ATI_Maternity_Study_Guide.pdf.docx
Nursing
Liberty University
(LU)
25 pag.
ATI RN MATERNAL NEWBORN
NURSING 10.0 STUDY GUIDE COMPLETE
DOCUMENT 2021
ABCDE PRINCIPLE
Airway/Cervical Spine: This is the most important step in performing the primary survey.
If a patent airway is not established, subsequent steps of the primary survey are futile.
Protect the cervical spine if head or neck trauma is suspected.
Breathing: After achieving a patent airway, assess for the presence and effectiveness of
breathing.
Circulation: After ensuring adequate ventilation, assess the circulation.
Disability: Perform a quick assessment to determine the client’s level of consciousness.
Exposure: Perform a quick physical assessment to determine the client’s exposure to
adverse elements such as heat or cold.
MASLOW’S HIERARCHY OF NEEDS
Physiological; oxygenation, circulation, nutrition, elimination, fluid balance, activity and
exercise, rest and sleep
Safety and security; living in a safe environment, adequate income, shelter from
environmental elements
Love and belonging; love, affection, relationships
Self esteem; self respect, personal worth, social recognition
Self Actualization; personal growth, fulfilling own potential
NY Heart Association Classifications
Class I: means no symptoms and no limitations in ordinary physical activity
Class II: mild symptoms and slight limitation during ordinary activity
Class III: marked limitation in activity due to symptoms, even during less than ordinary
activity.
Class IV: severe limitations, with symptoms experienced at rest
RANDOM NOTES FROM ATI Q’s
● The Kleihauer-Betke test is used to determine the amount of fetal blood in the
maternal circulation when there is a risk of Rh-isoimmunization
● A pregnant client should take 600 mcg of folic acid daily to prevent neural tube
defects.
● A pregnant client should drink 3 L water a day
● A pregnant client should increase protein intake to 71g during second and third
trimester
● A pregnant client should increase caloric intake by 340 cal during the second
trimester and 452 cal during the third trimester.
● If a pregnant patient is having a seizure, place oxygen on the patient to ensure
adequate oxygenation to the fetus.
● If a pt is using patterned breathing during labor and has tingling and numbness,
this is because the pt is hyperventilating. Placing an oxygen mask over the nose
and mouth will help bring up CO2 levels and reduce the intake of oxygen.
●Rhogam; given within 72 hours post delivery for Rh negative to prevent antibody
formation for future pregnancy
● Hx of cholecystitis, htn, and migraine headaches is a contraindication for oral
contraceptives
● Folate occurs naturally in foods like liver, dark-green leafy veggies, orange juice,
legumes
● Meconium should be passed within 24 to 48 hours after delivery
● Erythromycin ointment in eye prevent infection such as gonorrhea
● Vitamin K given to prevent hemorrhage to infant at birth
● First immunization is Hep B at birth, then 1 or 2 months and then 6 months
●Ectopic pregnancy
○ When the ovum becomes implanted outside of the uterus, often the
fallopian tubes
○ Comes with unilateral stabbing pain, and tenderness in the lower abd
quadrant.
○ The fallopian tube bursting can be very dangerous for mom
○ Severe shoulder pain is a finding with ruptured ectopic pregnancy
○ Abdominal cramping can indicate ectopic pregnancy or manifestations of
spontaneous abortion
●Molar pregnancy (Hydatidiform mole)
○ Proliferation and degeneration of trophoblastic villi in the placenta
○ Sx of bleeding that resembles prune juice/dark brown
●Placenta previa
○ When the placenta abnormally implants in the lower segment of the
uterus, over/near the cervical os
○ Painless bright red vaginal bleeding during 2nd or 3rd trimester
○ Can be complete, incomplete or partial
○ If completely covering the cervical os, cesarean section is DEFINITELY
needed
●Abruptio placentae
○ Premature separation of placenta from uterus
○ High rate of fetal and maternal morbidity/mortality
○ Sudden onset of excruciating and localized pain, bright red bleeding
●Incompetent cervix
○ Recurrent premature dilation of the cervix, or cervical insufficiency
○ Cervix does not stay clused during pregnancy, and can result in uterine
contents from leaking/falling out
○ Woman gets a cerclage to keep cervix from dilating. Removed at 37
weeks or when spontaneous labor occurs
○ Can resulting in a miscarriage
●Gestational Diabetes Mellitus (GDM)
○ Most oral antidiabetic meds are contraindicated with pregnancy. Insulin is
used most commonly to control glucose
○ Test occurs between 24-28 weeks, starts off with 1 hour test
○ No fasting required,
○ 50 g oral glucose is given to woman, and test an hour later
○ If it over 130-140 mg/dL, next test is done, which is the OGTT (Oral
Glucose Tolerance Test),
○ OGGT requires fasting, avoid caffeine/smoking/chewing gum/tea
■ Fasting glucose level will be taken, the Woman will be given
100mg of glucose, then test blood at 1 hour, 2 hours and 3 hours.
○ If GDM is developed, it places women at higher risk for developing
diabetes after pregnancy
○ Increase change of fetal macrosomia
Basal Body temperature
● Can drop slightly at time of ovulation
● Inexpensive and convenient
● Reliability can be influenced by variables causing inaccurate interpretations- temp
changes, stress, fatigue, illness, alcohol, warmth of sleeping environment
Diaphragm
● Replace every two years or with 20% weight change
● Leave in place 6 hours post intercourse
● Needs to be fitted properly
● Insert vaginally over cervix with spermicidal jelly or cream applied to
cervical side of dome and around rim
● Re-apply spermicide with each act of coitus
● Wash with mild soap and warm water after each use
● RISK: hx of TSS (Toxic Shock Syndrome), frequent UTI, increased risk of TSS-
high fever, faint feeling, drop in BP, watery diarrhea, HA, muscle aches
Presumptive Signs of Pregnancy
● Things that can be explained by a reason other than pregnancy
● Amenorrhea, Fatigue
● Nausea and vomiting
● Urinary frequency
● Breast changes (darkened areola)
●Quickening (fluttering movements 16-20 weeks)
● Uterine enlargement
Probable signs of pregnancy
● Abdominal enlargement
● Hegar’s sign: softening and compressibility of uterus
● Chadwick’s sign: deepened violet bluish color of cervix and vaginal mucosa
● Goodell’s sign: softening of cervical tip
● Ballottement: rebound of unengaged fetus
● Braxton Hicks: false contractions
● Positive pregnancy test
● Fetal outline
Positive signs of Pregnancy
● Fetal heart sounds
● Visualization of fetus by ultrasound
● Fetal movement
GTPAL
❖Gravidity (amount of pregnancies, to include current one)
❖Term births (38 weeks or more)
❖Preterm births (from viability up to 37 weeks/less than 38 weeks)
❖Abortions/miscarriages (prior to viability)
❖Living children
Physiological changes in pregnancy
● Uterus increases in size and changes shape. Ovulation and menses cease.
● Cardiac output increases. Blood volume increases.
○ S1, S2, S3 more easily heard after 20 weeks. Murmurs may also be heard
○ Weight of the uterus on vena cava causes episodes of maternal
hypotension
● Maternal oxygen needs increase. Respiratory rate increases and total lung
capacity decreases.
● Musculoskeletal; body alterations and weight increase
● Nausea, vomiting, constipation
● Renal filtration increases. Urinary frequency is common.
● Placenta becomes endocrine organ that produces large amounts of HCG,
progesterone, estrogen, human placental lactogen, and prostaglandins.
● Pulse increases 10-15/min around 32 weeks and remains elevated through
remainder of pregnancy.
● Chloasma: increase of pigmentation on the face
● Linea Nigra: dark line from umbilicus to pubic area
● Striae gravidarum: stretch marks on abdomen and thighs
Biophysical Profile (BPP)
● Real time US (Ultrasound) used to visualize physical and physiological
characteristics of fetus. Mixture of US and NST (nonreactive stress test).
● Potential Dx for use: NST, suspected oligo or polyhydramnios, suspected fetal
hypoxemia or hypoxia.
● Client will present with: premature rupture of membranes, maternal infection,
decreased fetal movement, IUGR (Intrauterine Growth Restriction)
● Prepare client just like reg US - full bladder
●What is scores: Reactive heart rate, breathing, body movement, fetal tone,
amniotic fluid volume
○Each area gets a score of 2
● Score is between 0-10
● Score;
○ Less than 4 abnormal - strongly suspect chronic fetal asphyxia
○ 4-6 abnormal suspect chronic fetal asphyxia
○ 8-10 normal, low risk of chronic fetal asphyxia
TORCH
● Toxoplasmosis, other infections (hepatitis), rubella virus, cytomegalovirus, and
herpes simplex are known as torch. These infections can cross the placenta and
have teratogenic effects on the fetus.
● Rubella immunization is contraindicated because rubella infection can develop.
● Avoid crowds of young children. Avoid consuming undercooked meat while
pregnant and cat liter boxes.
● Low titers prior to pregnancy should receive immunization
Hyperemesis Gravidarum
● Excessive nausea and vomiting (poss related to elevated HCG levels) past 12
weeks
● Nursing Implications: IV fluids, administration of B6, antiemetics (Reglan,
Zofran)
● Risk to the fetus for IUGR or preterm birth if condition persists
● Expected; vomiting, dehydration, weight loss, increased pulse, decreased BP,
poor skin turgor
● LABS ; Urinalysis for ketones and acetones (breakdown of protein/fat), elevated
urine specific gravity (normal 1.000-1.030); Chem Profile revealing electrolyte
imbalances Na, K, Chl reduced, Metabolic acidosis, Metabolic alkalosis, elevated
liver enzymes, bilirubin level; Thyroid indicating hyperthyroidism; CBC with
elevated Hct due to inability to retain fluids.
Gestational Hypertension
● Caused by vasospasm, which causes poor vissue perfusion
● After 20th week, if BP is 140/90 at least twice 4-6h apart, in same week, she is
positive for gestational hypertension. NO protein is present in urine yet
● Swelling of the face, sacral area, and hands can indicate gestational hypertension
or preeclampsia. Reduction in renal perfusion leads to sodium and water
retention. Fluid moves out of the intravascular compartment into the tissues,
causing edema.
●Mild preeclampsia : Hypertension, proteinuria greater than or equal to 1+, HA’s,
edema not present at this time, irritability
●Severe preeclampsia : BP 160/100 or higher, proteinuria 3+, oliguria (small amts
of urine), elevated serum creat greater than 1.2 mg/dL, visual disturbances
(blurred vision), HA’s, hyperreflexia, epigastric/ RUQ pain, thrombocytopenia,
peripheral edema.
●Eclampsia is severe preeclampsia with onset of seizure activity or coma
○Rx: Magnesium! Or possibly another type of anticonvulsant
●HELLP; Hemolysis, Elevated Liver enzymes, Low Platelets (under 100,000)
○ Sx will be like preeclampsia
○ Rx: Methyldopa, Nifedipine, Hydralazine, Labetalol. Avoid ACE and
ARBS
● Labs: liver enzymes, serum creatinine, BUN, uric acid, magnesium, CBC, clotting
studies, chemistry.
● NSG: Assess LOC, obtain pulse ox, monitor I&O, daily weight, NST, daily kick
counts, lateral positioning.
● Patient teaching: bed rest, avoid high sodium, avoid alcohol, caffeine, tobacco,
water 6-8 glass/day, dark environment to avoid seizure stimuli.
●Magnesium Sulfate used as an anticonvulsant to depress CNS and prevent
seizures
○ Pt may feel flushed, hot. Monitor BP. Fluid restriction 100-125ml/hr
○Calcium gluconate is the antidote for toxicity
○S&S toxicity : No reflexes, absence of patellar Deep Tendon Reflexes,
urine output less than 30ml/hr, respirations less than 12/min, decreased
LOC, cardiac dysrhythmias.
○ CI’s: fetal distress, vaginal bleeding, cervical dilation greater than 6 cm
Preterm Labor
● Contractions and cervical changes that happen between 20 and 37 weeks gestation
● Vaginal secretions may be tested for fetal fibronectin to diagnose preterm labor
●Preterm Contraction meds
○Mnemonic: “It’s Not My Time, B*tches” – Indomethacin, Nifedipine,
Magnesium (Sulfate), Terbutaline, Betamethasone
○ Indomethacin (NSAID); inhibits prostaglandins and supresses contractions
○ Nifedipine (calcium channel blocker) - suppresses contractions
○ Magnesium Sulfate (relax smooth muscle contractions)
○ Terbutaline - adverse effects are hyperglycemia, hypokalemia, and
hypotension; used to stop contractions.
○ Betamethasone (Steroid) - promotes fetal lung maturity, prevents
respiratory distress
●Premature rupture of membranes (PROM)
○ Nitrazine paper test will turn blue. Yellow would be urine.
○ Positive Ferning test can also indicate this
○ Abx may be used if it was caused by an infection
Labor and Delivery
●Premonitory Signs: backache, weight loss 0.5 kg- 1.5 kg (1-3lbs), lightening
(fetal head descends), contractions, increased vag dc or bloody show, energy burst
(nesting), GI changes
● Testing done : Group B strep test and urinalysis (protein, infection)
● Five P’s: passenger, passageway (birth canal), powers (contractions), position (of
the woman), psychological response
Stages of labor
● Stage 1
○ (onset of labor until complete dilation)
○ Latent Phase: cervix dilates from 0-3 cm, contraction 30-45 seconds
■ Talkative, eager
○ Active Phase: cervix dilates from 4-7 cm, 40-70 seconds
■ Restless, anxious, helpless
○ Transition Phase: cervix dilates from 8-10 cm, 45-90 seconds
■ Feeling “can’t do this”, urge to push, feels like bowel movement is
needed
● Stage 2:
○ Full dilation to Expulsion of the fetus
● Stage 3:
○ Birth of baby to delivery of placenta
● Stage 4:
○ Delivery of placenta until VS returns to normal
Bishop Score
● A score used to determine maternal readiness for labor. Five factors assigned a
numerical value 0-3 and totaled.
● Cervical dilation, effacement, consistency, position, station of presenting part
Therapeutic procedures to assist with L&D
● Amnioinfusion; normal saline or lactated ringers instilled into amniotic cavity
through a transcervical catheter. Reduces the severity of variable decelerations
caused by cord compression.
○ Indications: oligohydramnios (scant amount of amniotic fluid) caused by
uteroplacental insufficiency, premature rupture of membranes, post
maturity of fetus, fetal cord compression.
● Vacuum Assist
○ Vertex presentation, absence of cephalic disproportion, ruptured
membranes. Maternal exhaustion and ineffective pushing efforts, fetal
distress.
● Amniotomy
○ Labor progression too slow
○ Artificial rupture of membranes. Labor begins within 12 hours. Increased
risk for cord prolapse.
● Oxytocin
○ Post term preg, dystocia (prolonged diff labor), prolonged rupture
membranes, fetal demise, chorioamnionitis, maternal medical
complications (Rh, DM, pulmonary disease, Ges. htn).
○ Nurse must confirm fetus is engaged in birth canal at station 0.
○ Use infusion port closest to client. Connect piggyback to main line using a
pump.
○ Monitor BP, pulse, respirations every 30-60 min.
○ DC if contraction is more often than 2 min, longer than 90 sec, intensity
more than 90 mmhg
BUBBLEHE
● Breasts, uterus, bowel, bladder, lochia, episiotomy, Homan’s (sign), emotional
Thermoregulation-Newborns
●Conduction ; loss of body heat from direct contact with cooler surface (weight
scale/cold stethoscope)
●Convection; flow of heat from body to cooler environmental air (bassinet out of
line with fan, swaddle)
●Evaporation; Loss of heat as surface liquid is converted to vapor (dry newborn
after delivery/bath can cause this)
●Radiation; Loss of heat from body to cooler surface that is close to but not in
direct contact (window/air conditioner)
Assessment of Fetal Wellbeing
●LS Ratio: Lecithin Sphingomyelin; tests for fetal lung maturity
●Normal AFP (Alpha-fetoprotein) Level
○ If it is high it associated with neural tube defects. If low, it is chromosomal
disorders like Down's Syndrome (Trisomy 21).
●Amniocentesis
○ Usually performed around 14 weeks gestation and empty bladder before
○RISKS- amniotic fluid emboli, infection, leaking of amniotic fluid, rupture
of membranes (ROM), hemorrhage, miscarriage
○Amniocentesis is used to determine lung maturity, detect congenital
anomalies, and diagnose fetal hemolytic disease. (CHECKING GENETIC
ABNORMALITIES)
○ Checks for levels of AFP
■ If the levels of AFP are high: associated with neural tube defects
■ If levels of AFP are low: associated with chromosomal disorders
such as down syndrome
○ Checks for the Lecithin-sphingomyelin (LS) ratio
■ Assesses fetal lung maturity
○Cordocentesis is used to identify fetal blood type and RBC when there is a
risk of isoimmune hemolytic anemia
○ Be sure bladder is empty
●Chorionic Villus Sampling (CVS):
○ Performed between 10-12 weeks
○ Can be done earlier and abnormalities can be identified earlier, which
gives it an advantage
○ Taking a tiny piece of the placenta
●Fetal assessment during labor
○ Intermittent auscultation or continuous electronic fetal monitoring is 30-60
min latent phase, 15-30 min for active phase, 5-15 min second stage.
● A good way to remember fetal accels and decels: “VEAL CHOP” - Variable =
Cord Compression; Early deceleration = Head compression; Accelerations=Okay;
Late deceleration = Placental insufficiency
Pain Control
● Opioid analgesics; will cause sedation, hypotension, decreased variability in fetal
heart rate
●Epidural
○ Provides lack of sensation at level of umbilicus to the thighs.
○ Dilate to 4 cm or above
○ Maternal hypotension (IV bolus of fluids to counteract onset of
hypotension)
○ Fetal bradycardia
○ Mother should be side lying, or proped on her side
●Spinal block
○ C sections
○ Lack of sensation from nipples to the feet
○ Maternal hypotension, headache, fetal bradycardia
○ Higher incidence of bladder and uterine atony
FHR monitoring
○ 110-160 bpm is normal, we want to see variability and accelerations, early
decels okay
○ DO NOT WANT TO SEE LATE OR VARIABLE DECELERATIONS
○ Fetal Bradycardia
■ May want to Stop Pitocin, lay client on side, give more oxygen,
notify MD
○ Fetal Tachycardia (over 160)
■ Can indicate Maternal infection
■ Give antipyretics and oxygen if needed
○ Late Decels
■ Uteroplacental insufficiency
■ Lack of fetal oxygenation
■ Side lying position, increase fluids, DC oxytocin, administer
oxygen, notify MD
○ Variable Decels
■ Umbilical cord compression
■ Reposition onto side or do knee to chest, D/C oxytocin, administer
oxygen
Umbilical cord compression/prolapse
○ Cord is being crushed by fetus’ head , protruding
○ Notify MD, sterile gloved hand, insert 2 finger into vagina, lift baby’s
head off the cord
○ Reposition client into knee chest or trendelenburg
○ Warm sterile saline soaked towel on the cord
Fundal Height
○ From gestational weeks 18-32, the height of the fundus is approximately
equal to the number of weeks of gestation plus or minus 2 cm.
○ Immediately after delivery; fundus firm midline with umbilicus
○ 12 hours PP; go up 1 cm above umbilicus
○ Every 24 hrs after that, descends 1-2 cm per day
○ 6th postpartum day is should be half way down
○ 10 days after; not palpable
Lochia
○ Lochia Rubra ; bright red bleeding, at 1-3 post birth, fleshy odor, not
excessive
■ If a pad is saturated w/in 15 min, this indicates hemorrage and
needs intervention
■ Extending past 3 days, concern for atony
○ Lochia Serosa ; day 4-10 pp, serosanguinous, pinkish brown
○ Lochia Alba ; day 11-6 weeks pp, yellowish, white, creamy, fleshy odor
Uterine Atony
○ If retaining urine, bladder will be distended, and the uterus will be
deviated
■ Empty the bladder
○ May need fundal massage
Blood loss:
•Average during vaginal birth: 500mL
•Cesarean: 100mL
Phases of Maternal Role Attainment
○ Dependent taking in
phase;
■ 24-48 hr after birth
■ Relied on others for assistance
○ Dependent independent taking hold
phase
■ Day 2-3 goes up to the next couple weeks
■ Mom is focused on baby care and how to take care of baby
○ Interdependent letting
go phase
■ Resuming role as a partner, it isnt all about the baby
■ Looking beyond baby care and into other aspects of her life
Discharge Teaching Breast Feeding
○ Milk comes in 2-3 days after birth, engorgement is common
○ If engorgement occurs, apply cold compress between feedings, warm
shower before breastfeeding
○ Recommend to apply cold fresh cabbage leaves to breasts and/or take
mild analgesics in order to help allevieate engorgement symptoms
○ If NOT breastfeeding,
■ Tight bra, analgesics, cold compresses, no nipple stimulation
Mastiti
s
○ Infection in breast
○ Painful, tender, localized hard mass, often on one side
○ Flu like symptoms-chills, fatigue
○Pt teaching : Hand hygiene, keep breasts clean, air dry nipples, ensure
baby takes in entire nipple and areola, try to empty breasts completely
during each feeding
Storing Breast Milk
○ Room temp under clean conditions up to 8 hours
○ Refrigerated in sterile bottles must be used within 8 days
○ Frozen for up to 6 months; Deep freezer up to 12 months
○ Thaw milk in fridge for 24 hours do NOT microwave or refreeze thawed
milk
○ Used portions need to be discarded
Formul
a○ Refrigerate up to 48 hours
○ Discard any unused portion
Postpartum Complications
○ DVT; unilateral swelling, calf tenderness
○ Pulmonary Embolism; chest pain, dyspnea
Postpartum Hemorrhage
●Risk Factors- uterine atony, overdistended uterus, prolonged labor, precipitous
delivery, high parity, ruptured uterus, placenta previa, abruptio placentae,
inversion/subinvolution of uterus, DIC, retained placental fragments
●Expected findings- uterine atony, blood clots larger than a quarter, perineal pad
saturation in 15 min or less, constant oozing, trickling or frank flow of bright red
blood, tachycardia and hypotension, pale cool clammy skin, oliguria.
●Labs- Hgb, Hct, PT, blood type and crossmatch.
●Meds- Carboprost (Carboprost is a form of prostaglandin, a hormone-like
substance that occurs naturally in the body. Prostaglandins help to control
functions in the body such as blood pressure and muscle contractions.
Carboprost is used to treat severe bleeding after childbirth.)
●Uterine Atony
○ Uterine Stimulants
■ Oxytocin (contract), Methylergonovine, Misoprostol (Cytotec)
○Nursing Interventions: Ensure bladder is empty, massage the fundus
Postpartum Blues
○ Lasts about 10 days
○ Tearfulness, insomnia, lack of appetite, feeling of letdown
Postpartum Depression
○ Persistent feelings of sadness and mood swings
○ Occurs within 6 months of delivery
○ Estimately 10% of women are effected
Postpartum Psychosis
○ Disorientation, hallucination, paranoia, obsessive behaviors
○ Common if History of bipolar disorder
NEWBORN ASSESSMENT
● APGAR
○ 1 minutes, 5 minutes, and then 10 minutes if needed
○ optimal score is 7-10
○ 4-6 indicates moderate distress
○ 0-3 severe distress
○ heart rate, respiration rate, muscle tone, reflex irritability, color
○ each topic is worth 0-2
○ heart rate: needs to be greater than 100 for a score of 2
○ respirations: needs to have a good cry to score 2 (weak is 1)
○ muscle tone: well flexed is 2
○ reflex irritability: crying would be a 2, grimace would be 1
○ color: completely pink is 2, acrocyanosis is 1, cyanotic is 0
● New Ballard Scale
○ Neuromuscular maturity;
■ if baby is full term, they will be well flexed
■Items included for this section are: Square window, scarf sign,
popliteal window, arm recoil, heel to ear test
○ Physical Maturity (preterm vs full term) IMPORTANT
■Preterm: Transparent, sticky skin, not a lot of plantar creases, un-
developed breast buds, males have flat smooth scrotum, hypotonic,
weak grasp, clitoris will be promnent and labia flat
■Full Term: Wrinkled, cracked, leathery appearance (more so for
late), lots of small creases on plantar, developed breast buds 5-
10mm, scrotum rugae and pendulum-like, clitoris not prominent,
labia well developed
● NORMAL FINDINGS:
○ Mongolian spots, milia, head 2-3 cm larger than chest circumference,
barrel shaped chest, Epstein's pearls, anterior fontanel diamond shaped,
posterior triangle shape
● Fontanel : Sunken- dehydrated; bulging-hemorrhage or increased ICP
○ Caput succedaneum (cone head) is common with vaginally delivered baby
for 3-4 days
○ Eyes blue/grey at birth, changes over time (within 3-12 months it should
become established
○ Ears being low set can indicate chromosomal issue, such as down
syndrome
○ Esptein’s pearls: small white cysts found on gums
● Grey-white patchs on gums and tongue can indicate thrush
Hypoglycemia in a newborn
● Respiratory distress, abnormal high pitched cry, jitteriness, lethargy, poor feeding,
apnea, seizures, twitching, cyanosis, seizures, glucose under 40
● Nursing Intervention: Get baby food! Breastfeeding or formula
Cord Care
● Keep cord dry, above the diaper. Fold diaper down below cord
● Sponge baths only until cord falls off (10-14 days post birth)
● Monitor for redness, odor, purulent drainage (infection)
●Nuchal cord is when the cord is wrapped around the fetus’ neck
Circumcision
● Clamp procedure: petroleum jelly, no tub bath until completely healed
● Film of yellowish mucus by day two, do not wash off
● Acetaminophen for pain to baby
● Usually healed after 2 weeks
Preterm Baby
● Thin translucent skin, few creases on plantar, hypotonic/not well flexed, weak
cry, abundant lanugo, not a lot of fat
Macrosomic (Large for Gestational Age - LGA)
● (Cooked on outside, raw on the inside), born to moms with diabetes or post term
infants
● Hypoxia, hypocalcemia (can cause tremors), hypoglycemia,
● Plump full face
Post Term infant
● Wasted appearance due to losing subcutaneous fat, cracked, dry leathery skin, hair
and nails long, meconium staining on nails and umbilical cord
Hyperbilirubinemia
● Elevation of serum bilirubin levels, yellowing of the skin
●Physiologic jaundice; 24 hours of age resolves by 7 days. Considered benign
●Pathologic jaundice; extends past 7 days or within the first 24 hours, caused by
blood group incompatibility
●Kernicterus; untreated hyperbilirubinemia, levels could be higher than 25 mg/dL,
cerebral palsy
●TX: Phototherapy (undressed, eye mask, cover genitalia, avoid lotions, remove
them q4 hours, reposition q2 hours.
○Prescribed if newborn bilirubin level is greater than 15mg/dL prior to
48 hours of age
○ Greater than 18 mg/dL prior that 72 hours of age
○If greater than 20mg/dL at any time then photo therapy is used
○ Bronze discoloration or mild rash not too big of a complication.
○ Monitor for dehydration is a big priority
○ Encourage to breastfeed frequently to promote excretion to resolve
jaundice
Infertility:
•Inability to get pregnant after 12 months of trying
•Will usually test males first
Diaphragm contraceptive:
•Client should be refitted
oby the provider every 2 years
oClient gained more than 15 lbs
oOr if they have a full term pregnancy
oSecond term abortion
•You have to use spermicide for each act of sex when using diaphragm
•Needs to stay in place for 6 hours after coitus
•Leave in place 6 hours after sex
Oral contraceptives
•Adverse effects: Chest pain, SOB, leg pain, headache or eye problems for stroke
or HTN
•Smokers should not get these oral contraceptives, Hx of blood clots, stroke, CV
problems, breast or estrogen related cancers
Depoprovaera:
•Decrease in bone denisty, so need adequate intake of calcium/vitamin D
IUD:
•Increase risk of pelvic inflammatory disease, uterine perforation and ectopic
pregnancy
•Look for change in string length, foul smell, pain with intercourse, fever, chills
Naegele's rule:
•A method of calculating when a woman’s due date is
•Add nine months and a week from date of last menstrual period (LMP) ending
Weight gain during pregnancy:
•Underweight: weight gain of 28-40 lbs
•Normal weight: Normal weight gain is 25-35 lbs of a women at a normal/healthy
weight
•Overweight: weight gain should be 15-25 lbs
•First trimester - one should gain more than 1-2kg
•Second & third trimester - should be apprixmately 1 lbs gained per week
Calories during pregnancy:
•Extra 340 calories per dat during 2nd trimester
•450-452 extra calories per day during third trimester
Calories during breastfeeding
•Approximately 300-400 extra calories per day
Ultrasound:
Bladder should be full
Invasive procedures: Bladder should be empty
Non-stress test
•Non-invasive
•Measures fetal well being within the last trimester
•Measures response of the fetus heart rate to fetal movement
•Woman presses buttong when she feels fetal movement and the heart rate is
monitored in response to that movement
•Considerede reactive (which is normal) if the fetal heart rate accelerates during
movement
o(You want a result that indicated REACTIVE)
•Considered non-reactive (abnormal/bad) if the fetal heart rate did not accelerate
adequately during movement
Contraction stress test (CST):
•Might be performed due to a non-reactive stress test
•A contraction is induced using pitocin/ocytocin or through nipple stimulation
•During the contraction, youll monitor fetal heart rate to see if late decelerations
occur (which are never good)
•If no late decelerations occur then CST is negative (which is what you would
hope for)
•If late decelerations do occur during the contraction, it means the CST is positive,
which is not a good thing
•Inducing a test like this can possibly induce preterm labor
Iron deficiency Anemia:
•Iron supplement should be taken with Vitamin C to increase absorption
Non-pharmacological
pain management (During labor)
Breathing techniques
•Slow-paced breathing : the patient inhales slowly through the nose and exhales
slowly through the mouth (usually 6-9 times per minute and not fewer than 3-4).
•Modified-paced : the patient breaths slowly in and out through her mouth, and, as
each contraction reaches it’s peak, she breaths faster (usually 32-40 breaths per
minute), then she returns to slow breathing again.
•Pattern-paced breathing : requires more concentration as the patient sets up a
pattern of breathing to help her through the final centimeters of cervical dilation.
Breathing in and out of her mouth, she takes quick panting breaths and then
exhales or blows forcefully (“Pant-pant-pant-blow” or “hee” and “hoo”)
Touch
•Counterpressure : Steady pressure a support person applies to the sacral area of the
patient’s back. This is especially helpful for patients who have pain and internal
pressure in the lower back because the fetal head is in a posterior position. The
heels of the hand or fists are used to provide pressure
•Effleurage: is light massaging or stroking, usually at the patient’s abdomen in
rhythm with breathing during contractions
Water therapy
•Showering, bathing and sitting in a whirlpool bath can improve comfort, provide
relaxation and improve circulation and oxygenation, soften perineal area and help
women cope.
•Women can often stay in the bath for as long as she wishes, as long as there are
no contraindications. Facility policy may vary though.
•Jet hydrotherapy is usually recommended for 30-60 minutes
•Remember warm water can cause dizziness, so it is important to assist the patient
out of the tub/shower and provide a shower stool
Newborn reflexes:
•Moro : Also called startle reflex – hold baby and drop down slightly and they
extend arms and legs out
oNormal from birth to 4 months
•Rooting/suck : touch/stroke babies cheek, they turn to that direction and suck
oNormal from birth to 4 months
•Tonic neck : Extend arm and leg on the side their head is turned to, then they flex
arm on opposite side
oNormal form birth to 3-4 months
•Plantar
grasp : place finger on foot and they curl toes
oBirth to 6 months
•Palmar grasp : place finger in hand and they automatically grasp
oBirth to 8 months
•Babinski : Stroke outer edge of sole of foot and toes fan out
oBirth to 1 year
•Stepping reflex: hold infant and touch feet to surface and they respond with
stepping movements
oBirth to 4 weeks
Newborn Nutrition:
•Newborns can lose 5-10% of body weight after birth, but should regain it within
10-14 days after they’re born
•Breastfeed is better than formula
•No solid foods for 4-6 months
•First food is iron fortified cereal
•Breast feed right away
•Cramping is normal during breast feeding due to oxytocin stimulation with breast
feeding
•Feed for 15-20 minutes per breast
•Try to completely empty breast
•Best indicator that baby is getting enough milk is if they are voiding 6-8 diapers
per day
•Breast feed 8-12 times per day
Sleep:
•Infant should sleep supine/on back to prevent SIDS
•Newborns sleep approximately 17 hours per every 24 hours the first month or so
Car safety:
•Car seat in the back, rear facing, preferably in the middle seat until at least age 2
Tx of gonorrhea
Medication to tx gonorrhea: ceftriaxone IM and azithromycin PO
Labor and delivery processes: teaching findings of false labor
•Contractions are painless, irregular, decrease, felt in lower back or abdomen
above the umbilicus, often stop with sleep or hydration.
•Cervix: no change in dilation or effacement, remains in posterior position, no
bloody show.
•Fetus: presenting part is not engaged in pelvis.
Phases of maternal postpartum adjustment
•During the first 2 to 6 weeks after birth, the pt goes thru a period of acquaintance
w/ her newborn, physical restoration, and becoming a competent mother.
•Maternal identity is achieved around 4 months.
Engorgement of breasts
•Completely empty breast at each feeding. For engorgement, apply cool
compresses after feedings, and warm after 24 hours and prior to breast feeding for
circulation purposes.
•Due to decreased estrogen
Sore nipples
•apply small amount of breast milk to the nipple and allow it to dry.
•Apply cream or wear breast shields in her bra to soften nipple.
Prenatal care: second trimester
•Sex and pregnancy
•Fetal movement
•Complications like hypertension, diabetes, premature rupture
•Child birth classes
•Review birthing methods
•Develop a birthing plan.
Auscultating fetal heart tones
•PMI (point of maximal impulse) is the best location. Best heard on the fetuses
back.
•In vertex position: lower quad
•Breech position: upper quad
Sibling adaption
•Give a toy from the infant to the sibling
•Have sibling tour the unit.
•Arrange for one parent to spend time with sibling and other with infant.
•Allow sibling to help with care of the infant.
Naegele’s rule: take the FIRST day of the woman’s last cycle, subtract 3 months, and
then add 7 days.
Measurement of fundal height: between 18 to 32 weeks.
Placenta becomes an endocrine organ. Cardiac output increases 30-50% AND blood
volume 30-45% to meet the greater needs. Blood Pressure normally decreases during 1st
and 2nd trimesters, and return to baseline in 3rd trimester
1hr glucose tolerance: given glucose and assess 1 hour after.
3 hr glucose tolerance: fasting overnight prior to taking glucose and taking a sample at 1,
2, and 3 hours.
Increase of 340 calories is recommended during the 2nd trimester and 452 during the 3rd
trimester.
If a patient becomes pregnant, they should take 600mcg of folic acid a day. Recommend
1,000mg a day for calcium. Drink 8 to 10 glasses a day. Take 27mg a day of iron. 71g of
protein
Maternal phenylketonuria: start diet for at least 3 months prior to pregnancy and continue
throughout pregnancy. Fish, poultry, meats, nuts, eggs and nuts should be avoided.
Biophysical profile: score of 8 to 10 is normal. 4 to 6 is abnormal and suspects chronical
fetal asphyxia, less than 4 is strongly abnormal.
Amniocentesis
•Done at 14 weeks. Aspirate amniotic fluid by inserting a needle into the uterus.
•Have patient lay supine and place a wedge under the right hip.
•Administer Rho(D) immune after the procedure if the woman is Rh Negative.
Fetal lung tests: lecithin/sphingomyelin (L/S) ratio a 2:1 ration indicates fetal lung
maturity.
Maternal serum alpha-fetoprotein (MSAFP) determines if there are any neural tube
defects. Blood test.
Placenta previa is when the placenta plants into the lower segment of the uterus near or
over the cervical os.
•Complete: totally covering the cervical opening.
•Incomplete or partial: partially covering the cervical opening.
•Marginal or low lying: the placenta is attached in the lower part but does not
reach the opening.
oPainless, bright red vaginal bleeding with placenta previa.
oNo vaginal exams and do bed rest.
Abruptio placentae is the premature separation of the placenta from the uterus. Occurs
after 20 weeks of gestation and the leading cause of maternal death.
•Patient will have pain with dark red vaginal bleeding. Immediate birth is the
management. Give IV bolus, OS at 8-10L.
Vasa previa is when the fetal umbilical vessels implant into the fetal membranes rather
than the placenta.
Types of spontaneous abortions
•Threatened: mild craps, bleeding is spotting to moderate, no tissue is passed, and
the cervix is closed.
•Inevitable: moderate craps, mild to severe bleeding, no tissue passed, cervix is
dilated with membranes bulging at the opening.
•Incomplete: severe cramps. Heavy bleeding, partial fetal tissue or placenta passed,
and dilated with membranes bulging at cervix.
•Complete: mild cramps, minimal bleeding, complete expulsion of uterine
contents, and cervix is closed.
•Missed: no cramps, minimal bleeding, brown discharge, no tissue passed, cervix
is closed.
•Septic and Recurrent: varies with cramps, bleeding varies, tissue passed varies,
and cervix is usually dilated.
Gestational Diabetes
•Ideal blood glucose during pregnancy is 70-110 mg/dl.
•Women with gestational diabetes’ symptoms usually disappear in a few weeks
after delivery but more than 50% end up with Type 2 Diabetes within 5 years.
oGlucola/1 hour glucose tolerance test: 50g oral glucose load given,
analyzed results 1 hour later at 24-28 weeks gestation No fasting. Positive
results is 130-140 mg/dl or greater. Additional testing of 3 hr glucose
tolerance is indicated.
oOral glucose tolerance test: overnight fasting, avoid caffeine, and smoking
12 hours prior to testing, 100g glucose load is given and glucose is taken
at 1, 2, and 3 hours.
•Gestational DM is first managed with exercise and diet.
Do daily kick counts, educate about exercise.
Gestational hypertension
•Vasospasm contributing to poor tissue perfusion is the underlying mechanism for
the manifestation for gestational hypertension.
•Begins after the 20th week of gestation.
•Woman has a BP of 140/90 on 2 different occasions. No proteinuria. BP turns
back to normal 6 weeks postpartum.
oMild preeclampsia: GH in addition of proteinuria of greater than or equal
to 1+.
oSevere preeclampsia: BP is 160/110. Proteinuria is greater than 3+ ,
elevated creatinine greater than 1.1. Hyperreflexia.
oEclampsia: severe GH and onset of seizures or coma.
HELLP syndrome: hematologic conditions coexist with GH.
oH: Hemolysis resulting in anemia and jaundice.
oEL: elevated liver enzymes resulting in elevated ALT, AST, n/v.
oLP: Low platelets: less than 100,000 resulting in thrombocytopenia, petechiae,
bleeding gums,
•Antihypertensive meds: Nifedipine, Hydralazine,
•Anticonvulsant meds: Magnesium sulfate lowers BP, can initially feel
flushed and have hot flashes. PLACE ON FLUID RESTRICTION OF
100-125ML/HR.
•If mag toxicity, administer calcium gluconate.
Early Onset of Labor
Preterm labor: uterine contractions or cervical changes between 20-37 weeks of gestation
DIAGNOSTIC PROCEDURES:
•Obtain swab of vagina for fetal fibronectin between 24-34 weeks of gestation.
•Secretions are related to inflammation of the placenta that can lead to preterm
birth.
•Measure endocervical length.
•Obtain cultures and do biophysical profile.
Tocolytic Drugs (It’s Not My Time,
B*tches)
Indomethacin: an NSAID that blocks prostaglandin, which stops contractions. Cannot use
more than 48hours. Give with food or rectally.
Nifedipine: calcium channel blocker used to suppress contractions by inhibiting calcium
from entering smooth muscles.
Magnesium sulfate: tocolytic that relaxes the smooth muscle of the uterus and suppresses
contractions. Contraindication for mag sulfate is dilation of 6cm, greater than 34 weeks
gestation.
Terbutaline: is in a class of drugs called betamimetics. They help prevent and slow
contractions of the uterus. It may help delay birth for several hours or days.
Betamethasone: glucocorticoid given 24hrs apart. Enhances fetal lung maturity.
Rupture of membranes is a positive nitrazine paper test (blue, PH 6.5 to 7 or positive
ferning test.
Stages of Labor
FIRST STAGE
Latent: dilated 0-3cm. Contractions are irregular, mild to moderate. Frequency 5 to
30mins, and duration of 30-45 seconds.
Active phase: dilated 4 to 7 cm. Contractions are more regular and moderate to strong.
Frequency is 3 to 5mins. Duration is 40-70 seconds. Rapid dilation and effacement and
some fetal descent.
Transition phase: 8-10cm dilated. Contractions are strong to very strong. Frequency is 2-
3mins and duration is 45-90 seconds. Has urge to push and bloody show.
SECOND STAGE
•Full dilation. Intense contractions q1-2mins and results in birth. DELIVERS
BABY
THIRD STAGE
•Deliver placenta
FOURTH STAGE
•Postpartum
Frequency: beginning of one contraction to the beginning of the next.
Duration: Time between the beginning of the contraction to the end of that same
contraction.
Butrophanol and nalbuphine helps with pain relief and does not cause significant
respiratory depression in mother and baby.
Pudendal block: helps block nerves in the vaginal area.
Epidural block is bupivacaine and causes loss of sensation from umbilicus to thighs and
given in the 4th and 5th vertebrae.
Spinal Anesthesia: given in subarachnoid space for c-section and goes from breasts to
feet.
LEOPOLD MANEUVERS
1. Identify fetal part. Head should feel round and breech should feel irregular. This
identifies the fetal lie and the presenting part.
2. Palpate for the fetal back which should be smooth and the hands and feet which
should be nodules, this validates presenting part.
3. Determining part that presents over the true pelvis by grasping the lower segment of
the uterus between the thumb and finger. Identifies descent into the pelvis.
4. Face the client’s feet and outline the fetal head using the palmar surface to palpate the
cephalic prominence. Determines fetal attitude.
3 TIER SYSTEM:
Category 1: everything normal
Category 2: abnormal
Category 3: absent FHR
CULTURAL
Hispanic: mom to be present over partner.
Black: female family members
Asian: might prefer mother, labor in silence, no cesarean birth desired.
Native American: female doctors and nurses, use herbs and want to squat to deliver.
European: birth is public concern, partner is involved.
Lacerations
1st degree: goes through skin but not muscle
2nd degree: goes through skin and muscles but not the anal sphincter
3rd degree: skin all the way to sphincter
4th degree: skin all the way through anterior rectal wall.
Amniotomy: artificial rupture of the amniotic membranes using an Amnihook or sharp
instrument. Places woman at risk for infection. INDICATED FOR CORD
COMPRESSION.
Prolapsed cord: put sterile gloved hand into vagina and apply pressure on either side of
the cord to relieve pressure. Then put patient in a knee chest, Trendelenburg, or side lying
position. Apply soaked saline towel to cord to prevent drying and maintain blood flow.
VACCINES
Rubella: get after pregnant, do not get pregnant 1 month after getting this vaccine.
Hep B: Should receive within 12 hours after birth
RH: given within 72 hrs after delivery
Varicella: give before discharge, 2nd dose is given at 4 to 8 weeks. Don’t get pregnant up
to a month.
Tdap: give before discharge.
Idiopathic thrombocytopenic purpura (ITP): autoimmune disorder in which life span of
platelets is decreased by antiplatelet antibodies
Disseminated intravascular coagulation (DIC): Clotting and anticlotting occur at same
time and damages organs as well. Occurs secondary to other complications.
