ATI EXAM 2 Latest Completed for 2022/2023

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ATI EXAM 2 Norm pregnancy ranges  hct = preg 32-42%  Hgb = 10-14 g/dl  Platelets 150-350k increase 3-5days post  WBC 5-15,00 CHAPTER 20------ATI 23 NEWBORN ASSESSMENT Expected range... s  Weight---5.5-8.8lb (2500-4000g)  Length---45-55cm (18-22in)  Head circum---32-36.8cm(12.6-14.5in)  Chest circum---30-33cm (12-13in) VITALS  Respiratory rate---do first o 30-60bpm o should not have grunting or nasal flaring==resp distress  Heart rate o 110-160bpm  Blood pressure o 60-80 systolic and 40-50 diastolic  Temperature o 36.5-37.5 C (97.7-99.5F) LAB RANGES  hgb- 14-24  hct—44%-64%  platelets 150-300,000  glucose 40-60 Physiologic response of newborn to birth  Resp function established when umbilical cord is cut  Circulatory change occur with expulsion of fetus and cutting umbilicus o 3 shunts close-ductus arteriosus, ductus venous, and foramen ovaleo murmur over right and left auricles –latency in foramen ovale Physical assessment  Apgar scoring---rules out abnormalities o Completed at 1 min and 5 min o 0-3 severe distress o 4-6 mod diff o 7-10 minimal/no diff adjusting to life  don’t use rectal therm. Can injure rectal mucosa initial assessment  external –skin color, peeling, birthmarks, foot creases, breast tissue, nasal patency, meconium staining  chest----point of maximal impulse location, ease of breathing, auscultation for hr/tones, resp for crackles, wheezes, equality of breath sounds  abdomen---rounded, umbilicus has one vein two arteries AVA  Neuro----muscle tone and reflex reaction(MORO), palpation for presense/size of fontanels and suture, assess for fullness or bulges Gestational age  Performed within first 48 hrs  Uses measurements and new ballard scale  Ballard scale---assesses neuromuscular and physical maturity o Neuro maturity—  Posture  Square window wrist formation  Popliteal angle  Scarf sign---arm over chest  Heel to ear o Physical maturity  Skin texture  Lanugo  Plantar surface creases  Breast tissue buds  Eyes opening /ear cartilage  Genitalia development  AGA---appropriate for gestational age weight in 10th-90th percentile  SGA---- <10th percentile  LGA-- >90th percentile  LBW---low birth weight <2500 g  IUGR---growth rate does not meet norms  Postmature---after 42 weeks gestation with evidence of placental insufficiencySigns of cold stress—check temp  Moderately cyanotic  Mottled trunk  Active movement in extremities  Physical exam  Posture o Curled up position, moderate flexion, resistant to extension of extremities  Skin o Pink or acrocyanotic, no jaundice o Jaundice may appear on 3rd day and disappear on own o Texture—soft, dry, smooth, crack in hands and feet may be present.  Desquamation(peeling) may occur few days after with full terms o Vernix caseosa—protective thick cheasy covering o Lanugo-fine downy hair amount varies…on pinnae of ears, forehead and shoulders o Normal deviations  Milia---small white baby pimples, disappear on own  Mongolian spots—bluish purple spots common on shoulders, back, and butt present on dark skin babies  Telangiectatic nevi—(stork bites)—flat pink/red marks that blanch easily on neck, nose, upper eyelids, middle forehead…fade in 2nd year  Nevus flammeus (port wine stain)—capillary angioma purple or red does not blanch or disappear  Erythema toxicum---pink newborn rash during first 3 weeks anywhere on body no treatment needed  Head o 2-3cm > chest circum o hydrocephalus==head more than 4cm that chest o microcephaly ==<32cm abnormally small head o anterior fontanel==5cm and diamond shaped o posterior fontanel==smaller and triangle o fontanels should be soft and flat…can bulge with crying  bulging=increased cranial pressure, infection, or hemorrhage  depressed=can mean dehydration  sutures ---palpable, separated and overlapping(molding) o caput succedaneum- local swelling of soft scalp tissue caused by labor pressure  expected, can be palpated as soft edematous mass, crosses suture line  resolves 3-4 days no treatment o cephalohematoma—collection of blood on skull bone from birth trauma or forceps. Does not cross suture line. Egg shaped, bluish discoloration resolves 2-6 wks  eyes o lacrimal glands are immature minimal or no tears o subconjunctival hemorrhages can result from pressure during birth o eyeballs can have random jerky movements  Ears o Low set ears can mean down syndrome or kidney disorder o Cartilage should be firm and well formed o Inspect ears for skin tags  Nose o Midline, flat and brood with lack of bridge o No drainage o Nose breathers don’t open mouth to breath til after 3wks o Apnea <15seconds is normal due to adjusting to life o Nasal blockage can = flaring of nares, cyanosis , or asphyxia  Mouth o Assess strength of sucking o Lip movements should be symmetrical o Saliva should be scant…excessive=tracheoesophageal fistula o Epsteins pearls-small white cysts on gums and hard palates, normal o Protruding tongue=down syndrome o Gum and tongue should be pink  Neck o Short, thick with skin folds, no webbing o Absence of head control can equal=prematurity or down syndrome  Chest o Barrel shaped o Respirations primarily diaphragmatic o Clavicles intact, absence of retractions  Abdomen o Umbilical – odorless no intestinal structures exhibited o Round and dome shaped o Bowel sounds present 15-20 min after birth  Anogenital o Anus present, patens, uncovered o Meconium passes 24-48 hrs after birth o Female genitalia-labia majora covering labia minora and clitoris, usually edematous o Vgainal blood tinged can occur in females from mothers hormones—normal o Hymenal tag should be present o Urine passed within 24 hrs…rust color from uric acid in first couple days  Extremities o Assess for full range on motion with extremities flexedo Bowed legs and flat feet present due medial muscles more developed than lateral o No click in abducting hips o Gluteal folds symmetrical o No extra digits  Spine o Straight flat midline easily flexed  REFLEXES o Sucking/ rooting  Stroking cheek, turns head to suck  Disappears 3-4months can persist to 1 yr o Palmar grasp  Newborn grabs examiners fingers when touching palm  Lessens 3-4 months o Plantar grasp  Curling toes down  Birth-8months o Moro relex  Allow head and trunk to fall back in semisitting position, extends and abducts arms fingers form a C  Birth-6mnths o Babinski  Stroke outer edge of foor—toes fan out  Birth-1yr o Stepping  Hold newborn upright, does stepping movements  Birth-4wks  Senses o Can focus on objects 8-12 inches away o Prefer dim lighting o Mouth most sensitive to touch o Taste-prefer sweet o Smell-prefer sweet smells recognize mothers smell Diagnostics  Assess cord blood at birth for blood type, rh status Complications  If hypothermic, use skin to skin or radiant warmer  Check temp every hour until stableCHAPTER 21 CARE OF NEWBORN---ATI 24&26 Physical newborn assessments  After birth done every 30min x 2, every 1hr x 2 …then every 8hr  Weight check daily  In first 6-8 hrs of life check for periods of reactivity o 1st period  alert, exploring activity, sucking sounds  rapid hr ---160-180 lasts for 30 min after birth  can have rapid rr o period of relative inactivity  60-100 min after birth  quiet begins to rest/sleep  HR and RR decreases o 2nd period of reactivity  reawakens and responsive  can gag/choke on mucous  2-8hr after birth Labs  genetic mandated screening--must have been fed for at least 24hrs  PKU testing  Serum bilirubin-before discharge Respiratory complications  Bradypnea--<30/min  Tachypnea--- >60/min  Abnormal—expiratory grunting, crackles, wheezes  Respiratory distress---nasal flaring, retractions, grunting, gasping, labored breathing  Suction mouth then nasal passage for excess mucous  C-sections more susceptible to fluid remaining in lungs  Is bulb doesn’t work---back blows or chest thrusts can be used  BULB USE o Compress before insertion to side of mouth o Avoid center o Mouth first then nostril Identification  Newborn should have wrist and ankle band matching mothers record #  Staff must have photo id badge  Must verify with mother each time given Thermoregulation Monitor temp for hypothermia o <97.7 o cyanosis o increased RR  Keeps warm by metabolizing brown fat  Cold stress can increase oxygen demands and use up brown reserves (BAD)  Heat loss occurs by 4 mechanisms o Conduction- loss heat by contact with cooler surface  Preheat warmer, stethoscope, and scales o Convection—heat loss from body to cooler air  Do procedures under warmers  Cover head, swaddle in blanket o Evaporation--- heat loss by surface liquids evaporating  Rub newborn dry in warm sterile blanket immediately after delivery o Radiation--- loss of heat from body to cooler solid surface that is nearby but not in contact  Keep newborn away from examining tables and windows Bathing  Can begin with stabilized temp (97.7F) 36.5C  Sponge bath under warmer 1-2hrs after birth  Wear gloves Feeding  Breast-Start immediately after birth  Formula-2-4hr after birth , on demand normally 3-4hrs  Breast-6-8wet diapiers or 8-12x/day as demanded Sleep  Sleep 16-19hr/day  Supine to decrease SIDS  No shared beds  Need for immunizations as a measure to prevent SIDS Elimination  Monitor/document output  Should void once within 24hrs  6-8x/day after day 4  stool 3-4x/day after meconium pass  breastfed stools=yellow and seedy 3/day--lighter and loser than formula babies  avoid alcohol diaper wipes  cleanse area with water or mild soap after diaper change  apple antibiotic ointment, jelly or zinc oxide per hosp protocol Infection control  provide individual thermometer, diapers, bathing supplies  don’t mix with other newbornsFamily education  encourage holding newborn Umbilical cord care  cord clamp stays for 24-48hrs  cleaning with water during initial bath  assess for erythema, edema and drainage at each diaper change  fold diaper down and away  cords fall off in 10-14 days Complications Cold stress  hypoxia, acidosis, hypoglycemia  newborns with resp distress=higher risk hypothermia o monitor for cold stress o warm slowly over 2-4hr o correct hypoxia with oxygen Hypoglycemia  frequent in first few hrs of lide  risks o mother has DM o SGA or LGA o <37wks or >42wks o monitor these risky babies within first 2hrs  SIGNS o jitteriness, twitching, weak slow high-pitched cry, irregular resp effort, cyanosis, lethargy, eye rolling, seizing, blood glucose <40mg/dl heel stick o breastfeed immediately or give donor milk or formula o brain damage can result if depeleted of glucose Hemorrhage  improper cord care or placement of clamp o ensure clamp is tight, check for blood seepage o notify provider is bleeding continue Medications Erythromycin  EYE care prophylactic  Prevents eye infection through birth canal---opthalmia neonatorum  Side effects-redness, swelling, drainage, blurred vision 24-48hrs Vitamin K (phytonadione)  Prevents hemorrhagic disorders  Not produce in GI until day 7  Admin 0.5-1mg IM within 1hr after birth HEP B immunization Informed consent needed  For healthy womens babies---at birth, 1 month, and 6months old  For hep b babies – 12hrs with hep b immunoglobulin, hep B 1mnth, 2mnth, 12mnth  DON’T give with vit K on same thigh CHAPTER 26 ATI—nursing newborn care Discharge  48hr after vaginal  72hr after c section Education  Crying occurs when o Overfeeding, hungry, overstimulated, wet, cold, tired, hot, bored, or need burping  Quieting techniques o Swaddling, close skin contact, pacifier, rhythmic noises, movement(car,swing,rocking), on stomach while bouncing legs, stimulation, eye contact  Sleep-wake cycle o Sleep without feeding through night by 4-5mnths o Get day/night routine-bathe before bed to soothe, last feeding at 2300 o Use dim lights at night for changing to not fully wake them  Basic holding o Cradle o Upright o Football o Colic hold—face down on arm face by elbow, quiets fussy baby  Bathing o 2-3x/week using mild soap-no hexachlorophene o no immersion until umbilical and circumsicion healed o groin area washed last o for males do not push back foreskin on penis to wash o apply lotion fragrance free immediately after bathing  Health benefits of circumcision o Easier hygiene o Decreased risk of UTI o Decreased risk STIs and HIV o Decreased risk of penile cancer and cervical cancer for partner o Contraindications  Bleeding disorders  Parents declined vit k—can be more likely to bleed  Newborns with hypospadias(abnormal urethra positioning) or epispadias(urethral canal terminates on dorsum of penis)  Post care- Assess for bleeding every 15-30 min during 1st hr and hourly for next 4-6hr  Fan fold diaper to prevent pressure on area  DO NOT wash off yellow mucous film that may develop at day 2  Complications  Hemorrhage-provide gentle pressure if bleeding persists notify provider  Cold stress/hypoglycemia  Lack of voiding Wellness checkups-  examined within 72hrs 2-3days after discharge by a pediatrician  1mnth  2mtnhs  4mths  6mths  9mnth  12mnths  15mnths  18mnths  2yrs, 2.5yrs, 3yrs, 4yrs and every year after Manifestations of illness to educate parents  temp >100.4 (38C) or < 97.9F (36.6C)  poor feeding  frequent vomiting  decreased urine, or bowels, or diarrhea  labored breathing  jaudince  cyanosis  diff waking CHAPTER 10 PREGNANCY COMPLICATIONS---ATI 7&9 Chapter 7----bleeding  spontaneous abortion o terminated before 20wks or wt <500g. o types-threatened, inevitable, incomplete, complete, and missed o risks  chromosomal abnormatilies(50%) maternal illness---type 1 DM  advanced maternal age  premature cervical dilation  chronic maternal infection or malnutrition  trauma/injury  anomalies in fetus or placenta  substance use  antiphospholipid syndrome o Expected findings  Backache/abdominal tenderness  Ruptured membranes  Fever  Signs/symptoms of hermorrhage –hypotension/tachycardia o Labs  Hgb/hct-if lots of blood loss  Clotting factors  Wbc-inection  Hcg-confirm pregnancy o Therapeutic procedures  D&C-dilation and curettage—dilate and scrape to remove contencts for incomplete abortions  D&E-dilation and evacuation—evacuate uterine contents after 16wks gestation  Prostaglandins and oxytocin—induce contractions to expel products Causes of bleeding during pregnancy  1st trimester o spontaneous abortion o ectopic pregnancy-abrupt unilateral lower quadrant pain with or without vaginal bleeding  2nd trimester o gestational trophoblastic disease- uterine size increasing abnormally fast, abnormal high levels hcg, nausea/increased emesis, dark brown red vaginal bleeding. No fetus present  3rd trimester o placenta previa-painless vaginal bleeding o abruptio placentae-vaginal bleeding, sharp abdominal pain, tender rigid uterus o Vasa previa- fetal vessels implanted into membranes rather than placenta Other causes  Recurrent premature dilation of the cervix-painless bleeding with cervical dilation to fetal expulsion  Preterm labor-pink stained vaginal discharge  Hydatidiform mole-benign proliferation growth of the placental trophoblastNursing care for bleeding  Perform pregnancy test  Observe color, amount of bleeding (pad count)  Avoid vaginal exams  Admit meds/blood products as prescribed  Use lay term miscarriage nor abortion  Provide emotional support and referrals Medications  Analgesics  Prostaglandin-vaginal suppository  Oxytocin  Antibiotics  RhoD if rh negative Client education  Notify provider of heavy bright red bleeding, temp, or foul discharge  Refrain from tub baths, sex, or placing things inside vagina for 2wks  Avoid pregnancy for 2mnths Ectopic pregnancy  Abnormal implantation outside uterine cavity usually in fallopian tubes  2nd most frequent cause of bleeding in early pregnancy  leading cause of infertility---tube rupture  Risks o STIs o Tubal surgery o IUD o Assisted reproductive technologies  Findings o Unilateral stabbing pain/tenderness in lower ab quadrant o Delayed light irregular menses o Scant, dark red or brown spotting 6-8wks after last menses o Referred shoulder pain due to blood in peritoneal cavity o Faintness/dizziness---bleeding in ab cavity o Signs of hemorrhage—pallor, hypotension, tachycardia  Tests o Progesterone levels----if elevated rules out o hCG levels ----if elevated rules out ectopic pregnancy  therapeutic procedures o transvaginal ultrasound—shows empty uterus o methotrexate-inhibits cell division—dissolves pregnancy(avoid alcohol and folic acid—to prevent toxicity) photosensitive o salpingostomy-salvages tube if not rupturedo laparoscopic salphingectomy- removal of tube if ruptured  Care o Replace fluids o Education o Prepare for surgery o Obtain hCG/progesterone levels, liver/renal function, CBC and rH type Gestational trophoblastic disease-  Uterine size increasing abnormally fast, abnormal high levels hcg, nausea/increased emesis, dark brown red vaginal bleeding  Embryo fails to develop  Molar growths develop two types o Complete mole  Paternally derived genetic material  No fetus, placenta, or fluid  Hemorrhage in uterine cavity occurs o Partial mole  Genetic material from paternal and maternal  Abnormal fetal parts, amniotic sac, fetal blood with congenital anomalies  Risks o Prior molar pregnancy o Early teens or >40 years old  Findings o Excessive vomiting due to elevated hCG levels o Rapid uterine growth due to trophoblastic cells o Dark bleeding or bright red can be scant or profuse o Anemia from blood loss o Clinical findings of preeclampsia o Higher than expected fundal height  Labs o Serum level of hCG high with decline after 10-12 wks  Therapeutic procedures o Ultrasound reveals dense growth but no fetus o Suction curettage to evacuate mole o RhoD if needed o Serum hCG done weekly for 3wks then monthly for 6months-1yr to detect GTD  Nursing care o Measure fundal height o Assess GI status and appetite o Admin meds and chemo meds for malignant cells containing choriocarcinoma o Advise clients to save clots for evaluationPlacenta previa  Placenta abnormally implants in lowe segment of uterus or over cervical os instead of at fundus  Results in bleeding at 3rd trimester  Complete or total-cervical os completely covered by attachment  Incomplete/parital –cervical os partially covered  Marginal or low-lying—attached to lower uterine segment but does not reach os  Risks o Previous placenta previa o Uterine scarring o Age >35 o Multifetal pregnancy o Smoking  Findings o Painless, bright red bleeding 2nd-3rd trimester o Uterus soft, relaxed, nontender with normal tone o Fundal height greater than expected for gest. Age o Fetus in breech, oblique, or transverse position o Reassuring FHR o Decreased urinary output  Labs o Hgb & hct for blood loss assessment o CBC/coagulation profile o Kleihauer-betke test—detects fetal blood in maternal circulation o Transabdominal or transvaginal ultrasound for placement of placenta  Care o Assess bleeding & fundal height o Perform leopold maneuvers o Refrain from vaginal exam o Have oxygen available o Bed rest o Nothing inserted vaginally Abruptio placentae  Premature separation of the placenta from the uterus  After 20wks gest (3rd trim)  Leasing cause maternal death  Coagulation defect (DIC) is often associated with abruption  Risks o Maternal HTN o Blunt traumao Cocaine use o Smoking o Previous abruption o Premature rupture of membranes o Multifetal pregnancy  Findings o Sudden uterine pain with dark red bleeding o Uterine tenderness o Contractions with hypertonicity o Fetal distress o Clinical findings of hypovolemic shock  Labs o Hgb and hct decreased o Clotting defects o Kleihauer betke test o Biophysical profile for fetal well being o Ultrasound for placental placement  Careo Palpate uterus for tenderness and tone o Assess fhr o Immediate birth is the management  Need 8-10L o2 Vasa previa  Fetal umbilical vessels implant into fetal membranes rather than placenta  Velamentous insertion of the cord—vessels begin in the branch at the membranes then course to the placenta  Succenturaite insertion of the cord—placenta divided into 2 or more lobes and not one mass  Battledore insertion of the cord—marginal insertion, increased risk fetal hemorrhage  Use ultrasound for well being and vessel assessment CHAPTER 9 ATI—MEDICAL CONDITIONS Cervical insufficiency(premature cervical dilation)  Expulsion of products of conception  Risks o Hx of cervical trauma o In utero exposure to diethylstilbestrol o Congenital structural defects of uterus or cervix  Findingso Increase in pelvic pressure/urge to push o Pink stained vaginal discharge/bleeding o Rupture membranes o Uterine contractions with expulsion of fetus  Diagnostic procedures o Ultrasound showing short cervix, presence of funneling, effacement o Prophylactic cervical cerclage-reinforcement of cervix with heavy ligature to strengthen and prevent dilation..best if done at 12-14wks  Care o Assess discharge o Monitor reports of pressure and contractions  Meds o Tocolytics inhibit contractions  Discharge instructions o Bed rest/activity restriction o Encourage hydration o Avoid intercourse, tampons, douching Hyperemesis gravidarum  Excessive nausea/vomiting prolonged past 12wks, 5%wt loss, acetonurio, electrolyte imbalance, ketosis  At risk for preterm birth or intrauterine growth restriction  Risks o Age <30 o History migraines o Obesity o 1st pregnancy o multifetal gestation o gestation trophoblastic disease o fetus with chromosomal anomaly o high emotional stress o hyperthyroid disorder o GI disorder, diabetes  Findings o Excessive vomiting for prolonged periods o Dehydration o Wt loss o Increased pulse o Decreased BP o Urine ketones present  Tests o Urinalysis---for ketones and acetones & elevated urine spec gravity o Chem profile---electrolyte imbalance o Thyroid testo CBC—hct  Care o Monitor I&O o Monitor wt, vitals, assess skin turgor o NPO 24-48 hrs  Meds o IV lactated ringers—hydration o Pyridoxine (VIT b---vitamins as tolerated o Antiemetics---ondansetron, metoclopramide o Corticosteroids- treat refractory hyperemesis Gestational Diabetes  Ideal blood glucose during pregnancy 70-110 mg/dl  Impaired tolerance to glucose during pregnancy recognition  Risks to fetus o Spontaneous abortion o Infections o Hydramnios o Ketoacidosis o Hypoglycemia o Hyperglycemia---excessive fetal growth  Risk factors o Obesity o HTN o Glycosuria o Age >25 o Family Hx diabetes o Previous delivery of infant large or stillborn  Findings o HYPO--Nervousness, headache, weakness, irritability, hunger, blurred vision , tingling of mouth./extremities---shaking, clammy skin, shallow respirations, rapid pulse o HYPER—polydipsia, polyphagia, polyuria, nausea, ab pain, dry flushed skin, fruity breath----vomiting & excessive wt gain.  Tests o Routine urinalysis—check for glucose, ketones o Glucola screening/1hr glucose tolerance test  @24-48wks gestation 50g oral glucose wait 1hr  don’t fast  positive=130-140 or > o oral glucose tolerance test  overnight fasting  avoid caffeine, smoking for 12hr prior 100g glucose test at 1,2,and 3 hr following  diagnostics o biophysical profile for fetal well being o amniocentesis with alpha fetoprotein o nonstress test for well being  Meds o Manage with diet and exercise o Begin insulin if no change  Education o Daily kick counts o Diet and exercise Gestational HTN  Underlying cause-vasospasms contributing to poor tissue perfusion  Associated with placental abruption, kidney failure, hepatic rupture, preterm birth, and fetal/maternal death  GH---Begans after wk 20….BP >140/90 no proteinuria, goes to baseline after 6 wks post  Mild preeclampsia---GH with proteinuria 1+ or more, headaches, and edema  Severe preeclampsia—BP>160/110, proteinuria 3+, oliguria, elevated serum creatinine >1.1, hyperreflexia with clonus, visual disturbances, epigastric/upper quadrant pain, thrombocytopenia  Eclampsia---severe preeclampsia with seizure/coma activity o Warnings of convulsions by headache, severe epigastric pain, hyperreflexia, and hemoconcentrations  HELLP syndrome---GH with hepatic dysfunction o H=hemolysis—anemia/jaundice o EL= elevated liver enzymes –ALT and AST, epi pain and N/V o LP= low platelets <100,000---abnormal bleeding, bleeding gums, petechiae Risks  <19 yo or >40  1st pregnancy  morbid obesity  multifetal gestation  chronic renal disease  chronic HTN  DM  Rheumatoid arthritis  Lupus Findings  Severe continuous headache  Nausea  Blurred vision  Flashes of lights/dotsPhysical assessment findings  HYN, proteinuria, facial/hand/ab edema, pitting edema, vomiting, oliguria, hyperreflexia, scotoma, epi pain, dyspnea, seizures, diminished breath sounds Abnormal labs  Elevated LDH, AST liver enxymes  Increased creatinine  Increased plasma uric acid  Thrombocytopenia  Decreased hgb  Hyperbilirubinemia Care  Assess LOC  Pulse ox  Monitor urine output and assess for proteinuria  Daily wt  Encourage lateral positioning  perform daily kick counts Meds  antihypertensives—(methyldopa, nifedipine, hydralazine, labetalol)  avoid ace inhibitors and angiotension II  Magnesium sulfate for anticonvulsants o Will initially feel flushed hot and sedated o Toxicity—absence oof deep tendon reflexes o Urine <30/hr o Resp <12 o Decreased LOC o Cardiac dysrhythmias o Antidote==calcium gluconate or chloride Chapter 17 postpartum  BP & PULSE q 15min for first 2hrs after birth  Temp q4hr for first 8hr after birth then q8hr BUBBLE RhoD globulin- admin within 72hrs to women neg and infant + Kleiauer betke test—determines if fetal blood is in mother circulation FUNDUS  Fundus descends 1cm per day  After 2wks the uterus should lie within the true pelvis and not be palpable Assess q8hr  Care  Admin tocolytics to promote uterine contractions o Oxytocin& misoprostol (watch hypotension)methylergine, ergovine, and carboprost(watch HYPERtension)  Early breastfeeding will stimulate oxytocin and prevent hemmorhage 3 stages of lochia  Rubra- bright red, fleshy odor 1-3 days, can contain small clots  Lochia serosa- pinkish brown and serosanguinous consistency 4-10 days  Lochia alba- yellowish creamy white color, fleshy odor last 11days-4-8wks Amount  Scant- <2.5cm  Light 2.5-10cm  Heavy-one pad within 2hr  Excessive one pad in 15min or less Care  Can apply ice to the perineum for the frst 24-48 hrs  Sitze bath 2x day  With hazel can help with swelling and hemorrhoids CHAPTER 17 POSTPARTUM ADAPTATIONS AND NURSING CARE  Uterine involution-return to previous size o Contraction of muscle fibers  Contraction controls bleeding and shrinks uterus o Catabolism-  Convert cells into simpler compounds o Regeneration of uterine epithelium  Outer portion expelled  Leaves the endometrial layer smooth and spongy  Uterine Descent o Immediately after delivery  Size of a large grapefruit  Palpate between the symphysis pubis and the umbilicus-midline o 24 Hrs  within 12 the fundus rises to level of umbilicus o By day 10  Descends by 1cm/finger per day  No longer palpable by day 14. – into pelvic cavityReproductive system  Afterpains—intermittent uterine contractions o Loss of muscle tone  In multipara this is more painful due to less muscle tone o Over distention  Primipara may have more pain if uterus was overdistended o Breast feeding  Causes more pain due to oxytocin release during breast feeding causing strong uterine contractions o Use analgesics o Should become less severe by 3rd day  Cervix o 1 week = firm and external os 1cm and slit-like o external os remains permanently slit like and slightly open in nullparous  Vagina o Mucosa atrophic(thinning) until estrogen production is reestablished o Vaginal dryness and dyspareunia(sex pain) is likely if breastfeeding-estrogen not producing o 6-10 wks for vaginal epithelium to be restored  Perineum----REEDA o Episiotomy-heals in about 2-3wks o Lacerations –less discomfort 2-3wks healing  Cardiovascular system o Increase in cardiac output due to =  Blood from uteroplacental unit returns to central circulation  Decreased pressure from uterus on vessels  Excess extracellular fluid foes into the vascular compartment  Returns to pre-pregnancy levels-6-12wks postpartum o Excess plasma volume  Diuresis  Diaphoresis o Coagulation  4-6wks return to pre preg state  may use compression stockings if not ambulating enough o Blood values  WBC up to 30,000  Hgb/Hct-return to norm 4-6wks after o GI  Begins to be hungry and thirsty after birth  Constipation is common  Offer stool softeners  Normal pattern resume 8-14days after o Urinary  Kidneys return to norm 4wks post Increased capacity and decreased muscle tone-little sensation of voiding  Uterine distention can lead to increase bleeding as the uterus is not contracting o Musculoskeletal  Diastasis recti  Use gentle exercises to strengthen wall –may take 6wks to return o Integumentary  Pigmentation reduces or disappears o Hair  Loss starts at 4-20wks and is regrown by 6 months o Neuro  Anesthesia/analgesics may cause temporary dizziness/lack of feeling  Prevention of injury is priority  Carefully assess headaches  Headache with blurr vision/photophobia/ab pain—preeclampsia  Severe headaches may be from postdural puncture—lay supine o Immune-  Administer rubella after birth for nonimmune mothers  Wil need 2nd vaccine in 4-8wks  Avoid pregnancy for 1 month after vaccine  Safe if nursing  Flu-symptoms may occur  Rho(D) immune globe  Admin is mother is (-) and baby is (+)  Negative coombs test—rh factor. Mom has not developed antibodies against babies (+) blood  Receive issued card Postpartum Initial assessments  BUBBLET3E  BREASTS o Size, contour, symmetry, nipple cracks/fissures/flat or inverted/mastitis  UTERUS o Fundus should be firm midline below umbilicus o If boggy-support lower segment and massage o If displaced/high-have pt void o Soft after massage-express clots, notify, begin oxytocin  BOWEL o Bowel movement o Flatulence o Hemorrhoids  BLADDER o Void w/in 6-8hrso Have decreased urge o Assess for distention o Risk for UTI o Stress incontinence o 150ml upon voiding-retention o 300-400ml- usually empty  LOCHIA---TACO o Rubra-day 1-3 scant o Serosa= day 4-10 o Alba= day 10-up to 6wks o Moderate---rubra with small clots 2nd day  EPISIOTOMY/LACERATION---REEDA o Redness, ecchymosis, edema, discharge, approximation  THROMBUS o Assess using homans sign o Deep tendon relfexes  EMOTIONS o Baby blues o S/S= postpartum discomforts, sleep deprivation, anxiety, body image concern o Returning to weork  RHOGAM/RUBELLA (if indicated) Maternal adaptation:phases of role attainment  Taking in phaseo Wants to talk about and labor o Makes phone calls goes over all details  Taking hold phaseo Becomes more independent o Assumes responsibility for own care o Shifts attention to newborns behaviors o “teachable, reachable, referable”  Letting go phase o Parents give up previous roles and accept parenting o At this point can be disappointed in fantasy’s When to call health provider  Fever==over 100.4  Persistent perineal pain  Breast infection  S/S UTI  Abdominal tenderness  Abnormal change in lochia S/S thrombi  Pelvic fullness or pressure  S/S infection of incision Postpartum discharge  Hospital length stay o Vaginal---48hrs o C-section---72hrs  Preventing discharge o Mother o Infant Resumption of menstruation  Lactating—6months  Non lactating—27-75days after birth, menses resumes 4-6wks CHAPTER 9 ANTEPARTUM FETAL ASSESSMENT Biophysical profile includes  Fetal breathing movement  Fetal tone  Amniotic fluid volume Amniocentesis  Evaluate fetal lung maturity using the (L/S) lecithin/sphingomyelin ratio  Empty bladder before procedure  Supine position, wedge under right hip to displace uterus off vena cava  Identifies fetal genetic defects  Lecithin/sphingomyselin ratio (L/S)---test done to determine fetal lung maturity Nonstress test uses an acoustic vibration device to awake the fetus  Assesses FHR in relationship to fetal movement  Mom pushes button everytime she feels fetal movements Contraction stress test indications Decreased fetal movement  Intrauterine growth restriction IUGR  Post-maturity CHAPTER 18 POSTPARTUM COMPLICATIONS Postpartum hemorrhage  Loss of >500mL – vaginal delivery  >1000mL c section  decrease in hct >10% since admission Assess 4 T’S  Tone  Trauma  Tissue  thrombin  risks--- o infection o prolonged labor o meds o uterine inversion o precipitate labor or delivery or operative delivery o multiparity o clotting disorder o uterine leiomyomas—fibroids o placenta abnormalities o C-section  Early hemmorhage o Uterine atony o Trauma o Retained tissue o Abnormal coagulation  Late o Subinvolution o Retained tissue o Infection  Signss o Fundus soft or boggy o Hard to locate fundus o Firm with massage but then loses toneo High fundus o Excessive lochia---1pad 15min o Excessive clots  Meds----uterotonics o Methylergonovine (HTN)and carboprost(don’t use in asthma,MAD DIARRHEA) most common o Oxytocin o Misoprost—Can be rectal o Stimulate uterine contractions Retained placental fragments  preventable through inspection of placenta after delivery  Risks o Attempts to deliver placenta prior to separation o Manual removal o Abnormal implantation o previous c section o Uterine leiomyomas  Thromboembolic disorders o Most common during pregnancy/post  Superficial venous thrombophlebitis  Deep vein thrombosis  Pulmonary embolism o Primary cause  Venous stasis  Hypercoagulable blood  Injury to vessel Late postpartum hemorrhage  Failure of uterus to involve  Signs o Prolonged discharge of lochia o Excessive uterine bleeding o Possibly profuse hemorrhage o Pelvic pain/heaviness o Backache o Fatigue o Uterus larger and softer than norm Hypovolemic shock Puerperal infection—infection after childbirth  Endometritis-uterine infection  Wound infection UTI—1-2 days post o Risks-epidural, catheter, frequent pelvic exams, hx utis, c section  Mastitis—2-4wks post o Completely empty ech breast at feeding, prevents milk stasis/bacteria growth  Septic pelvic thrombophlebitis---2-4days post CHAPTER 27 – WOMENS HEALTH//STI’s  Bacterial STIs o Chlamydia trachomatis  Most common/fastest spreading  Often silent/diff to diagnose  Asymptotic is pregnant women  Often coexist with gonorrhea  Can lead to PID(tubal scarring), infertility or ectopic pregnancy if untreated **  Yearly screening sexually active women >25  Screen in 1st prenatal and 3rd trimester –if <25 or high risk  Risks---multiple partner & unprotected sex  Findings---  Male= urethral discharge(mucoid,watery), dysuria  Female=dysuria, urinary frequency, spotting/postcoital bleeding o Mucopurulent endocervical discharge o Easily induced endocervical bleeding  Lab tests----  Urine culture-male  Endocervical-female  Care----  Take entire prescription  Identify/treat all partners  Pregnant clients retest 3 wks after treatment  Report cases of disease  Meds----  Azithromycin or amoxicillin o Gonorrhea  Perinatal complications  PROM, preterm birth, chorioamnionitis, neonatal sepsis, IUGR, maternal post partum sepsis  Can be spread genital-genital-anal-oral-newborn delivery  Typically asymptotic Can lead to PID and infertility  Yearly screening>25, 1st prenatal and 3rd trimester  Risks----multiple partners, unprotected sex  Findings----  Male=dysuria, urethral discharge  Female=dysuria, vaginal bleeding btwn periods, dysmenorrhea, yellow/green discharge, easily induced endocervical bleeding  Labs----  Urine culture=male  Endocervical=female  Care----  Education  Identify/treat all partners  Erythromycin following delivery for infant  Report disease  Avoid intercourse treat partners simultaneously  Meds-----Ceftriaxone and azithromycin PO  Pelvic inflammatory disease (PID) o Increased risk for ectopic pregnancies, infertility and chronic pelvic pain o Risks---  IUD  Douche products  Untreated STIs o Symptoms---asymptotic or subtle  Pelvic pain, pain, fever, purulent discharge, nausea, anorexia, irregular vaginal bleeding  Abdominal or adnexal tenderness o Screening & labs---  Sexual history  Leukocytosis, increased ESR o Management  Serious may need to go to hospital  Will need IV antibiotics for next 48hrs  Ceftriaxone plus azithromycin or doxycycline  Cefixime plus azithromycin or doxy  Pelvic abscess may require surgical intervention  Educate on how to prevent STDs  Avoid IV drug use//HIV risks  HIV- Human immunodeficiency virus o Destructs T lymphocyteso Test in 3rd trimester—rapid if in labor and status unknown o Avoid amniocentesis and episiotomy if (+) o Don’t administer injections until after first bath o Risks----  IV drug us  Multiple partners  Hx of STIs  Blood transfusion(rare)  Gay men o Findings----  Fatigue-flu like findings  Fever  headache  Diarrhea/weight loss  Lymphadenopathy and rash  Anemia  myalgia o Tests---  Need maternal consent  Antibody screening-enzyme immunoassay  Rapid HIV antibody test—blood or urine  Screen for STIs  Obtain viral load levels and CD4 cell counts throughout pregnancy o CARE---  Counseling  Use standard precautions  Encourage immunizations  Encourage condoms  Plan for c section at 38ws is viral load >1,000copies/mL  DO NOT breast feed o Meds----antiretroviral  Nucleoside reverse transcriptase inhibitor  admin at 14wks gestation, throughout pregnancy, and before labor/c section  admin retrovir to infant at delivery and for 6wks following o Contraindications for HIV patients---episiotomy, internal fetal monitoring, forceps----all can cause bleeding  Trichomoniasis o STI o Common cause of vaginal infection o Can lead to PID and infertility o More likely to have preterm babies and LBW o Risks--- Multiple partners  Unprotected sex o Findings—  Penile itching or irritation, dysuria—urethral discharge—male  Yellow-green frothy vaginal disorder with foul odor----women  Dyspareunia (painful sex) and itching-----women  Dysuria  Strawberry spots on cervic, cervix bleeds easily o Labs//screening---  Whiff test---discharged placed on pH paper  Speculum exam  Pap smear o Diangnosis---  Whiff + if Ph>4.5  Wet mount saline prep  o Care----avoid alcohol with meds o Meds---metrodinazole tinidazole—single dose INFECTIONS----Group B streptococcus Screening at 35-37 weeks Associated with poor pregnant outcomes Effects of STIs  Premature rupture of labor  Premature labor  Dystocia  Miscarriage Fetal effects- preterm birth  Pneumonia  Systemic infection  Congenital infection TORCH infection---toxoplasmosis  Contracted by consuming undercooked meats, or handling cat feces  Joint pain, rash, malaise, tender lymph nodes CHAPTER 22 INFANT FEEDINGNewborns nutrition needs  Breastfed---85-100kcal/kg/daily  Formula---100-110kcal/kg/day  May lose 10% of birth weight Breast milk composition  Colostrum=="liquid gold”  Transitional milk==like 2% yellowish white  Mature milk Benefits to breast feeding---infant  Less allergies develop  Immunologic properties  decreased infections  lower incidence of obesity/diabetes/SIDS  meets specific needs of baby  easily digested  unlikely to be contaminated  less likely to over-feed  constipation less likely Mother benefits  oxytocin releases enhances uterine involution  less blood loss  resumption of ovulation delayed  decrease cancer risk  mom can rest during feeds  burns calories  skin ti skin  convenient(traveling)  cheaper Formula  cows milk to compare with breast o reduced protein o remove sat fats  formula for special needs infants o soy/protein hydrolysate  Factors influencing choice of feeding o Support from others o Cultural influenceso Employment o Staff knowledge Normal breastfeeding  Prolactin-activate milk production. Suckling increased prolactin levels  Oxytocin-increases in response to nipple stimulation and causes milk ejection Nursing care for breastfeeding  Teaching positions  Latching on  Suckling pattern  Removal from breast  Frequency and length Common concerns  Sleepy  Nipple confusion  Suckling problems- poorly positioned nipple  Infant complications o Jaundice o Prematurity –mother should self express milk o Illness and congenital defectsEngorgement  Breast o Heat o Pump/breastfeed o Pain meds o Supportive bra o Cold compress between feedings can help with engorgement  Bottle-feeding o Cold o Avoid stimulation o Pain meds o Supportive tight fitting bra for first 73hrs Interventions to assist with breastfeeding  Pumps  Breast milk storage  Shells---for inverted/weird nipples  Shieds  Seek assistance from lactation consultant CHAPTER 18 POSTPARTUM COMPLICATIONSPostpartum hemorrhage  Loss of >500mL – vaginal delivery  >1000mL c section  decrease in hct >10% since admission Assess 4 T’S  Tone  Trauma  Tissue  thrombin  risks--- o infection o prolonged labor o meds o uterine inversion o precipitate labor or delivery or operative delivery o multiparity o clothing disorder o uterine leiomyomas—fibroids o placenta abnormalities o C-section  Early hemmorhage o Uterine atony o Trauma o Retained tissue o Abnormal coagulation  Late o Subinvolution o Retained tissue o Infection  Signss o Fundus soft or boggy o Hard to locate fundus o Firm with massage but then loses tone o High fundus o Excessive lochia---1pad 15min o Excessive clots  Meds----uterotonics o Methylergonovine (HTN)and carboprost(don’t use in asthma,MAD DIARRHEA) most common o Oxytocino Misoprost—Can be rectal o Stimulate uterine contractions Retained placental fragments  Reventable through inspection of placenta after delivery  Risks o Attempts to deliver placenta prior to separation o Manual removal o Abnormal implantation o previous c section o Uterine leiomyomas  Thromboembolic disorders o Most common during pregnancy/post  Superficial venous thrombophlebitis  Deep vein thrombosis  Pulmonary embolism o Primary cause  Venous stasis  Hypercoaguable blood  Injusry to vessel Late postpartum hemorrhage  Failure of uterus to involve  Signs o Prolonged discharge of lochia o Excessive uterine bleeding o Possibly profuse hemorrhage o Pelvic pain/heaviness o Backache o Fatigue o Uterus larger and softer than norm Hypovolemic shock Peurperal infection—infection after childbirth  Endometritis-uterine infection  Wound infection  UTI—1-2 days post  Mastitis—2-4wks post  Septic pelvic thrombophlebitis---2-4days post [Show More]

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