Exam 2 Blueprint Pt.1 (CH 19,20,21,22).pdf

1 NUTC 3814: Exam 2 Blueprint (75 questions) (part 1) Chapter 19 (continued) Chapter 23 Nursing Care of the Family during Labor and...

1 NUTC 3814: Exam 2 Blueprint (75 questions) (part 1) Chapter 19 (continued) Chapter 23 Nursing Care of the Family during Labor and Birth Transition to Extrauterine Life Heat Loss Assessment of Newborn’s Reflexes Sleep-Wakes State Sensory Behaviors Newborn Assessment Chapter 20 Chapter 24 Postpartum Anatomic and Physiologic Changes Nursing Care Management: Birth Through the First 2 Normal lab values for the postpartum woman Hours Weight/Head Circumference and Body length Gestational Age Assessment Cold Stress Common Newborn Problems Hyperbilirubinemia Collection of Specimens Newborn Medications Phototherapy Circumcision Management of Neonatal Pain Chapter 21 Chapter 25 Nursing Care of the Family during the Postpartum Nutrient Needs Period Contraindications of Breastfeeding Medications administered during the postpartum period Lactogenesis Care Management: The Breastfeeding Mother and Infant Supplements, Bottles, and Pacifiers Special Considerations Expressing and storing breast milk Common concerns of the breastfeeding mother Parent Education (Formula) Chapter 22 Chapter 26 Parental Attachment, Bonding, and Acquaintance Daily Fetal Movement Counts Sibling Adaptation Ultrasonography Biophysical Profile Amniocentesis Chorionic villus sampling Percutaneous umbilical blood sampling Alpha-fetoprotein Nonstress Test Contraction stress test Heparin dosage calculation (Refer to Dosage Calculation Resources)  2 Chapter 19: Nursing Care of the Family during Labor and Birth (Continued) Assessment of uterine contractions Increment= “Building up” of a contraction from its onset. Peak Decrement= The “letting down” of the contraction. Frequency: how often uterine contractions occur; the time that elapses from the beginning of one contraction to the beginning of the next contraction. Intensity: the strength of a contraction at its peak. o Mild: Nose. o Moderate: Chin. o Strong: Forehead. Duration: the time that elapses between the onset and the end of a contraction. Resting tone: the tension in the uterine muscle between contractions; relaxation of the uterus. Nutrient and fluid intake Oral intake Common hospital practice is to allow clear liquids during labor. Elimination Voiding Encourage voiding every 2 hours. A distended bladder may impede descent of the presenting part, slow or stop uterine contractions, and lead to decreased bladder tone or uterine atony after birth (uterine atony increases risk of postpartum hemorrhage). Women who receive epidural anesthesia are especially at risk for the retention of urine. Catherization If an obstacle that prevents advancement of the foley catheter is present, this obstacle is most likely the presenting part (e.g., baby’s head). If you cannot advance the catheter, stop the procedure, and notify the primary health care provider of the difficulty. Bowel elimination When the presenting part is deep in the pelvis, the woman may feel rectal pressure and think she needs to defecate, even in the absence of stool in the anorectal area. Nursing alert: If the woman expresses the urge to defecate, perform a vaginal examination to assess cervical dilation and station. If a multiparous woman experiences the urge to defecate, it often means that birth will follow quickly. Ambulation and positioning Upright positions and mobility during labor may be more pleasant for laboring women. These practices have also been associated with improved uterine contraction intensity and shorter labors, reduced need for pain medications, reduced risk for C-section, and increased maternal autonomy and control. When the woman lies in bed, she will usually change her position spontaneously as labor progresses. If she does not change position every 30 to 60 minutes, assist her to do so. The side-lying (lateral) position is preferred. A squatting position is beneficial if the baby is in occiput posterior position (OP position; “sunny side up”). Squatting helps open the pelvic diameter, giving the baby space to turn and rotate into OA position. Another position that helps with this is the hands and knees position (being on all 4s).  3 Labor support by the nurse Helping the woman conserve her energy. Protect the woman's privacy and modesty. Heat or cold applied to the lower back. In the event of back labor, a cool cloth applied to the forehead. Second Stage of Labor Begins with full cervical dilation (10 cm) and complete effacement (100%). Ends with baby’s birth. For nulliparous women without an epidural, upper limits are set at 2 hours and with an epidural 3 hours. In multiparous women, the limits are set at 1 hour without an epidural and 2 hours with an epidural. o 2nd stage in nullipara: 2-3 hours o 2nd stage in multipara: 1-2 hours Two phases Latent: relatively calm with passive descent of baby through birth canal The urge to bear down is not strong, and some women do not experience it at all or only during the peak of a contraction. Delayed pushing (a type of labor technique) is associated with a longer second stage of labor but a decrease in actual pushing time. o In delayed pushing, a woman who is fully dilated rests and waits to push until she feels the urge to do so. Descent: active pushing and urges to bear down The urge to bear down intensifies as descent progresses and the presenting part reaches the perineum. Bearing-Down Efforts The woman may either push instinctively and spontaneously as she feels the need to do so or be told to hold her breath, close her glottis, and push as the nurse or partner counts to 10. When they are not instructed to push in a specific manner, most women will push with an open glottis. Women should be encouraged to use the pushing technique they prefer and believe is more effective for them. Open glottis pushing involves exhaling while pushing, which can lead to grunting, groaning, or moaning. Closed glottis pushing involves holding your breath while pushing, which doesn't produce sounds.  4 Supplies, instruments, and equipment Birth in a delivery room or birthing room The lithotomy position makes dealing with complications that arise more convenient for the primary health care provider. To place the woman in this position, bring her buttocks to the edge of the bed or table and place her legs in stirrups. Take care to pad the stirrups, to raise and place both legs simultaneously, and to adjust the shanks of the stirrups so that the calves of the legs are supported. No pressure should be placed on the popliteal space. Stirrups that are not the same height will strain ligaments in the woman's back as she bears down, leading to considerable discomfort in the postpartum period. Once the woman is positioned for birth either in a delivery room or in a birthing room, the vulva and perineum are cleansed. Beginning Birth with Vertex Presenting Anteroposterior slit Oval opening Circular shape Crowning=Occurs when the widest part of the head (the biparietal diameter) distends the vulva just before birth. BOX 19.11 Guidelines for Assistance at the Emergency Birth of a Fetus in the Vertex Presentation Find ‘emergency delivery kit’ in woman’s room. Wash your hands and put on gloves. Instruct the woman to pant or pant-blow, thus minimizing the urge to push.  5 Place the flat side of your hand on the exposed fetal head and apply gentle pressure toward the vagina to prevent the head from “popping out.” o Dr. Darby suggests using a sterile towel instead of your gloved hand to push on the fetal head. After the birth of the head, check for the umbilical cord. If the cord is around the baby's neck, try to slip it over the baby's head or pull it gently to get some slack so that you can slip it over the shoulders. Then, with one hand on each side of the baby's head, exert gentle pressure downward so that the anterior shoulder emerges under the symphysis pubis and acts as a fulcrum; then, as gentle pressure is exerted in the opposite direction, the posterior shoulder, which has passed over the sacrum and coccyx, emerges. Cradle the baby's head and back in one hand and the buttocks in the other. Keep the head down to drain away the mucus. Use a bulb syringe, if needed, to remove mucus from the baby's mouth and nose. o Suction mouth first, nose after. (to help you remember, “m” comes before “n” in the alphabet) If birth occurs outside a hospital setting, to minimize complications, do not cut the cord without proper clamps and a sterile cutting tool. Immediate assessments and care of the newborn Perform a brief assessment of the newborn immediately during skin-to-skin contact. This assessment includes assigning Apgar scores at 1 and 5 minutes after birth. Maintain a (1) patent airway, supporting respiratory effort, and (2) prevent cold stress by drying the newborn and covering the newborn with a warmed blanket/hat or placing him or her under a radiant warmer. o Priority #1: Maintain a patent airway. o Priority #2: Keep the baby warm. Perineal trauma related to childbirth Perineal lacerations First degree: Confined to the skin. (torn down to the skin) Second degree: Extends into the perineal body. (torn down to the muscle) Third degree: Injury to the external and sphincter muscle. (torn all the way down to the anal sphincter muscle) Fourth degree: Extends completely through the anal sphincter and the rectal mucosa. (torn all the way down to the rectal mucosa) With 3rd and 4th degree laceration: mom cannot receive enema or rectal suppository in the postpartum unit. Episiotomy An episiotomy is an incision made in the perineum to enlarge the vaginal outlet. Midline (median) and mediolateral episiotomy. Routine episiotomy has no role in modern obstetric care and should be avoided whenever possible. Indicated episiotomy, however, may still be performed in specific situations, such as the need to hasten birth when FHR abnormalities are present.  6 Third Stage of Labor The third stage of labor lasts from the birth of the baby until the placenta is expelled. Placental separation and expulsion The placenta is usually expelled within 15 minutes after the birth of the baby. Signs of placental separation: o Uterus changes from discoid (flat) to globular shape. o Umbilical cord lengthens. o There is increased bleeding. Placenta enters vagina, cord is seen to lengthen, and an increase in bleeding may be seen. Expulsion (delivery) of placenta and completion of third stage. Provider examines placenta and membranes for intactness (checks if all cotyledons are present → if not, risk of postpartum hemorrhage). Fourth Stage of Labor 1st hour after delivery of the placenta; up to 1 hour pp.  7 Chapter 20: Postpartum Anatomic and Physiologic Changes Uterus Involution: return of uterus to nonpregnant state following birth o When you’re not pregnant, your uterus is the size of a deck of cards. o Right after delivering a baby, your uterus is the size of a grapefruit. o Involution: Uterus shrinks from grapefruit to deck of cards. Within 12 hours, the fundus can rise to approximately 1 cm above the umbilicus. o The fundus is 1 cm above the umbilicus 12 hours after birth, and then gradually descends lower and lower. o When the fundus reaches the umbilicus, it can be documented as “FF at U,” which stands for Firm Fundus at Umbilicus. Fundus descends 1 to 2 cm every 24 hours. o After 1 day, the fundus should be FF at U -1. FF at U -1 = 1 cm or 1 fingerbreadth under the umbilicus. o After 2 days, the fundus should be FF at U -2. FF at U -2 = 2 cm or 2 fingerbreadths under the umbilicus. o After 3 days, the fundus should be FF at U -3. FF at U -3 = 3 cm or 3 fingerbreadths under the umbilicus. o And so on… 2 weeks after childbirth, uterus should not be palpable abdominally. o If it’s palpable after 2 weeks, that means the uterus didn’t shrink (subinvolution). Subinvolution: failure of uterus to return to nonpregnant state. o Subinvolution is a sign of late postpartum hemorrhage. Most common causes of late postpartum hemorrhage are: 1. retained placental fragments (e.g., retained cotyledons). 2. infection.  8 Contractions *Know hormones for the exam* Hormone oxytocin, released from the posterior pituitary gland, strengthens and coordinates uterine contractions. Afterpains Cramps after birth. Can be very painful. Afterpains are more noticeable after births in which the uterus was overdistended (e.g., large baby [>8 lb, 15 oz], multifetal gestation, polyhydramnios). o So, women who (1) gave birth to a heavy baby, weighing 8 lb + 15 oz or more; (2) gave birth to twins/triplets; or (3) had a large amount of amniotic fluid within their uterus during pregnancy; will have more painful afterpains. Breastfeeding and exogenous oxytocic medication usually intensify these afterpains because both stimulate uterine contractions. o Examples of oxytocic medications: Oxytocin and Pitocin. Oxytocin and Pitocin are the same medication; Oxytocin is just the generic name, while Pitocin is the trade name. Placenta site Upward growth of the endometrium causes sloughing of necrotic tissue and prevents the scar formation that is characteristic of normal wound healing. o In other words, no scars will form where the placenta was. Lochia Postbirth uterine discharge Lochia rubra Bright red. Duration of 1 to 3 days Lochia serosa Pink or brown. Duration of 4 to 10 days Lochia alba Yellow to white. 10 to 14 days; can last 3-6 weeks. Extra notes If the woman receives an oxytocic medication, the flow of lochia is often scant until the effects of the medication wear off. o This is because oxytocic drugs stimulate the uterus to contract. (When the uterus contracts, its blood vessels constrict, reducing bleeding.) The amount of lochia is typically smaller after cesarean births. o One of the reasons for this is that, during a C-section, doctors suction out blood from the uterus (using a Yankauer suction). Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; on standing the woman may experience a gush of blood. o This gush should not be confused with hemorrhage! Lochia should smell similar to normal menstrual flow; an offensive odor usually indicates infection. It’s important that a woman’s lochia occurs in this specific order: rubra → serosa → alba. If a woman regresses back to lochia rubra after having had lochia serosa or alba, that means she is having a late postpartum hemorrhage.  9 Cervix After birth, the ectocervix appears bruised and has small lacerations (optimal conditions to develop infection). Cervical os (dilated to 10 cm during labor) closes gradually. In class, Dr. Darby also mentioned that you can tell if a woman has had a baby before just by looking at her cervix. A mother’s cervical dimple (cervical os) will look oval-shaped and flattened, rather than circular. A: before birth. B: after birth. Ovaries The mean length of time to initial ovulation is approximately 6 months. o In other words, after giving birth, a woman typically doesn’t ovulate for 6 months (unless she bottle feeds her baby—in which case, she begins menstruating and ovulating sooner than 6 months). Breastfeeding=Anovulation is influenced by the frequency and duration of breastfeeding and bottle feeding. o Breastfeeding prevents ovulation. Bottle feeding doesn’t. Bottle-feeding=Menstruation usually resumes by 12 weeks (3 months) after childbirth. Because of the uncertainty about the return of ovulation and menstruation, discussion of contraceptive options should be discussed early in the puerperium. Vagina Estrogen deprivation is responsible for thinness of vaginal mucosa and absence of rugae after birth (returns to normal within 3 weeks). Dryness and coital discomfort, dyspareunia, may persist until return of ovarian function. The use of a water-soluble lubricant during sexual intercourse is usually recommended.  10 Perineum Following vaginal birth, women must have their perineum checked often (e.g., q4h) for signs of infection and hemorrhoids. Assess a woman’s perineum using the REEDA scale: redness, ecchymosis (bruising), edema, drainage, and approximation. There should be no redness, ecchymosis, edema, or drainage at the perineum; and all incisions should be approximated (closed). o Note: obviously, if a woman just gave birth, she will have some swelling, pain, and redness down there—and that’s normal. It just shouldn’t persist. You should assess her for REEDA regularly to check if her condition is improving; if it’s not, she may have an infection. Episiotomies initially heal within 2 to 3 weeks. Hemorrhoids and anal varicosities are common and decrease within 6 weeks of childbirth. o If a woman has hemorrhoids, count how many she has, note their size, and ask her if they’re painful. If desired, she can receive medications to treat the hemorrhoids. Pelvic muscular support During childbirth, the supportive tissues of the pelvic floor are torn or stretched. o This leads to stress incontinence. Require up to 6 months to regain tone. Kegel exercises encourage healing. Later in life, women with weak pelvic muscles can experience pelvic relaxation (pelvic prolapse), leading to the prolapse of pelvic organs like the uterus, bladder, or rectum. Again, Kegel exercises help to prevent this. Breasts: Breastfeeding Mothers Before lactation begins, a yellowish fluid (colostrum) can be expressed from the nipples. Some women experience engorgement, but with frequent breastfeeding and proper care, this condition is temporary and typically lasts only 24-48 hours. o Engorgement is very painful. Non-breastfeeding Mothers Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hours. Vital signs Temperature Temperature during first 24 hours may rise to 38° C (100.4° F). → This temperature elevation is usually due to dehydration, so give moms plenty to drink. o After 24 hours, the woman should be afebrile. If her fever continues, she may have an infection and you need to call her HCP. Pulse Postpartum bradycardia is common, with heart rate decreasing to 40-50 bpm. Postpartum bradycardia is caused by diuresis, diaphoresis, and blood loss during delivery. o Diuresis: urinating often. ▪ Women pee a lot after birth. o Diaphoresis: sweating. ▪ Women sweat a lot during labor and delivery. o Peeing and sweating a lot is important—it helps women get rid of the extra blood volume they accumulated during pregnancy… remember, blood volume increases by 45% during pregnancy.  11 Respirations Respiratory function rapidly returns to nonpregnancy levels after birth. Blood pressure Blood pressure shows a transient increase of approximately 5% over the first few days after birth, returning to prepregnancy levels over weeks or months. Orthostatic hypotension, as indicated by feelings of faintness or dizziness immediately after standing up, can develop in the first 48 hours as a result of the splanchnic engorgement that may occur after birth. o This is why, after a mom gives birth, she must be accompanied to the bathroom by a registered nurse (at least for the very first bathroom trip). The nurse must have her sit on the side of the bed for 1-2 minutes before standing her up to go to the bathroom. o Dr. Darby’s steps for getting a postpartum mom to the bathroom: Step 1: check if mom is wearing socks with treads (b/c she’s at risk of falling). Step 2: check if mom is wearing a pad and underwear (b/c lochia will gush out of her once she stands). Step 3: inform mom that she’s at risk of fainting and tell her to report any dizziness or ringing in the ears. Step 4: sit mom up for 1-2 minutes on the side of the bed. Step 5: if she isn’t dizzy, stand her up for 1-2 minutes. Step 6: if she still isn’t dizzy, take her to the bathroom; a bedpan can be used if she’s too dizzy to walk. Cardiovascular System Blood volume The average blood loss for a vaginal birth ranges from 300 to 500 mL (10% of blood volume). The typical blood loss for women who give birth by cesarean is 500 to 1000 mL (15% to 30% of blood volume). It’s important to keep track of how much blood is being lost to determine if a woman is hemorrhaging. Cardiac Output Remains increased for 1 hour postpartum because of an increase in stroke volume. Why is this important to know? If you have a patient with cardiovascular disease, you must monitor her for acute respiratory distress syndrome (ARDs), as an increase in cardiac output can cause ARDs. Cardiac output generally returns to normal by 6 to 8 weeks after birth. Varicosities Varicosities of the legs and around the anus (hemorrhoids) are common during pregnancy. Total or nearly total regression of varicosities is expected after childbirth. Blood Components Hematocrit and hemoglobin=Reaches nonpregnant levels by 4 to 8 weeks postpartum. o This means that moms will still be a little anemic for the first 4-8 weeks (1-2 months) after they give birth. o Remember: A normal Hgb & Hct during pregnancy is 13 and 33.  12 White blood cell count=During and after labor, the WBC may rise to 30,000/mm3. Normal is 5,000 to 15,000. o This naturally happens to prevent postpartum infection. Coagulation factors=Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk for venous thromboembolism (DVT) and pulmonary embolism for up to 12 weeks after birth. o This naturally happens to prevent postpartum hemorrhage. Placental Hormones Expulsion of the placenta results in dramatic decreases of the hormones produced by that organ (hCG, human placental lactogen, estrogen, progesterone). Pituitary Hormones Prolactin, a hormone released from the pituitary gland, is responsible for making milk. Breastfeeding=Prolactin levels in the blood rise and remain elevated. Bottle feeding=Prolactin levels decline after birth and reach the prepregnant range by the third postpartum week. Urinary System Renal function Risk of UTI may be increased postpartum as a result of tissue trauma from labor and birth, effects of epidural analgesia or anesthesia (urinary retention), or perineal/vaginal discomfort. o After birth, women are at risk of developing a UTI. Ketonuria may occur in women with an uncomplicated birth or after a prolonged labor. This is normal; it’s caused by dehydration. Fluid Loss Within 12 hours women begin to diurese (void excessively). o May void 3000 mL/day. Profuse diaphoresis (sweating) often occurs at night for the first 2 to 3 days. Again, this happens so that moms can get rid of their excess blood volume. Urethra and bladder Excessive bleeding can occur because of displacement of the uterus if bladder is full. o In other words: full bladder= increased risk of bleeding/hemorrhage because uterus can’t “clamp down” or fully contract. o You can tell if a woman’s bladder is full by feeling for her fundus. If her fundus is displaced upwards, that means her bladder is full. Gastrointestinal System Spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth. This delay can be explained by decreased muscle tone in the intestines during labor and the immediate puerperium; pre-labor diarrhea; lack of food; dehydration; or the effects of opioid analgesics. Integumentary System Chloasma of pregnancy usually disappears in the postpartum period. Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth. o Some women will have permanent darker pigmentation of those areas. Striae on breasts, abdomen, hips, and thighs may fade but not disappear.  13 Vascular abnormalities, spider angiomas and palmar erythema (rash on palms caused by estrogen) regress with rapid decline in estrogens. o Spider nevi may persist indefinitely for some women. Musculoskeletal System After giving birth, a woman will still look pregnant. During first 2 weeks, abdominal wall remains relaxed. Return to prepregnancy state takes 6 weeks. o Depends on previous tone, proper exercise, and amount of adipose tissue. Diastasis recti abdominis o Abdominal wall muscles separate. o Caused by overdistention because of a large fetus (>8 lb, 15 oz) or multiple fetuses. o Abdominis surgical correction is rarely necessary. Abdominal binders can be used instead to push those muscles back together. Joints are completely stabilized by 6 to 8 weeks after birth. o Relaxin levels decrease and joints no longer feel loose. New mother may notice permanent increase in shoe size. Diastasis recti abdominis Neurologic System Headache requires careful assessment. Postpartum headaches may be caused by postpartum preeclampsia, stress, and/or leakage of cerebrospinal fluid into extradural space during placement of needle for epidural or spinal anesthesia. Pregnancy-induced neurologic discomforts (e.g., carpal tunnel syndrome; numbness or tingling in fingers) disappear after birth. Elimination of physiologic edema through the diuresis that follows childbirth relieves carpal tunnel syndrome by easing compression of the median nerve. Periodic numbness and tingling of fingers usually disappears after birth unless lifting and carrying the baby aggravates the condition. o Tell mom, “Don’t lift anything heavier than your baby for a while.” Immune System The rebound of the immune system can trigger exacerbation of autoimmune conditions, such as multiple sclerosis or lupus erythematosus.  14 Chapter 21: Nursing Care of the Family during the Postpartum Period Planning for Discharge The typical stay in the hospital after vaginal birth is approximately 48 hours. Preventing excessive bleeding Uterine atony The most common cause of excessive bleeding after birth is uterine atony, failure of the uterine muscle to contract firmly. With uterine atony, the uterus will feel boggy, almost like a sponge. The most important interventions for preventing excessive bleeding are: o maintaining good uterine tone (through massaging/putting pressure on the fundus) this is always the first intervention you should try! o preventing bladder distention Nursing Alert A perineal pad saturated in 15 minutes or less and pooling of blood under the buttocks are indications of excessive blood loss, requiring immediate assessment, intervention, and notification of the primary HCP. Assessing amount of lochia on a pad: Scant (