum hemorrhage is considered to occur if the client loses more than 500 mL blood after a vaginal birth or more than 1000 mL after cesarean birth
o Risk factors
Uterine atony, inversion of uterus, subinvolution of the uterus, Retained placental fragments o Expected findings
Uterine atony (hypotonic or boggy)
Perineal pad saturation in 15 min or less
Constant oozing trickling, or frank flow of bright red blood from the vagina
Tachycardia and hypotension o Nursing care
Firmly massage the uterine fundus
Assess bladder for distention. Insert an indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output
o Medication – uterine stimulant
Oxytocin – promote uterine contractions
Methylergonovine – controls postpartum hemorrhage
• Assess uterine tone and vaginal bleeding. Do not administer to clients who have hypertension
• Monitor for adverse reactions, including hypertension, nausea, vomiting and headache
Misoprostol - controls postpartum hemorrhage
• Uterine atony o Uterine atony results form the inability of the uterine muscle ot contract adequately after birth o Perform fundal massage is indicated
Chapter 21 – postpartum infections
• Infections (endometritis, mastitis, and wound infections)
• Mastitis o Mastitis is an infection of breast involving the interlobular connective tissue and is usually unilateral o Expected findings
Flu-like clinical findings, such as body aches, chills, fever and malaise
Painful or tender localized hard mass and reddens area, usually on one breast o Client education
Instruct the client to thoroughly wash hands proor to breastfeeding
Allow nipples to air-dry
Proper infant positioning and latching-on techniques, including both the nipple and the areola
Instruct the client about completely emptying her breasts with each feeding to prevent milk stasis, which provides a medium for bacterial growth
Chapter 23 – postpartum depression
• Postpartum blues o Generally, continues for up to 10 days o Tearfulness, insomnia, lack of appetite, and feeling of letdown o Postpartum blues typically resolves in 10 days without intervention o Feeing sadness o Crying easily for no apparent reason
• Postpartum depression o Occurs within 6 months of delivery and is characterized by persistent feelings of sadness and intense mood swings
• Postpartum psychosis o History of bipolar disorder o Confusion, disorientation, hallucinations, delusions, obsessive behaviors, and paranoia o The client might attempt to harm herself or her infant
Chapter 23 – Newborn assessment
• Apgar scoring
o HR: Absent (0), less than 100/min (1), greater than 100/min (2)
RR: Absent (0), weak cry (1), good cry (2)
Muscle tone: flaccid (0), some flexion of extremities (1), well-flexed (2)
Reflex irritably: none (0), grimace (1), cry (2)
Color: blue, pale (0), pink body, cyanotic hands and feet (1), completely pink (2)
• New Ballard scale o New born maturity rating scale that assesses neuromuscular and physical maturity o Neuromuscular maturity
- Fully flexed
- Square window
- Arm recoil, where the neonate’s arm is passively extended and spontaneously return sto flexion
- Popliteal angle, degree of the angle to which the newborn’s knees can extend
- Scarf sign, which is crossing the neonate’s arm over the chest
- Heal to ear, which is how far the neonate’s heels reach to her ears o Physical maturity
- Skin texture, ranging from sticky and transparent to leathery, cracked and wrinkled - Lanugo presence
- Plantar surface creases, ranging form less than 40 mm to creases ove the entire sole
- Breast tissue amount, full areola with a 5 to 10 mm bud
- Genitalia development – ranging form flat smooth scrotum to pendulous testes with deep rugae for males and prominent clitoris with flat labia to the labia majora covering the labia minora
• Normal deviations o Milia (small raised whit spots on the nose, chin and forehead) can be present. Theses pots disappear spontaneously without treatment (parents should not squeeze the spots)
o Mongolian spots (bluish purple spots of pigmentation) are commonly noted on the the shoulder, back and buttocks. Be sure the parents are aware of Mongolian spots, and document location and presence
• Head o Head should be 2 to 3 cm larger than chest circumference o Anterior fontanel should be palpated and approximately 5 cm on average and diamond shaped.
o Fontanel should be soft and flat
o Fontanel can bulge when the newborn cries, coughs or vomits and are flat when the newborn is quiet o Bulging fontanels can indicate increased intracranial pressure, infection, or hemorrhage o Depressed fontanels can indicate dehydration
o Caput succedaneum
- (localized swelling of the soft tissues of the scalp caused by pressure on the head during labor) an expected finding that can be palpated as a soft edematous mass and can cross over the suture line
- Caput succedaneum usually resolves in 3 to 4 days and does not require treatment o Cephalohematoma
- Collection of blood between the periosteum and the skull bone that is covers - It does not cross the suture line
- It results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery
- It appears in the first 1 to 2 days after birth and resolves in 2 to 3 weeks
• Ears – that are low set can indicate a chromosome abnormality such as down syndrome, or a kidney disorder
• Mouth [Show Less]