NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide, Exams of Nursing

Download NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide and more Exams Nursing in PDF only on Docsity! NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide ATI Maternal Newborn Nursing Contraception Barrier Methods - Condoms - Diaphragms – must be refitted for one every 2 years by a provider or if you have gained more than 15lbs or have had a full term pregnancy or a 2nd term abortion, you must also use spermicide with every act of sex, must remain in place for 6 hours after sex - Hormone methods, nuva ring, patch, etc. side effects very similar to all they include; chest pain, SOB, leg pain, HA, vision problems, could mean potential blood clot or stroke, of PE, or HTN. Smokers are at higher risk and it is recommended they do not take oral BC Contraindications include: history of blood clots, stroke, cardiac problems, or estrogen related cancer, or if you are a smoker Depo Shot – can cause decrease in bone density, loss in calcium mineral, will need adequate calcium and vitamin D to protect bones. IUD’s – can increase risk for pelvic inflammatory disease, and uterine perforation, and will increase risk of ectopic pregnancy, LOOK for change in string length, foul smelling discharge, painful intercourse, fever, chills, etc Infertility – inability to conceive after trying for at least 12 months (1yr) -work up will be done after that, will start with male (usual 40% of time issue is with them) -test on female, any test that has dye ensure no shellfish allergy or iodine Pregnancy Signs 3 Signs 1. Presumptive – can be explained by a reason other than pregnancy 2. Probable – abd enlargement, etc 3. Positive – very distinct, fetal heart tones, or fetus on US, feel movement Negals Rule – tells you when your due date is based on last menstrual cycle (JUST ADD 9 months and 1 week) GTPAL Gravidity - # of times woman has been pregnant including current pregnancy Term births - # of pregnancies that have gone to 38wks or more NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Preterm births - # of pregnancies that have gone before 38wks Abortions or miscarriages - # of Living children - # of Weight Gain and Nutrition during Pregnancy NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide -symptoms are painless, bright red, vaginal bleeding during 2nd or 3rd trimester, VERY DANGEROUS Aburpta Placento – symptoms will be intense localized uterine pain with dark red vaginal bleeding *Yeast infections are very common during pregnancy Incompetent Cervix – cervix does not stay closed causing miscarriage *if woman is known to have IC she will have a cerclage done (closes cervix) usually removed at 37wks. Hyperemesis – excessive N/V well past 12 weeks, interventions include B6 admin, and antiemetic meds IF iron deficiency anemia – provider will order iron supplements (take with food rich in vitamin C) Gestational Diabetes If woman has this she is at high risk for developing diabetes after pregnancy, oral meds usually contraindicated, woman will likely have to use insulin to control sugar levels * test occurs 24-28wks of gestation with a 1hr glucose tolerance test, NO fasting required for initial test, woman is given 50 grams of oral glucose and then 1hr later test BS level, IF over 130 or 140 they will proceed with next test, OGTT (oral glucose tolerance test) this DOES require fasting will take fasting glucose level then give 100 grams of glucose and then test BS levels at 1hr, 2hr, and 3hr Gestational Hypertension – caused by vasospasm which is caused by poor tissue perfusion, there is NO proteinuria Mild Preeclampsia – GH with addition of proteinuria Severe Preeclampsia – BP that is 160/110 or greater, proteinuria, elevated serum creatinine, visual disturbances, hyperreflexia, etc. Eclampsia – severe preeclampsia with onset of seizures HELP syndrome – is a variant of GH in which hepatic dysfunction comes in H: hemolysis – resulting in anemia and jaundice EL: elevated liver enzymes, resulting in high ALT or AST LP: low platelets – less than 100,000/mm3 resulting in thrombocytopenia Hypertension Meds: methyldopa, nifidepine, labetalol, and magnesium for eclampsia *helps prevent seizures but monitor patient for mag toxicity: no reflexes, low urine output, low respirations and LOC and dysrhythmias (calcium gluconate is antidote) Pre-term Labor – cervical changes from 20-37wks, vag swab to see if it has fetal fibronectin, meds NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide include nifidipine, indomethacin Premature rupture of membranes – major causes of infection Physiological changes with impending labor -back ache NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide -small amount of weight loss (1-3lbs) -lightening, when fetal head descends into pelvis -contractions -bloody show -energy burst - GI changes - rupture of membranes (check with nitrozine paper) 4 stages of Labor 1. Onset – until complete dilation of cervix (10cm) 2. Fully dilated – birth of baby 3. Birth of baby – delivery of placenta 4. Delivery of placenta – moms vitals return to baseline Phases of Labor Latent – 0-3cm, mom usually talkative and eager Active – 3-7cm, mom restless, anxious, feeling helpless Transition – 7 – 10cm, mom over it, urge to push, or poop (increased rectal pressure) Meningitis – viral and bacterial (more dangerous), 2 vaccines that largely prevent 1. PCV 2. HIB, symptoms include photophobia , N/V, irritability, HA, in newborns – poor muscle tone, weak cry, refusal to eat, and may V/D, bulging fontanels are a LATE sign of meningitis 3m – 2yrs can see seizures or high pitched cry, fever, irritability, bulging fontanels, 2yr – adolescents neck rigidity, and seizures * + buziskis sign etc. Rye Syndrome: can cause levels dysfunction of cerebral edema, associated with giving children aspirin for fever Seizures – risk factors – cerebral edema, fever, trauma or hemorrhage, brain tumor, or lead poisoning, hypoglycemia, and electrolyte imbalances Post-Partum Depression – 1. Post-partum blue – common, expect to last up to 10 days, symptoms include tearfulness and insomnia, lack of appetite, feeling of backing out 2. Postpartum depression – occurs within 6months of delivery and includes persistent feelings of NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide -reduces risk of infection, helps brain growth, inexpensive and convenient and can reduce SIDS -first 6months, no food other than breast milk/formula -6months first food usually iron fortified rice cereal, no solids before 6months of age NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Begin breast feeding immediately and can expect some uterine cramps while breast feeding due to release of oxytocin 15-20 minutes per breast and empty breast during breast feeding Diaper output best go to for gauge of baby getting enough milk from mom, should be voiding 6-8 diapers a day. Breast milk can be stored at room temp for 8 hours, must be stored in sterile bottles in fridge, and used within 8 days or frozen up to 6months or deep freezer for 12 months, thawing milk with fridge for 24 hrs, no microwave and do not refreeze Formula – fridge for 48hrs discard any unused portion Put baby to sleep on back , no SIDS Newborns sleep 17 hours a day/first month Cord care – keep dry and above diaper, sponge baths only until cord fall off, 10-14 days Circumcision care – petroleum jelly with each diaper, change every 24hrs, 0 tub bath til after healed Rear facing care seat middle of backseat until age 2 Newborn complications Hyperbilirubinemia – high serum bilirubin levels resulting in jaundice, 1. Physical – begins starts around 24 hours resolves around 7 days due to break down of fetal blood cells, 2. Pathological – lasts longer than 7 days, 3. Bilirubin encephathy – cerebral palsy, MR. *note time jaundice sets in* Questions: 32 weeks of gestations experiencing preterm labor should plan to administer betamethasone IM, glucocorticoid, stimulate fetal lung maturity and thereby prevent respiratory depression. Lab test to confirm pregnancy will be urine test for the presence of human chorionic gonadotropin. Palpable fetal movement is a positive sign of pregnancy. The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma. A hydatidiform mole or a molar pregnancy is a benign proliferative growth of the chronic villi, NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide which gives rise to multiple cysts. The products of conceptions transform into a large number of edematous, fluid filled vesicles, as cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters. The nurse should inform the client that taking prescription antiviral medication every day decrease the risk of transmission of HIV to her newborn. NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Exposure to cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding. A client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus. Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborns cues and feed her 8 to 12 times per day. To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborns head to one side when he is sleeping or falling asleep. The newborns arm and leg should extend outward to the same side that the nurse turned his head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months. The nurse should administer methylergonovine, an ergot alkolid, which promotes uterine contractions. Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective. The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding, and a firm fundus to identify a cervical laceration. Every newborn born in the US should receive erythromycin ophthalmic ointment to prevent gonorrhea or chlamydial infections that the newborn can contract during birth. When the clients fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia. Uterine atony risk factors – mag sulfate infusion, distended bladder, and prolonged labor Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full- term newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead. A newborn who has congenital hip dysplasia can have limited abduction because the head of the femur might have slipped out of the acetabulum. The nurse should administer Rh(D) immune globulin to a client who is pregnant and has Rh- negative blood at 28 weeks of gestation. Rh(D) immune globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBC’s in the maternal circulation and block maternal antibody production. NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix is dilated. If administered too close to the time of delivery the analgesic could cause respiratory depression in the newborn. The nurse should obtain a vaginal/anal group B strep (GBS) culture at 35 to 37 weeks of gestation to screen for GBS. NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Mag Sulfate can cause respiratory and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression. Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication. O2 therapy can cause retinopathy of prematurity, especially in preterm newborns, it is a disorder of retinal blood vessel development in the premature newborn. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. It can reduce vision or result in complete blindness. Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be firm at midline. A deviated, firm fundus indicates a full bladder. The nurse should instruct the client to void. A contraction interval is how often a uterine contraction occurs. The nurse will measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 minutes is = to contractions every 4 minutes. Clients who receive anesthesia before the active phase of labor usually find the progression of labor starts to slow. The medication depresses the CNS therefore it will take longer for the cervix to dilate and efface. The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics admin during labor. Oxytocin is contraindicated for clients who have active genital herpes infection. Vena cava syndrome or hypotension occurs in clients who are pregnant upon assuming a supine position. It is caused by the compression of the inferior vena cava by the gravid uterus with a consequent reduction in venous return. A side lying position promotes uterine perfusion and fetoplacental oxygenation. Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. IT is important to assess the newborns blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels return. STUDY CHAPTER 9 NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Nursing Care Assess for bleeding, leakage, or contractions Assess fundal height Perform Leopold maneuvers NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Refrain from preforming vaginal exams Admin IV fluid, blood products, and meds as prescribed. Corticoidsteriods, such as betamethasone to promote fetal lung maturation if early delivery is antic pated Have O2 equipment available in case of fetal distress Client Ed Bed rest Nothing inserted vaginally FHR can be detected at early appointments by ultrasound. The hearbeat can be heard by Doppler late in the first trimester. Listen at the midline, right above the symphysis pubis, by holding the Doppler firmly on the abdomen. During the second trimester, there are rapid physical changes due to the enlargement of the abdomen and breasts. Skin changes can also occur, such as stretch marks and hyperpigmentation. Skin changes: chloasma: an increase of pigmentation of the face, linea nigra: dark line of pigmentation from the umbilicus extending to the pubic area, striae gravidarum: stretch marks most notably found on the abd and thighs. Discontinue oxytocin if uterine hyperstimulation occurs. Clinical findings of uterine hyperstimulation include: Contraction frequency more often than every 2 minutes Contraction duration longer than 90 seconds Contraction intensity that results in pressures greater than 90mmhg as shown by IUPC Uterine resting tone greater than 20 mmhg between contractions No relaxtion of uterus between contractions Indications for an amnioinfusion -oligohydraminos (scant amount or absence of amniotic fluid) caused by any of the following: uteroplacental insufficiency, premature rupture of membranes, post maturity of the fetus. -fetal cord compression secondary to post maturity of the fetus (macrosmic, large body) which places NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide the fetus at risk for variable deceleration from cord compression. Newborn Reflexes Sucking and rooting reflex NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Do notes protect against stis Risks: risk of ectopic pregnancy occurs Vasectomy (male sterilization) Client Ed Following the procedure, scrotal support and moderate activity for a couple of days is recommend to reduce discomfort Sterility is delayed until the proximal portion of the vas deferens is cleared all of remaining sperm (apx. 20 ejaculations) Alternate forms of birth control must be used until the vas deferens is cleared of sperm Follow-up is important for sperm count Advantages Permanent contraceptive method Procedure is short, simple, and safe Sexual function is not impaired Disadvantages Requires surgery Reversal is possible but not always successful Does not protect against STIs Complications: rare, but can include bleeding, infection and anesethia reaction Nonpharmalogical pain management Interventions: Cognitive strategies Childbirth ed Childbirth prep methods such as Lamaze and patterned breathing exercises, promote relaxation and pain rmanagement NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Hypnosis Biofeedback Sensory Stimulation Strategies Aromatherapy NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Breathing techniques Imagery Music Use of focal points Subdued lighting Cutaneous Stimulation Strategies Therapeutic touch and massage Walking Rocking Effleurage: light, gentle circular stroking of the clients abdomen with fingertips in rhythm with breathing during contractions Sacral counterpressure: consistent pressure is applied by the support person using the heel of the hand or fist against the clients sacral area to counteract pain in the lower back Application of heat or cold TENS therapy Hyrothreapy Acupressure Frequent maternal positon changes to promote relaxations and pain relief -semi-sitting -squating -kneeling -kneeling and rocking back and forth -supine postion only with the placement of a wedge under one of the clients hips to tilt the uterus and avoid supine position. Pudendal block Consists of local anesthetic, such as lidocaine or bupivacaine, administered transvaginally into NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide interpreted as reactive if the FHR is a normal baseline rate with moderate variability, accelerates at least 15/min (10/min prior to 32 weeks) for at least 15 seconds (10 seconds prior to 32 weeks) and occurs two or more times during a 20-min period. (6 .1)●Nonreactive NST is a test that does not demonstrate at least two qualifying accelerations in a 20-min window. If this is so, a further assessment, such as a contraction stress test (CST) or BPP, is indicated NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide RN MATERNAL NEWBORN NURSINGCHAPTER 16CompliCations Related to the laboRpRoCess107UNIT 2INTRAPARTUM NURSING CARESECTION:COMPLICATIONS OF LABOR AND DELIVERYCHAPTER 16 Complications Related to the Labor ProcessComplications occurring during the labor process are emergent and require immediate intervention in order to improve maternal fetal outcomes. this chapter explores prolapsed umbilical cord, meconium-stained amniotic fluid, fetal distress, dystocia (dysfunctional labor), precipitous labor, uterine rupture, and anaphylactoid syndrome of pregnancy (amniotic fluid embolism).Prolapsed umbilical cordA prolapsed umbilical cord occurs when the umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix. This results in cord compression and compromised fetal circulation.ASSESSMENTRisK FaCtoRs●Rupture of amniotic membranes●Abnormal fetal presentation (any presentation other than vertex [occiput as presenting part])●Transverse lie: Presenting part is not engaged, which leaves room for the cord to descend.●Small-for-gestational-age fetus●Unusually long umbilical cord●Multifetal pregnancy●Unengaged presenting part ●Hydramnios or polyhydramnioseXpeCted FindinGsClient reports that she feels something coming through her vagina.PHYSICAL ASSESSMENT FINDINGS ● Visualization or palpation of the umbilical cord protruding from theintroitus●FHR monitoring shows variable or prolonged deceleration●Excessive fetal activity followed by cessation of movement; suggestive of severe fetal hypoxiaPATIENT-CENTERED CAREnURsinG CaRe●Call for assistance immediately.●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 a 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.●Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia.●Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation.●Initiate IV access, and administer IV fluid bolus.●Prepare for an immediate vaginal birth if cervix is fully dilated or cesarean section if it is not.●Inform and educate the client and her partner about the interventions.CHAPTER 1616 .1Prolapsed cord LGA or Macrosomic Newborn Risk Factors: Newborns who are postmature Maternal DM during pregnancy (high glucose levels stimulate continued insulin productions by the fetus) Fetal cardiovascular disorder of transposition of the great vessels Genetic factors NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Maternal obesity A mother who is multiparous Expected Findings: Weight above 90th percentile NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide A newborn requires additional actions at the follow-up visit. Screening tests must be repeated if they were performed before the newborn was 24hr old. APGAR scoring The increase in blood volume during pregnancy increases the workload on the heart, which can cause dyspnea, orthopnea, and pulmonary edema Cocaine use increases the risk for vasoconstriction and possible abruptio placenta. Swaddle the newborn during or immediately after the puncture is an effective technique to diminish the pain experience for the newborn. A rubella titer is obtained at the initial prenatal visit to determine immunity to rubella. Use of medroxyprogesterone (Depo Shot) causes a decrease in bone mineral density and places client at risk for development of osteoporosis. Rupture of membranes places the fetus at risk for umbilical cord prolapse; therefore the priority action after “my water just broke” is FHR. Betamethasone is given to stimulate fetal lung maturity and prevent respiratory distress. During the immediate postpartum period, the greatest risk to the client is bleeding. The amount of lochia can assist the nurse in determining if excessive bleeding is occurring. The nurse should observe for postpartum hemorrhage. Suprapubic pressure can be used to attempt to push the shoulder to go under the symphysis pubis and pass through the birth canal. Prolonged contractions reduce the blood flow to the placenta and result in FHR decelerations, therefore, oxytocin should be discontinued. To avoid burns to the infant, the hot water heaters should be set no higher than 49 degrees, 120F Hands and knee position can help relieve back pain and the fetus rotate. A postpartum client who is breastfeeding should increase her daily caloric intake by 330 calories per day. Leopold maneuvers help to assess the position of the fetus to best determine the optimal placement for the fetal monitoring transducer. A positive oxytocin-stimulated contraction test indicates an adverse reaction by the fetus and should be reported to the provider. The use of an internal electrode is contraindicated for a client who is using jet therapy. NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide When assessing a newborn expected findings include: breast nodule 6mm, overlapping suture lines, and lanugo over the shoulders. When the clamp method is used for circumcision petroleum jelly should be applied around the glans during each diaper change. NURSING BS NURSING BS C471 ATI Maternal Newborn Nursing study guide Reporting of tingling sensations in the fingers indicate that the client is hyperventilating. This causes respiratory alkalosis, resulting in dizziness, tingling of the fingers, and circumoral numbness. This can be reversed by having the client breathe into her cupped hands or placing a paper bag tightly around her mouth and nose to breathe carbon dioxide. Epigastric pain is an indicator of hepatic involvement and is a clinical manifestation of serve preeclampsia, this should be reported to the provider immediately. IF left untreated, the condition can be life-threatening for the mother and the fetus. Amniotic fluid index (AFI) is one of the variables included in the BPP. AFI measures the amount of amniotic fluid present in the uterus. Adequate amniotic fluid is important for the maintenance of placental perfusion. Neonatal sepsis signs are temp instability, tachypnea, nasal flaring, and irritability Premature rupture of membranes is a risk for the client who has gonorrhea. For late decelerations the nurse should first reposition the client on her side, increase the maintenance fluid, palpate the uterus to assess for tacysystole. And admin O2. An adverse effect of terbutaline is hypokalemia A client who has ITP will have an autoimmune response resulting in a decreased platelet count.