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Maternity ATI key points

Maternal & Newborn Nursing Lab (University of New Hampshire)

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Chapter 1: Contraception

Chapter 2: Infertility

 Female: >35 yrs, more than 1 yr w/o contra, >35 only 6 mos, endocrine dx,

pelvic/abdominal procedures, ob: spontaneous abortions, hormone levels, uterine

contours, scar tissue, intercourse hx, STIs, environmental hazards, alcohol,

tobacco, heroin, methadone,, dx: pelvic exam, hormone analysis, postcoital test,

US, hysteroscopy, laprascopy, hysterosapingography

 Male: mumps, same as above, semen analysis, US

 Stress that it is nobodies fault

 Methods of conception: IVF, intrauterine insemination, gamete intrafallopian

transfer, donor oocyte, donor embryo, gestational carrier, surrogate mother, donor

sperm

 Genetic counseling: recommended

Chapter 3: Expected Physiological Changes During Pregnancy

 Signs of pregnancy: presumptive: amenorrhea, fatigue, N/V, urinary frequency,

breast: dark areola, quickening (16-20 wks,) uterine enlargement, probable:

abdominal enlargement, Chadwick: blue vagina, Goodell: soft cervix,

Ballottement: rebound of fetus upon palpation, Braxton-Hicks, positive pregnancy

test, positive: FHR, ultrasound, movement felt by provider; Serum tests: hCG (7-

8 days)

 EDD: Naegle’s Rule: LMP minus 3 months plus one week plus one year, 18-32

weeks approximately matches fundal height, grava: number of pregnancy, parity:

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number of pregnancies that fetus aged to 20 wks, GTPAL: G: grava, T: term birth

(38 wks) P: preterm (37 wk or less) Abortion (prior to 22 wk) L: living children

 Physio Changes: repro: uterus grows, CV: CO inc 50%, BV inc, HR inc, resp:

lungs smaller, RR increase, MS: relaxin, GI: N/V/C, renal: frequency, endocrine:

placenta makes hCG, progesterone, estrogen

 Ax: BP: slight increase, pulse: slight increase, RR: slight increase, may hear S3,

36 weeks fundus reaches xiphoid, SOB

Chapter 4: Prenatal Care

 Ax: hx, birth plan, medical hx, psych, care begins @ 12 wks, monthly appt from

16-28 wks, q2 wks 29-36, qwk 36 wks until birth

 Lab tests: blood type, Rh, irreg antibodies, Rh neg Coombs’ test @ 24/38 wks,

Rhogam after amnio… CBC, Hgb, Hct, Rubella, GBS (35-37 wks,) Hep B,

urinalysis, GTT (>140 requires follow up,) PPD, CXR, HIV, MSADP (down

syndrome, TORCH

 Education: avoid OTC meds, supplements, prescription meds unless talking to

provider, tobacco (low birth weight,) alcohol (birth defect,) exercise q30/day, no

hot tubs or saunas, 8-10 glasses of water/day, emotional liability, ambivalence is

normal, conflicting feelings

o First tri: physical and psych changes, discomforts, complications, growth,

exercise, lab testing

o Second tri: benefits of BF, discomforts, sex, posture, clothing, seat belt,

complications (GDM, PROM, HTN,) birth plan, child birth classes

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o Third tri: childbirth prep/classes, relaxation techniques, TENS, music,

infant/PP care, kick counts two-three times/day, 2 hr post meal or bed

time, less than 3/hr or none for 12h is danger

 Discomforts: N/V: crackers before rising, no spicy foods, avoid empty tummy,

breasts: tight, supportive bra, urinary freq: Kegel’s, UTI: cotton undies, water,

retaining urine is no good, heartburn: sit up after meals, small feels, not too full or

too hungry, leg cramps: extend the leg, keep knee straight, dorsiflexion of foot,

sleep in LL position, nasal stuffiness normal d/t estrogen

 Danger Signs: burning on urination, hyperemesis, diarrhea, fever (tachy in baby,)

ab cramp, vaginal bleeding, gush of fluid from vagina, changes in fetal activity,

headaches, dysuria, blurred vision, edema of face and hands, epi pain, fruity

breath

Chapter 5: Nutrition During Pregnancy

 Gain 25-30 lb during preg, 1-2 kg (2.2-4.4 lb) first tri, 0.4 kg (1 lb) per week after

that. Underweight women 28-40 lb, overweight: 15-25 lb.

 Increase calories 340/day second tri, 462/day third tri, 450-500 for BF moms, 400

mcg folic acid non preg, 600 mcg/day preg woman, iron (vit C aides in

absorption,) calcium: 1,000 mg/day >19 yrs old, 1,300/day <19 yrs old, no more

than 200 mg of caffeine/day

 Risk factors: pica: eating non nutritive foods, vegeterains need protein, calcium,

iron, zinc, B12; ED, do not take nausea meds (call provider,) ginger may help,

frequently eat q2-3h, PKU is dangerous to fetus, low in phenylalanine, high in

protein foods avoided, aspartame avoided, monitor carbs and limits sweets

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Chapter 6: Assessment of Fetal Well Being

 Ultrasound: 20 min, full bladder for external, 2D, 3D, 4D (video,) why? Confirm

preg, gestational age, growth, site of placenta, confirm viability, rule out

anomalies, amniotic fluid volume, movement. Edu: no risk, drink 1 qt water

 BPP: US w/ characteristic measurements, why? NR NST, oligo/polyhydraminos,

hypoxia. Variables: FHR: reac: 2, NR: 0, RR: 1> 30 sec in 30 min: 2, ab/no: 0,

body movements: 3 movements in 30 min: 2, less than 3: 0, tone: extension and

flexion: 2, low, lack of, or none: 0, amniotic fluid: 1 pocket >2cm in 2 places: 2,

absent, less than 2 cm: 0… score: 8-10: norm, 4-: abnormal, >4: suspect fetal

demise

 NST: watch FHR for 30 min, reactive: baseline, mod variability, accelerates at

least 15/min for 15 sec, 2 or more times in 20 m, press button when fetus moves

 CST: contractions, watch FHR, pattern of 3 contract in 10 mins that last 40-60

sec, nipple or oxytocin, watch for s/s labor (accidental) negative: no decels,

positive: uteroplacental insufficiency

 Amniocentesis: after 14 wks, empty bladder, high AFP presence: neural tube

defects, spina bifida, low AFP: chromosomal dx (down syndrome,) hydantiform

mole, assess for leakage of fluid, bleeding, contractions, baby not moving

 Lung Test: Lechithin: 2:1 ratio, lungs of baby work

 Percutaneous Umbilical Blood Sampling: cordocentesis, evaluates fetal blood and

blood supply

 Chorionic Villus Sampling: 1st tri alternative to amniocentesis, fill bladder

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 Quad Marker Screening: hCG, AFP, estriol, Inhibin A: low AFP down syndrome,

high AFP: neural tube defects, high ACG, inhibin A: down syndrome, low estriol:

down syndrome

 Maternal Serum AFP: high: neural tube defect, open abdominal defect, low: down

syndrome

Chapter 7: Bleeding During Pregnancy

 Spontaneous abortion: prior to 20 weeks or <500g, threatened (may be okay,

BEDREST,) inevitable, incomplete (D&C,) complete (toilet,) missed (cervix too

tight) term is miscarriage: don’t offend, bleeding varies

 Ectopic pregnancy: ovum implanted in fallopian tube, IUDs are RF, stabbing pain

in abdomen, tender lower quadrants, scant dark red or brown spotting, red

bleeding if rupture, methotrexate or salpingostomy: salvage tube, -ectomy:

remove tube

 Gestational Trophoblastic Disease: grape like clusters, rapid growth (molar

pregnancy,) complete mole: paternally derived, no fetus, placenta, membranes,

fluid, no placenta to receive blood; partial mole: maternal and paternal, abnormal

embryonic parts, anomalies are present, excess vomiting, rapid uterine growth,

dark brown blood, or bright red blood, hCG levels are high, Rh women need

Rhogam post removal, contraception for follow up care, f/u d/t choriocarcinoma

 Placenta previa: partial or complete coverage of cervical os: complete (she’s

there,) incomplete (partially there,) marginal (barely there,) painless bright red

bleeding during second or third tri, Kleihauer-Betke test: fetal blood in maternal

circ, NO VAGINAL EXAMINATIONS, C-section imminent, bed rest

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 Abruptio placentae: premature separation of placenta from uterus, partial or

complete, after 20 weeks, sudden back pain with dark red bleeding, contractions,

hypovolemic shock, IVF, oxygen, VS, FHR

 Vasa previa: velamentous cord: cord vessels begin to branch at membranes then

course to placenta, succentriate cord: placenta has divided into two or more lobes,

not one mass, battledore: marginal insertion

Chapter 8: Infections

 HIV/AIDs: destruction of T lymphocytes, avoid amnio and episiotomy, do not

blood test or inject until first bath is done, confirmed by Western blot test or

immunofluorescence assay, retrovir: 14 wks, throughout preg, to baby post birth

and 6 wks following, do not BF

 TORCH: toxoplasmosis: raw meat, cat feces, rubella: children w/ rashes, mom is

pos during preg, cytomegalovirus: droplet, semen, vaginal, breast milk, urine,

feces, herpes: direct contact of active lesions, rubella: immunize post birth if neg

titer, do not get pregnant

 GBS: culture 35-37 wks, admin antibiotics PRN, penicillin G, ampicillin

 Chlamydia: asymptomatic, leads to PID, urethral discharge, dysuria, frequency

spotting, meds: erythromycin to all babies post birth (1hr post birth)

 Gonorrhea: genital to genital/oral/anal contact, leads to PID, cefrixaone IM and

azithromycin PO

 Syphilis: primary: cahncre, secondary: skin rashes, tertiary: damage to internal

organs, penicillin G IM x1, abstain from sex until sores heal, test partners, safe

sex

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 HPV: genital warts, oral/anal/vaginal sex, C-sec recommended, cream or acid to

treat, Pap smear to dx if cancerous cells are suspected

 Trichomoniasis: STI, penis to vagina, vagina to vagina, lead to PID, more likely

to deliver preterm or baby with LBW (5.5 lbs) penile itching, dysuria, frothy

discharge, strawberry spots, pH >4.5, metronidazole: orally, single dose, avoid

alcohol, treat partners

 Bacterial vaginosis: most common, PID, infertility, douching is a RF,

metronidazole, avoid tight fitting clothes, cotton lined undies

 Candidasis: fungal, thick creamy white cottage cheese like discharge, vulvar or

vaginal erythema, inflammation, white patches, gray patches on tongue and gums

(baby), fluconazole, topical for pregnant women

Chapter 9: Medical Conditions

 Cervical insufficiency: expulsion of products of conception, cerclage (surgical

closure of cervix) done at 12-14 wks, removed around 37, avoid intercourse,

tampons, douching

 Hyperemesis gravidarum: excessive N/V, past 12 wks, 5% body wft loss, assess

for urinalysis of ketones, acetones, urine specific gravity, chemistry profile (met

acidosis due to starvation and met alkalosis d/t excess vom) throid test, CBC, IV

lactated ringer’s for hydration, B6 supplement, antiemetic meds, advance to clear

liquids after 24 h w/ no vomiting, advance diet as tolerated, toast, crackers,

cereals, then soft diet, then normal, enteral nutrition may be indicated in serious

cases

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 Iron-deficiency anemia: inadequate iron stores, no dietary iron, pica, Hgb: <11,

Hct: <3, increase iron, prenatal vitamin has 30 mg typically, may need 60-120,

legumes, green leafy vegetables, meat, ferrous sulfate (take w/ vit. C [orange

juice])

 Gestational Diabetes Mellitus: ideal BG: 70-110, 50% will develop Type II,

hypogylc: nervous, headache, weak, irritable, hungry, blurred vision, tingling of

mouth or extremities; hyperglyc: polydipsia, polyphagia, polyuria, nausea, ab

pain, flushed dry skin, fruity breath, GTT: 130-140 come back for 3 hr GTT

 Hypertension: r/f: placental abruption, kidney failure, hepatic rupture, preterm

birth, fetal/maternal death

o Gestational: after 20th week, 140/90 or greater @ 2 diff times, 4 hrs apart,

no proteinuria, edema doesn’t matter, BP return to baseline in 6 weeks

after baby is out

o Milk preeclampsia: GH w/ proteinuria 1+, transient headaches, edema,

irritable

o Severe: BP 160/110, proteinuria 3+, elevated creatinine (>1.1,) cerebral or

visual disturbances, hyperreflexia, ankle clonus, pulm/cardiac

involvement, extensive peripheral edema, hepatic dysfunc, epigastric pain,

thrombocytopenia, eclampsia: onset of seizures and coma, preceded by

headache, epigastric pain, hyperreflexia, hemoconcentrations

o HELLP: h: hemolysis, EL: elevated liver enzymes, LP: low platelets (less

than 100,00)

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 Assess: HTN, proteinuria, periorbital facial hand abdominal edema, vomiting,

oliguria, hyperreflexia, RUQ pain, dim LS, seizures, jaundice, monitor BP

 Meds: methyldopa, nifedipine, hydralazine, labetalol, avoid ACE and ARBs, mag

sulfate: anticonvulsant, depresses CNS and lowers BP, flushed, hot, sedated,

monitor BP, HR, RR, DTR, LOC, urinary output, headache, epi pain, fluid

restriction of 100-125 mL/hr, monitor for urine 30 mL/hr, no DTR, no urine, RR

<12, dec. LOC is toxicity, d/c infusion, admin calcium gluconate

Chapter 10: Early Onset of Labor

 Preterm labor: uterine contractions, cervical changes 20-37 weeks, FFP in vaginal

secretions can be d/t inflamed placenta, restrict activity, ensure hydration, ID/treat

infx, (fetal tachycardia indicates this)

 Meds: nifedipine: CCB, suppress contractions, do not admin w/ mag sulfate or

beta-2 adrenergic agonist, adequate hydration, mag sulfate: tocolytic: suppresses

smooth muscle (contractions,) contraindicated in vaginal bleeding, dilation >6 cm,

corioamnionitis, greater than 34 wks gestation, acute fetal distress, d/c for pulm

edema, d/c for toxicity, indomethacin: NSAID that blocks prostaglandin

production, suppresses uterine contractions, do not exceed 48 hr trtmnt, only if

GA <32 wks, w/ food, betamethasone: glucocorticoid IM x2 24h apart, needs 24h

to be effective, fetal lung maturity and surfactant (24-34 wks) deep gluteal muscle

 Premature rupture of membranes (PROM) and Preterm premature rupture of

membranes (PPROM:) prom: rupture 1 hr or more prior to onsent of true labor,

pprom: after 20 weeks, prior to 37 wks, r/f infx, monitor FHR immediately if

membranes rupture (decel,) pos nitrazine (blue) paper, VS q2h, hydration

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 Meds: ampicillin: infx (commonly chorioamnionitis,) betamaethasone

 Edu: don’t put anything in your vagina, if you’re less than 3 cm you’re going

home, no sex, no tubs, wipe from front to back, call about a temp that is greateer

than 100F, limited activity, stay hydrated

Chapter 11: Labor and Delivery Processes

 First stage: 12.5 hr, latent: 0-3 cm, active: 4-7 cm, transition: 8-10 cm

 Second stage: 30 m- 2 hr, full dilation, pushing

 Third stage: delivery of neonate

 Fourth stage: placentas delivery

 Physiological changes: backache: low, dull, weight loss, lightening (fetal head

drops,) bloody show, energy burst (nesting,) GI changes (N/V/I,) cervical ripening

(soft and open, effaced, dilated,) ROM (transition phase,) amniotic fluid (500-

1,200 mL, deep blue, pH 6.5-7.5)

 5 P’s: passenger: presentation: part of fetus entering inlet first, lie: fetal to

maternal axis, attitude: body part position, flexion or extension, position:

relationship of presenting part to maternal pelvic quadrant, station: 0 ischial

spines, minus above, plus below, passageway: pelvis, cervix, vagina, and

introitus, powers: contractions cause effacement (shortening and thinning) and

dilation (opening of cervix and canal,) involuntary urge to push, position: gravity

can aide, psychological response: stress and pain can impair progress

 Pre: Leopold’s Manuever: assess part, lie, attitude, descent, loc of heart tones,

external and internal FHR monitoring

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 Intra: VS, temp q1-2h post ROM, FHR, contractions (beginning of one to

beginning of another is ONE contraction,) duration is time of one at beginning to

end, intensity is the peak, mild, moderate, or strong, resting tone, vaginal exam:

dilation, descent of fetus, position, membranes

 Post: VS, fundus, lochia, perineum, output, bonding, VS q 15m/2hr, temp q4h/8h,

then q8h, fundus/lochia q15m

Chapter 12: Pain Management

 Epidural: monitor for hypotension

Chapter 13: Fetal Assessment During Labor

 Leopold’s, empty bladder before, supine with pillow under head, knees slightly

flexed, auscultate FHR post maneuver

 Intermittent auscultation and uterine contraction palpation: placental perfusion

dec during contraction, latent phase: q30-60m, active: 15-30m, second: 5-15m

 Continuous FHR monitoring: contraction intensity difficult to measure, palpate

fundus to ID uterine activity, frequent position changes and tocotransducer

changes, monitoring necessary post ROM

 Interpreting findings: normal HR: 110-160, variability: min: 5/min, mod:

6-25/min, marked: >25/min, cat I: 110-160, mod variability, accels: pres or

absent, early decels: pres or absent, variable or late decels: absent, cat II: tachy,

brady, minimal variability, marked variability, cat III: variable/late decels, brady

 Variable Cord

Early Head

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Acceleration Okay!

Late Placental Insufficiency

Positional changes, O2, increase fluids, etc.

Chapter 14: Nursing Care During Stages of Labor

 First stage: regular contractions to full effacement and dilation of cervix, assess

for meconium post ROM (green,) amniotic fluid ferns, deep breaths, effleurage

(circular motions on abdomen,) diversion activities, ambulate, pant-pant-blow,

bearing down when fully dilated

 Second stage: dilated cervix fully to birth, 1st-4th degree lacs, partner involvement,

promote rest between contractions, provide feedback

 Third stage: birth of fetus until placenta, fundus firm, swift gush of blood,

umbilical cord lengths, vagina fullness, APGAR, baby friendly activities, BF

releases oxytocin (encourage,) skin to skin

 Fourth stage: placenta to first 2 hours, BP, HR q15m/2hr, temp q4h/8h then q8h,

encourage voiding

Chapter 15: Therapeutic Procedures to Assist with Labor and Delivery

 External version: 36-37 wks in hospital, contra: uterine anomalies, previous C-

section, placenta previa, multifetal gestation, oligohydraminos, admin Rhogam @

28 wks to ensure no cross of blood

 Bishop score: cervical dilation, effacement, consistency, position, station, 0-3,

(total 15,) 39 wks should be greater than 8

 Cervical ripening: balloon, membrane stripping, misoprostol, void prior to, side

lying, terbutaline for hyperstimulation of uterus SQ

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 Induction of labor: amniotomy, oxytocin when fetus @ 0 station, d/c if

contractions more than every 2 min, longer than 90 seconds, no rest

 Augmentation: amniotomy: within 12 hr post procedure labor will probably

happen, r/f cord prolapse, infx, presenting part engaged prior to ROM, temp q2h

 Amnioinfusion: infused fluid will continuously leak

 Vacuum-assisted delivery: cuplike suction device on fetal head, removed after

delivery of head, monitor for hematomas and episiotomy

 Forceps-assisted birth: spoon like blades assist in delivery head, monitor for

bruising, monitor FHR (obviously)

 Episiotomy: median, out towards rectum, least painful, higher incidence of third

and fourth degree lac, mediolateral: towards left or right, blood loss is greater,

local anesthetic administer prior

 C-section: why? Malpresentation, nonreassuring FHR, placental abnormalities,

placenta previa, abruption placentae, high risk: HIV, hypertensive, DM, active

herpes, previous C-sect, dystocia, multiple gestations, umbilical cord prolapse,

thrombophlebitis post surg, ambulate early

 Vaginal birth after cesarean (VBAC:) attempting, only titled this when it happens,

trial of labor

Chapter 16: Complications Related to the Labor Process

 Prolapsed umbilical cord: umbilical cord is displaced, call for assistance, use

sterile gloved hand, apply pressure to either side of cord to the fetal presenting

part to elevate it off the cord, saline soaked towel to exposed, knee chest,

Trendelenburg, face mask (nonrebreather,) IVF

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 Meconium stained amniotic fluid: increased risk post 38 wks of gestation,

hypoxia can stimulate vagal nerve, green fluid, NICU team on standby, APGAR

 Fetal distress: FHR below 110, above 160, no variability, hyperactivity or no

activity, left side lying, oxygen, d/c oxytocin, increase IVF

 Dysotcia (dysfunctional labor:) hypotonic uterus: easily indentable, hypertonic:

cannot be indented, even between contractions, hands and knees, ambulation,

counter pressure, hypertonic: fluids, lateral position, rest, oxygen, do not give

oxytocin

 Preciptious labor: 3 hrs or less, hypertonic uterine dysfunction: nonproductive,

uncoordinated uterine contractions, too frequent or too long, no relaxation, pant

with an open mouth, side lying

 Uterine rupture: ripping, tearing, sharp pain, ab pain, uterine tenderness, IVF, O2,

immediate C-section

 Anaphylactoid syndrome of pregnancy (amniotic fluid embolism:) amniotic fluid

enters veins, clogs pulmonary veins, respiratory distress, coagulation failure,

circulatory collapse

Chapter 17: Postpartum Physiological Adaptations

 Physical changes: oxytocin released from BF, helps uterus clamp down on open

wound, dec estrogen causes breast engorgement, diaphoresis, diuresis, dryness in

vagina, dec progesterone results in inc muscle tone, non BF women: period in 4-6

weeks

 Assess: BUBBLEHE, Rhogam admin(?) uncontrollable shaking following birth

(normal)

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 Fundus: every 24h descend 1 cm, 2 weeks uterus back in true pelvis, midline,

lightly massage in circular motion, oxytocics: oxytocin, methylergonovine,

carboprost, misoprostol (hypo/hypertension,) empty bladder

 Lochia: rubra: red, 1-3 days, serosa: pink-brown, 4-10 days, alba: yellow, creamy,

11 days-4/8 wks; scant: less than 2.5, light: 2.5-10, mod: >10cm, heavy: one pad

saturated in 2 hr, excessive: one pad saturated in 15m, pooling of blood under

buttocks

 Cervix, vagina, perineum: shortens, regains form, thickening of vaginal mucosa,

muscle tone never restored, pelvic floor muscles overstretched, weak, bright red

blood trickle from episotomoy is normal, ice packs, Sitz bath

 Breasts: colostrum: 2-3 days, milk 3-5 days, assess for correct latch, early demand

BF, nbn takes in areola and nipple, contractions…

 CV: ABL: 500 mL vaginal, 1,000 C-section, diuresis and diaphoresis first 2-3

days d/t excess fluid, 500 mL of blood back into mom’s system after delivery of

placenta, hypercoaguability

 VS: 24h PP temp (100.4) not abnormal, pulse inc, encourage early ambulation

 GI: constipation not abnormal, hemorrhoids, inc apetite, soften stools (ambulate,

water, fiber, stool softener PRN)

 Urinary: loss of elasticity in bladder, void q2-3h, uterine atony: up and to the

right/left, >3,000 mL urine normal, freq voiding of 150 mL of urine is indicative

or urinary retention w/ overflow

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 MS: Joints return to pre-pregnant state, feet may stay large, disastis recti: broken

abdominal muscles, 6 wks will resolve, postpone abdominal muscles for 4 wks w/

C-section

 Immure: rubella: neg titer, SQ inject, no pregnancy for 1 mo, hep B: vax and

immune globulin 12 hr post birth, Rh: IM Rhogam 72 hr post birth, varicella: do

not get pregnant for 1 mo, TDaP

Chapter 18: Baby-Friendly Care

 Maternal identity around 4 mos post birth, dependent: taking in phase, 24-48h,

excited, talkative, review birth, dependent-independent: taking hold phase, 2-3

days, focus on baby care, need acceptance, learn and practice, independent:

letting-go phase, focus on family as a unit

 Assess: infant as family member, face to face, eye contact, skin-to-skin, smiles at,

talks to, responds to cues, lability, rooming in, reassure client

 Paternal adaption: expectations and intentions: emotionally connected w/ infant,

confronting reality: expectations might not be met, sad, jealous, creating role of

father: actively involved, reaping rewards: infant smiles, completeness

 Sibling: bring a gift and give it “from” the infant, may experience regression in

toileting, aggression toward baby, attention-seeking behaviors, let sibling be first

one to see him, one parent to spend with infant, encourage family togetherness

Chapter 19: Client Education and Discharge Teaching

 Self care

o Perineal: front to back, warm water

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o Breast: well fitting supportive bra, feed on demand, cool compresses for

engorgement after feeding, warm shower prior to breastfeeding, roll

nipples between fingers, allow nipples to air dry, if you choose not to

breastfeed: tight bra, no breast stimulation, cold compresses, cold cabbage

can be placed inside the bra

o Activity: no heavy lifting or housework for three weeks, nothing heavier

than the baby, do not cross legs, limit stair climbing, do not drive for the

first 2 weeks

o Nutrition: 2-3 L fluid day, non-lactating: 1,800-2,000 kcal/day, lactating

client increase intake by 330 calories per day

o Postpartum exercises: pelvic floor muscles w/ Kegel exercises, relax and

contract 10 times, 8 times a day

o Sexual intercourse: avoid intercourse until everything is healed and

vaginal discharge is white (alba,) 2-4 weeks, OTC lube needed 6 wks to 6

mos

o Contraception: do not take oral contraceptives until milk production is

well established

Chapter 20: Postpartum Disorders

Chapter 21: Postpartum Infections

Chapter 22: Postpartum Depression

 Postpartum blues: sadness, lack of appetite, sleep pattern disturbances, feeling

inadequate, crying, restless, headache, anxiety, 50-85% of new moms

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 Postpartum depression: guilt, inadequate feeling, anxiety, irritable, fatigue, loss,

sad, intense mood swings, wgt loss, flat affect, rejection of infant, anxiety, within

6 mos, 10-15% new moms

 Postpartum psychosis: pronounced sadness, disorientation, confusion, paranoia,

hallucinations, thoughts of harm of self or infant, 2-3 wks

 Monitor client and infant, encourage bonding, reinforce that feeling down is

normal and self limiting, reinforce compliance with med regimen, ask about

thoughts of harm to self or baby

Chapter 23: Newborn Assessment

APGAR 0 1 2
HR Absent <100 >100
RR Absent Weak Good cry
Tone Flaccid Some flexion Well flexed
Reflex None Grimace Cry
Color Blue Acrocyanosis Pink

 Measurements: wgt: 2,500-4,000g, (5.5-8.8 lb,) length: 45-55cm (18-22 in,) head:

32-36.8 cm, chest: 30-33 cm

 VS: RR: 30-60, brief 5 sec periods of apnea normal, grunting and nasal flaring

bad, HR: 110-160, full min, apical, BP: 6-80/40-50, normal temp: 36.5-37.5

(97.7-99.5,)

 H to T

o Posture: curled up, resistance to extension

o Skin: pink or acrocyanotic, desquamation (peeling,) vernix: creases and

skin folds, lanugo: ears, forehead, shoulders, milia: small white spots on

forehead (do not squeeze,) Mongolian spots: bluish purple spots on

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bottom, document, explain to parents, telangiectatic nevi: flat pink or red

arks that blanch on neck nose eyelids, fade by year 2, nevus flammeus:

capillary angioma seen on face, does not disappear, erythema toxicum:

newborn rash, no treatment, will fade

o Head: 2-3 cm longer than chest, bulging fontanels: increased ICP, caput:

localized swelling os tissues on scalp, cross over sutures,

cephalohematoma: does not cross suture line, collection of blood between

skull and bone

o Eyes: symmetry, random, jerky movements

o Ears: draw imaginary line through eyes, cartilage firm, respond to voices

o Nose: midline, sneeze a lot to clear nasal passages

o Mouth: Epstein’s pearls: small cysts on gums, palates intact

o Neck: short, thick, skin folds, no webbing, absence of head ctrl: down

syndrome (?)

o Chest: barrel-shaped, diahphragmatic breathing, intact clavicles, no

retractions, breast nodules: 3-10 cm

o Abdomen: umbilical cord odorless, no intestines out, BS 1-2h post birth

o Anogenital: anus patent, meconium 24-48 hr, rugae on scortum, testes

present, edematous vagina (labia,) vaginal blood tinged discharge normal,

hymenal tag, urine passed within 24h, uric acid crystals (rust colored piss)

o Extremities: full ROM, bowed legs, flat feet, no click on abduction of

hips, gluteal folds symmetrical, soles well lined 2/3rds of feet

o Spine: straight, flat, midline

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o Reflexes

 Sucking, rooting: stroking cheek, towards head toward side, starts

to suck, 3-4 mos will be gone

 Palmar: finger will be grasped by nbn, 3-4 mos lessen

 Plantar: finger at base of toes, nbn will grasp, birth-8 mos

 Moro: head and trunk of nbn in semisitting pstn to fall backward,

abduct arms to form “C,” birth-6 mos

 Tonic neck: turn nbn head quickly, arm and leg extend and

opposing arm flex, birth-3/4 mos

 Babinski: stroking outer edge of sole, toes fan out, birth-1yr

 Stepping: hold nbn upright, will “step,” birth-4wks

o Senses: vision: focus on objects 12 inches away, dim light, hearing:

selective listening to familiar voices, touch: tactile messages, mouth most

sensitive, taste: sweet, smell: recognize mom, habitation: they get used to

things

o Labs: Hgb: 14-28, platelets: 150-300,000, Hct: 44-64%, glu: 40-60, RBC:

4.8 x10^6, bili: 24h: 2-6, 48h: 6-7, 3-5 days: 4-6, leukocytes: 9,000-30,000

Chapter 24: Nursing Care of Newborns

 Physical Ax: VS q30minx3, qhx2, q8h, inspect umbilical cord, 6-8 h of life

systems begin to stabilize, period of reactivity: nbn awake, alert, active HR, 30

min post birth, relative inactivity: nbn will sleep, HR/RR dec 60-100 min post

birth, second period of reactivity: nbn reawakens, 2-8h post birth, last 10m-

several hrs

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 Lab tests: heel stick 24h post birth, received formula or BF for at least 24h, all

states require PKU test

 Care

o Resp: bradypnea: less than 30, tachy: greater than 60, abnormal: grunting,

crackles, wheezes, flaring, retractions, labored breathing, bulb syringe,

oxygen, mechanical suction, compress bulb prior to entering mouth, avoid

center of mouth, aspirate mouth, then one nostril, then other nostril

o Identifiation: two, permanent locks, ankle and wrist, foot pints and thumb

prints of mom, ID band verified every time baby is given to mom, photo

ID for all employees on badge

o Thermoregulation: metabolizing brown fat, becoming child causes

increase oxygen demands, conduction: loss of body heat from cooler

surface, convection: flow of heat from body surface to cooler

environmental air, evaporation: loss of heat as surface liquid is converted

to vapor, radiation: loss of heat from the body surface to a cooler solid

surface close to but not in direct contact

o Bathing: begin once temp is stabilized to 97.7 (36.5,) gloves until first

bath

o Feeding: immediately following birth, ASAP, nbn fed on demand, 3-4 hr

for bottle fed, more frequently for BF

o Sleep: 16-19 hr/day nbns sleep, safe sleep (on the back,) no loose linens or

toys, sleep ion close proximity but do not share a bed

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o Elimination: void once within 24h of life, void 6-8x/day after day 4,

meconium passed within 24-48h, BF baby seedy yellow, 3x/day first

month, at diaper change cleanse area w/ clear water or water w/ mild soap,

pat dry, avoid alcohol, zinc oxide or petroleum jelly on the bottom if you

must

o Infection control: don’t share stuff with other memebrs of family and baby

(clothes, sheets, thermometer,) scrub from fingertips to elbows

o Family education: eye contact with baby, provide edu with all nursing

care, foster sibling interxn

o Umbilical cord: clamp on 24-48h (until dry,) clean cord with water during

initial bath, diaper folded down and away from stump, do not submerge in

water until cord is off, wall off within 10-14 days

o Meds: erythromycin: quickly, small 1-2cm ribbon inner canthus and

outward, vit K: produced in colon from bacteria once normal feeding

pattern established, admin 0.5-1 mg IM vastus lateralis, within 1h post

birth, hep B: informed consent, birth, 1mo, 6mo admin, immunoglobulin

and vax if mom is infx within 12h of birth, then heb B vax 1 mo, 2 mo, 12

mo

Chapter 25: Newborn Nutrition

 Nutritional needs: loss of 5-10% birth weight, regain 10-14 days post birth, gain

110-200g/week for first 3 mos, nbns need 100-140 mL/kg/day. 110 kcal/kg/day,

3-6 mos 100kcal/kg/day. BF and bottle supply 20 kcal/oz. Vegetarian mothers

need B12 supplementation. 6 mos of age: iron fortified cereal

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 Breastfeeding: 8-12/24hr, every 2-3h, 3hr during day, 4h at night, colostrum has

IgA (first 2-3 days,) interventions: skin-to-skin, let down reflex, uterine cramps,

proper latch, spread few drops across nipple, nose, cheeks, chin will touch breast,

15-20m/breast, insert a finger in the side of nbn’s mouth to break suction to

prevent trauma, begin feeding with breast you last stopped with, gaining wgt,

voiding 6-8x/day means adequate nutrition, content between feedings, do not

offer formula or pacifier until BF has been established, on back after feedings

 Storage of breast milk: @ room temp: up to 8h, refrigerated: 8 days, freezer: 6

mos, deep freezer: 1 yr, thawing mild in fridge is best way to preserve

immunoglobulins, do not refreeze thawed milk, used portions must be discarded

 Formula: 3-4h, follow mixing instructions, boil water and bottles PRN, wash lid

of a can of formula w/ warm, soapy water before opening (shake it, too,) prepared

formula refrigerated 24h, not in supine pstn, 45 degree angle, nipple on top of

tongue, give nbn opportunity to burp, discard any unused formula

 6+ wet diapers, BF babies: 3 stools per days, bottle: less, 1 maybe, assess wgt 2-3

days post d/c

Chapter 26: Nursing Care and Discharge Teaching

 Crying: you will learn why they are crying, swaddle, close contact, rhythmic

noises, pacifier, stimulate, eye contact

 Sleep: supine, 16-19hr/day, do not five solid food, in 4-5 mos baby will sleep

through the night, keep environment quiet at night, bring them out in the center of

house with noise during the day, teach them what time of day it is (with noise and

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stimulation,) put to bed around 2300, keep small night light, don’t startle with

bright lights

 Swaddle: makes them feel like their in utero, they like it

 Bathing: face, diaper area, skin folds cleaned daily, bathing 2-3x/wk, mild soap,

not done until cord off, circ healed, wash the area around the cord, don’t get it

wet, cleanest to dirtiest, eyes, face and head, chest, arms, legs, groin, not after

feeding, do not leave unattended, move quick baby will get cold, test water with

wrist, clean washcloth, inside of eyes to outside

 Feeding/Elimination: baby seen 72h post d/c, lactation consultant, avoid timing

them out

 Diapering: clean and dry, changed frequently, dried thoroughly

 Cord: clamp removed prior to d/c, sponge bath until it’s off, red, moist, foul oder

it’s probably infected

 Circumcision: contraindicated in: hypospadias, epispadias, fam hx of bleeding dx,

no vit K IM injection, don’t feed baby 2-3 h before if bottle fed, BF don’t matter,

may get acetaminophen, sucrose, local anesthetic, restrained on board, change

diaper q4h, petroleum jelly and sterile gauze, keep area clean, yellow mucus not

abnormal, redness, pus, swelling abnormal, premoistened towelletes NO, b/c

alcohol

 Clothing: washed w/ hot water, mild detergent, dress lightly indoors, dress as you

would dress yourself, cover nbn head

 Home Safety: never leave unattended with pets or children, small objects out of

reach, do not put anything around their neck, slats on crib 5.7cm (2.25 in) apart,

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awa from windows, drapery cords, blinds, on inner wall, do not out them on high

surfaces unless adult is within arms reach, fire hazard (fire retardant pajamas,)

control temp, no cigarette smoke, wash hands, no shaking!

 Carseat Safety: back sweat, in the middle, rear facing until 2y/o

 Checkups: 72 hr post d.c, 1mo, 2mo, 4mo, 6mo, 9mo, 12mo, 15mo, 18mo, 2yr,

2.5yr, 3 yr, then yearly

 Illness: call if: 100.4 temp, less than 97.9, poor feeding, voimiting, decreased

urination, diarrhea, cyanosis, jaundice, labored breathing, lethargy, inconsolable,

difficulty waking, bleeding, draining from eyes

Chapter 27: Assessment and Management of Newborn Complications

 Neonatal substance withdrawal: high pitched, shrilly cry, irritable, tremors,

hyperactivity, increased Moro reflec, inc deep tendow reflex, inc muscle tone,

hypertonicity, nasal congestion, frequent yawning, retractions, apnea, tachypnea,

sweating, poor feeding, diarrhea, uncoordinated sucking, meds: morphine: opioid,

phenobarb: anticonvulsant,

o Alcohol: small eyes, flat face, thin lip, wide spaced eyes, small teeth, cleft

lip, deaf, abnormal palmar creases, irregular hair, heart irregularities (with

septum)

o Tobacco: low birth weight, bronchitis, SIDS, pneumonia

 Hypogylcemia: LGA, SGA, preterm, DM, stress @ birth, less than 40 BG, less

than 45 serum BG

 Respiratory Distress, Asphyxia, Meconium Aspiration: s/s resp distress: nasal

flaring, grunting, retractions, meds: beractant, calfacant, lucinactant: lung

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surfactant, restores and improves respiratory compliance, avoid suctioning of ET

tube 1hr post admin

 Preterm Newborn: born 20 wks-37 wks, late preterm: 34-36, early term newborn

37-38 6/7, cardiac and resp support main priority, complcations: respiratory

distress, bronchopulmonary dysplasia: stiff and oncompliant lungs, aspiration,

apnea: immature neuro and chem mechanisms, intraventricular hemorrhage:

bleeding in ventricles, retinopathy: abnormal growth of retinal BV, may cause

blindness, patent ductus arteriosus: reopens d/t hypoxia, necrotizing enterocolitis:

necrosis of gut, additional: infx, hyperbilirubinemia, delayed growth

 SGA: sprase hair, wgt below 10th percentile, dry, loose skin, no fat, dec muscle

mass, thin umbilical cord, hypotonia, acrocynaosis, warmer, IV nutrition, protect

from infx

 LGA: >4,000 g, shoulder dystocia, plump, full faced, hypoxia, birth trauma,

sluggish, tremors, hypoglycemia… inc ICP: dilated pupils, vomiting, bulging

fontanels, high pitched cry

 Postmature Infant: 42 week gestation, dysmaturity (placenta only good for about

40 weeks,) continued growth of fetus in utero (nbn is LGA,) wasted appearance,

loss of SQ, peeling, dry, cracked skin, long thing body, meconium, hair and nails

long, alertness of 2 week old nbn, cold stress, macrosomia

 Infection: S. aureus, S. epidermidis, E. coli, H. influenza, and group B strep, temp

instability, suspicious drainage, poor feeding, vomiting and diarrhea,

hypoglycemia, ab distention, decreased O2 sat, color changes, tachypnea/cardia,

bradycardia, low BP, seizures, irritable, poor muscle tone

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 Trauma: skull: fracture, scalp: caput, IC: epidul or subdural hematoma, spinal:

injury, plexus: brachial, cranial: radial nerve

 Hyperbilirubinemia: physiological jaundice: benign, normal, pathologic: before

24h, persistent after day 14, acute encephalopathy: deposited in brain, >25 nbn is

at risk, kernicterus: irreversible, chronic result of bili tox; yellow skin, mucous

membranes, elevated serum bili, eye mask, diaper on, leave skin uncovered, move

ever 2hr, take off lights every 4hr, turn lights off for blood draws,feed early and

frequently

 Congenital anomalies: read

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