Maternity: Management of Care

Management of Care

• Newborns of diabetic mothers should have their blood glucose monitored to check for hypoglycemia
• Emergency C-sections are situational crises linked to increased emotional and psychological needs for the mother
• Vaginal exams via dilation, effacement and station assess labor progress
• Amniotomy can cause risk of infection, fetal heart tones and temperature should be monitored
• Postpartum hemorrhage is blood loss of >500 mL (vaginal) or >1000 mL (C-section), caused by uterine atony, lacerations, or retained placenta, requires fundal massage, meds as prescribed and ordered, monitoring of vital signs, and fluid replacement
• Normal postpartum bleeding occurs as: Lochia rubra (3–4 days), serosa (22–27 days), and alba (2–6 weeks)
• Hypothermia is high-risk in preterm and late preterm infants and requires thermoregulation
• Post-term complications that occur after >42 weeks gestation include risk of placental insufficiency, meconium aspiration, macrosomia
• Forceps-assisted birth can cause birth injuries like facial nerve damage
• Immediately after birth, newborns should have thermoregulation, airway management, and APGAR scoring performed
• Maternal vital signs to look out for are temperature ≤100.4 within the first 24 hours and elevated pulse during the first hour post-birth, newborns should be monitored for sepsis signs
• Normal weight for newborns varies depending on gestational age and other factors
• The Ballard assessment was not convered
• Breastfeeding promotes GI protection, and decreases risk for necrotizing enterocolitis (NEC), the nurse should assess latch and signs of effective feeding
• Breast engorgement is common in both breastfeeding and non-breastfeeding mothers and should be treated with supportive bra, ice packs, feeding/pumping
• Appropriate post-partum pain management includes both nonpharm and pharm strategies like ice, positioning, and analgesics
• Dosages and drug calculations should be reviewed
• Vital signs on a child should be monitored for sepsis and hypoglycemia
• Suicidal ideation should be screened for in postpartum depression
• The four modes of heat loss are important in newborn thermoregulation
• Physiologic or pathologic jaundice is a risk with ABO or Rh incompatibility and should be treated with phototherapy or transfusions

Physiological Integrity: Pharmacological and Parenteral Therapies

• Carboprost (Hemabate) 0.25 mg IM treats PPH, but is contraindicated in asthma and HTN
• Oxytocin (Pitocin) 125–200 milliunits/min IV or 10–20 units IM treats PPH
• Rho immune globulin should be administered within 72 hrs for Rh-neg mothers with Rh-pos babies in order to prevent isoimmunization

Postpartum Care: Safety and Infection Control

• Assess REEDA during postpartum pericare; hygiene is important
• Monitor vital signs closely postpartum, especially in high-risk infants

Basic Care and Comfort

• Bulb suctioning a newborn is routine after delivery to clear the airway

Health Promotion and Maintenance

• Breastfeeding encourages immunity and nutrition
• Effective breastfeeding includes audible swallowing, adequate output, and good latch
• Tetanus and Hepatitis B vaccines are mentioned with regards to newborn care needs

Reduction of Risk Potential

• Pathologic jaundice is seen in ABO/Rh incompatibility
• Physiologic jaundice is normal in newborns and appears after 24 hours
• Hypoglycemia in newborns should be monitored, especially in infants of diabetic mothers or late preterm infants

Psychosocial Integrity

• 80% of people experience postpartum blues which resolves in days
• 10–15% of people experience postpartum depression which causes sadness, mood swings, may need meds/therapy
• Postpartum Depression with Psychotic Features is an emergency and may cause delusions, requires hospitalization
• Miscarriage is a source of grief that requires emotional support and memory creation

Physiological Adaptation

• Vaginal lacerations are a cause of PPH and must be assessed and repaired
• Uterine infections include endometritis and puerperal sepsis causing fever, abnormal lochia
• Newborn vital signs are monitored for sepsis and respiratory distress

Newborn Care

• Assess respiration, provide warmth, clear airway, dry/stimulate, evaluate HR and color immediately after birth
• Apgar assessment is performed at 1 and 5 minutes. It assesses HR, respiration, muscle tone, reflex irritability, and color
• Erythromycin ointment is used for eye prophylaxis to prevent ophthalmia neonatorum
• Vitamin K prevents bleeding and 0.5–1 mg IM should be given within 2 hours of birth
• The umbilical cord falls off in 6-10 days and should be kept clean and dry
• Infant abduction requires maintaining infant security protocols
• Caput succedaneum is swelling across the scalp that crosses suture lines
• Cephalhematoma is a collection of blood that does not cross suture lines
• With bulb suctioning a newborn, suction the mouth before the nose
• Appropriate pain management for circumcision includes acetaminophen, sucrose, lidocaine, and swaddling
• The first breastfeeding should occur during the period of reactivity with 8–12 feeds/day, LATCH technique, monitor weight gain, wet diapers, stools
• Effective breastfeeding includes a good latch, audible swallowing, and appropriate output
• Hepatitis B vaccine is administered within 12 hours of birth and HBIG is given if mom is HBsAg positive
• Tetanus vaccine is mentioned alongside standard newborn immunizations
• Hypoglycemia occurs with BG under 40–45 mg/dL, risk factors include SGA, LGA, IDM, late preterm, and it is treated with early feeding
• Physiologic jaundice appears after 24 hours and resolves gradually
• Pathologic jaundice appears within 24 hours and requires intervention like phototherapy
• Normal newborn temperature is 97.8–98.6°F, assess for respiratory distress (grunting, nasal flaring, retractions)
• Newborns are classified as: AGA, LGA, SGA, preterm (<37 wks), term (37–41.6), and postterm (>42 weeks)
• Gestational age estimation is based on physical and neuromuscular maturity
• Promote early skin-to-skin contact, recognize attachment behaviors, support parental role to promote Parent-infant bonding
• Discharge teaching includes instructions on temperature, respirations, feeding, elimination, car seat safety, bathing, and signs of illness
• Postterm infants (gestation >42 weeks) have an associated risk of placental dysfunction, birth injuries, fetal distress (dysmaturity syndrome), and meconium aspiration
• Newborn Resuscitation requires assessing: term, tone, breathing/crying, clear fluids. Provide warmth, suction (mouth before nose), dry and stimulate. Evaluate HR, RR, color
• Apgar score assesses HR, respiratory effort, muscle tone, reflex irritability, and color and is scored at 1 and 5 minutes
• Newborn classification is based on weight percentiles: Preterm <37 weeks, Late Preterm 34–36 6/7, Term 37–41 6/7, Postterm ≥42 weeks, and AGA/LGA/SGA
• Postpartum assessment (BUBBLE-E) includes: Breasts, Uterus, Bowel, Bladder, Lochia, Episiotomy/Perineum, and Emotional status
• Parental role transition occurs as: Dependent → Dependent-independent → Interdependent

Safety and Infection Control: Infant Safety

• The leading cause of death for children: Unintentional injuries (emphasized safety around water, burns, falls, poisoning)
• Safe sleep includes: ABCs—Alone, on Back, in Crib (Prevent SIDS in infants <1 year)
• Car seat safety precautions include: Rear-facing until age 2 or until height requirement is met, back seat is safest
• Prevent poisoning by keeping meds and chemicals locked, using childproof containers
• Prevent aspiration by avoiding small objects and certain foods (nuts, grapes, hot dogs), no feeding while lying down

Health Promotion and Maintenance: Pediatric

• In terms of obesity and measuring growth curve, track weight gain milestones; double birth weight by 6 months, triple by 12 months, monitor toddler nutrition to prevent milk-induced anemia and obesity
• Tetanus and Hepatitis B vaccines are administered in infancy, IM in vastus lateralis, includes documentation and parental consent
• Ensure immunization safety with atraumatic care, report adverse events to VAERS, and educate parents with VIS forms

Psychosocial Integrity: Developmental Theorists

• Freud: Oral stage (birth–1 yr), Anal stage (1–3 yrs)
• Erikson: Trust vs. mistrust (infants), Autonomy vs. shame/doubt (toddlers)
• Piaget: Sensorimotor (infants), Preoperational (toddlers)
• Kohlberg: Preconventional level—morality based on consequences
• Fowler: Spiritual growth-Stage 0 (undifferentiated) to Stage 2 (mythical-literal)

Psychosocial Integrity: Developmental Milestones

• Infants: Rolls over 5–6 mo, sits unsupported ~8 mo, walks ~12 mo
• Toddlers: Runs, stairs at 2 yrs, 300-word vocab by age 2
• Play: Solitary play (infants), Parallel play (toddlers)
• Sleep: 14-15 hrs/day in infancy, 11–12 hrs/day with 1 nap in toddlerhood
• Language: Understands more than they can express

Management of Care: Vital Signs in Children

• Temperature: oral preferred > age 5; rectal only if necessary
• Pulse: apical for infants, full minute
• Respirations: count for full minute; infants use abdominal muscles
• BP: baseline, correct cuff size

Physiological Integrity: Pain Management

• Pain scales by age: FLACC, FACES, NIPS, numeric
• Reassess pain, monitor effectiveness
• Use weight-based dosing for medications
• Monitor for signs of physical dependence, tolerance, and addiction with opioid use
• Normal newborn temperature is 98.6°F oral; rectal is slightly higher, newborn RR is 30-55, and newborn HR is 100-170 bpm
• The newborn may lose up to 10% of birth weight initially and regain it after a few days, also doubles in weight by 5–6 months, triples by 1 year
• Cephalhematoma does not cross suture lines and is soft swelling due to birth trauma
• Caput succedaneum, edema crosses suture lines and resolves in a few days
• Preschoolers can localize pain and use age-appropriate pain scales
• Appropriate pain management includes acetaminophen, NSAIDs for mild/moderate pain, and opioids for severe pain, use EMLA/topical anesthetics as needed

Reduction of Risk Potential: Drug Calculations

• Dosage calculations are always weight-based in kg and should be calculated ensuring that drug action, side effects, and safe ranges are known

Infants of Diabetic Mothers

• Infants of Diabetic Mothers are at risk for macrosomia, birth injury, hypoglycemia, and congenital anomalies and need nursing interventions such as thermoregulation, frequent feeding, and glucose monitoring
• Late Preterm Infants (34–36 6/7 weeks) are at risk for hypoglycemia, jaundice, sepsis, respiratory complications, and poor thermoregulation

Discharge Teaching

• Teach S/S of complications, contraception, medications, follow-up, infant care, car seat safety, and how to access warm line resources

Physiological Integrity of Newborns

• Neonatal Sepsis includes temp instability, respiratory distress, is at risk with maternal infection, prevented by handwashing, and treated with cultures and broad-spectrum antibiotics
• Hypoglycemia is Glucose 42 weeks, and managed with RhoGAM within 72 hrs if indicated

Safety & Infection Control: General

• Circumcision requires pain control (acetaminophen, sucrose, lidocaine) and to monitor bleeding/voiding
• Watch for >100.4°F fever, pain, and abnormal lochia with postpartum infections like endometritis, mastitis, UTI, and wound infection
• Least restrictive restraints should be used first and monitor circulation
• Parent required informed consent, minors >12 give assent, some minors consent for reproductive/mental health

Reduction of Risk Potential: General Tips

• Dosage Calculations: Always weight-based in kg
• SIDS: ABCs (Alone, Back, Crib), no co-sleeping, soft bedding
• Lead Poisoning: Screen at 1 & 2 years, Chelation if ≥45 mcg/dL
• BRUE/ALTE: Sudden apnea/color change, resolves, evaluate
• Thromboembolic Disease: Monitor for DVT, PE, DIC
• Specimen Collection: Urine, stool, blood, respiratory

Psychosocial Integrity: Postpartum

• Postpartum Mental Health: Blues (80%), Depression (10–15%), Psychosis (emergency)
• Hospitalization Reactions: Protest → Despair → Detachment

Fluid Management

• Daily fluid needs depends on weight:
• <10kg = 100 mL/kg
• 10–20kg = 1000 + 50 mL/kg

• 20kg = 1500 + 20 mL/kg

• Hourly fluid needs depends on weight:
• <10kg = 4 mL/kg/hr, then 2 and 1 mL/kg/hr

Additional Topics from the Test Plan

• Betamethasone is an IM corticosteroid given during preterm labor to enhance fetal lung maturity and to monitor for maternal hyperglycemia
• Magnesium Sulfate is used for preeclampsia (to prevent seizures) and neuroprotection in preterm labor, to monitor for toxicity: decreased reflexes, respiratory depression, urine output 2 are safest, prevent transmission, support family
• Adolescent Issues: Eating disorders, reproductive disorders, substance use (i.e., CRAFFT), enuresis (DDAVP), ADHD meds
• Car Seat Safety: Rear-facing until age 2 or max height, back seat is safest
• Burn & Poison Prevention: Bath 10 mo, walks ~12 mo, 300-word vocab by 2 yrs
• Sleep patterns: Infants 14–15h/day, toddlers 11–12h + nap, preschoolers ~12h, school-age 9–11h
• Play: Infants (solitary), toddlers (parallel), preschoolers (associative/cooperative)
• Newborn resuscitation: Assess term, tone, breathing/crying, clear fluids then provide warmth, suction (mouth before nose), dry and stimulate, evaluate HR, RR, color
• Apgar assessment: Scored at 1 and 5 minutes for HR, respiratory effort, muscle tone, reflex irritability, and color
• Newborn Classification: Preterm 6/7, Term 37–41 6/7, Postterm ≥42 weeks with AGA/LGA/SGA based on weight percentiles
• Postpartum Assessment (BUBBLE-E): Breasts, Uterus, Bowel, Bladder, Lochia, Episiotomy/Perineum, Emotional status
• Parental Role Transition is dependent transitioning to dependent-independent towards interdependent