Final Exam - Maternal Newborn PDF

1. Condoms are important – No specific STD questions 2. Pregnancy tests Positive test is a probable sign of pregnancy - not a positive sign Measures Human Chorionic Gonadotropin ○ May also indicate ectopic/molar pregnancies _______________________________...

1. Condoms are important – No specific STD questions 2. Pregnancy tests Positive test is a probable sign of pregnancy - not a positive sign Measures Human Chorionic Gonadotropin ○ May also indicate ectopic/molar pregnancies ___________________________________________________________________________ 3. Difference b/w true and false labor ___________________________________________________________________________ 4. Bonding En face position = face-to-face with baby ○ Should assume to promote bonding immediately after birth ○ Allows parent to make direct eye contact Skin-to-skin asap, kangaroo care ___________________________________________________________________________ 5. Physical signs of pregnancy (What happens physiologically, What are changes that might appear, Mask of pregnancy + stuff like that) Chadwick Sign: bluish-purple coloration of the vaginal mucosa + cervix ○ Increased vascularization Goodell Sign: Softening of the cervix Hegar Sign: Softening of the lower uterine segment or isthmus Vaginal secretions: more acidic, white, + thick ○ Leukorrhea GI Changes: Gums may be hyperemic + look inflamed/swollen ○ Remember hyperemia = excess blood (usually causes swelling/redness) Ptyalism (excess salivation) Hemorrhoids (constipation + increased venous pressure + pressure from uterus) Slowed gastric emptying, decreased peristalsis, heartburn, nausea, vomiting Nausea + Vomiting Cardiovascular Changes: Increased blood volume, CO, HR, venous return ○ Note: often slight DECLINE in blood pressure for first half of pregnancy Increased # RBCs + plasma ○ Plasma volume > than RBCs, leading to hemodilution (physiologic anemia) Increased fibrin, plasma fibrinogen, + some clotting factors ○ Hypercoagulable state More frequent nosebleeds (epistaxis) MSK Changes: Softening/Stretching of ligaments around pelvis Swayback, Increased lordosis, Waddle Gait Urinary Changes: Increase in: GFR + Urine flow/volume Integumentary Findings: Hyperpigmentation: Facial Melasma/Chloasma (mask of pregnancy) ○ Dark patches often found on cheeks, forehead, chin ○ Harmless - increased melanin deposition due to hormonal shifts Linea Nigra ○ Dark vertical line from umbilicus to pubic area Striae Gravidarum ○ Stretch marks - primarily on abdomen and thighs Varicosities ○ Superficial veins in legs Vascular Spiders (spider veins) ○ Usually on face and legs Palmar Erythema ○ Palms develop red patches, symmetrical  ○ Due to increased blood flow Decline in hair growth Increase in nail growth ___________________________________________________________________________ 6. Know about prevention of neural tube defects The cause of neural tube defects is not known ○ Drugs, malnutrition, chemicals, and genetics may be involved Maternal preconception supplementation of folic acid decreases NTDs ○ Continue to take throughout pregnancy Note: Increased Alpha-fetoprotein (AFP) may indicate neural tube defect present ___________________________________________________________________________ 7. Gravida/para Gravida = # of times she’s been pregnant ○ Includes current pregnancy ○ Each pregnancy counts as 1, even if twins Para = # of times a woman has given birth to a fetus that was at least 20 weeks gestation (includes both stillbirths and live births) ___________________________________________________________________________ 8. Different teaching for pregnant women (Hemorrhoids, Nausea/vomiting, Etc.) Urinary frequency or Incontinence ○ Pelvic floor exercises can increase control of leakage ○ Avoid caffeine ○ Reduce fluid intake after dinner Fatigue ○ Schedule daily nap in the early afternoon ○ Pause to rest when feeling tired Nausea/Vomiting ○ Avoid an empty stomach at all times Eat several small meals throughout the day Avoid brushing teeth immediately after eating Avoid gag reflex Drink fluids b/w meals instead of with meals Eat dry crackers/toast in bed before arising  Backache ○ Avoid sitting/standing in one position for long periods ○ Lumbar support when sitting ○ Avoid high heels Leg cramps ○ Elevate legs frequently throughout day ○ Increased calcium may reduce leg spasms Varicosities ○ Walk daily to improve peripheral circulation ○ Elevate both legs above heart level while resting ○ Avoid standing in one position for long periods of time Hemorrhoids ○ Avoid constipation + straining ○ Use warm sitz baths and cool witch hazel compresses for comfort Constipation ○ Increase fiber ○ Drink at least 8 glasses of fluid per day ___________________________________________________________________________ 9. Birthing process (the 5 P’s of labor) Power: strength and frequency of uterine contractions during labor ○ Ideal contractions are close together and regular Passageway: Anatomy of mom’s pelvis ○ Pelvic shapes: most favorable for vaginal birth = gynecoid Passenger: Fetal size, position, presentation ○ Fetal skull ○ Fetal attitude (flexion is best) ○ Fetal lie (vertical more favorable for vaginal birth) ○ Fetal presentation (Cephalic - Vertex preferred) Position: Labor position Psyche: Mom’s mental state ___________________________________________________________________________ 10. Know your stages of labor First Stage (Beginning of true labor → complete cervical dilation) ○ Cervix dilates from 0 → 10 cm ○ Longest of all stages ○ 2 phases: Latent: contractions every 5-10 mins, last 30-45 secs, Intensity: Mild Active: contractions every 2-5 mins, last 45-60 secs, Intensity: Moderate ○ Interventions: Support and encouragement Breathing techniques Monitor mom’s vitals + fetal heart rate Especially note differences before, during, and after contractions Assess dilation status + effacement Don’t want to start pushing until 10 cm dilated Second Stage (Complete dilation → birth of the baby) ○ Contractions every 2-3 minutes (or less), last 60-90 secs, Intensity: Strong ○ 2 phases: Pelvic phase: Fetal descent Perineal phase: Active pushing ○ Interventions: Assess perineum prior to birth of baby, look for certain changes: Bulging perineum + rectum Increase in bloody show or visible baby parts Continue to monitor mother and fetal vitals At birth: Dry baby, Apgar score, ID Third Stage ○ Separation + Delivery of the placenta ○ Usually takes 5-10 mins, may be up to 30 mins Short is good, longer = higher risk of hemorrhage or retained placenta fragments ○ Interventions: Monitor mom’s BP before and after (due to hemorrhage risk) Administer Pitocin (oxytocin) if prescribed for after delivery of placenta to prevent hemorrhage Assess placenta once delivered Need to make sure it’s intact! If mother retained any parts, risk for future hemorrhage or infection  Try to make mom more comfortable Get her cleaned up, fresh linens Encourage bonding time between mom and baby Help her start breastfeeding Fourth Stage (Recovery) ○ First 1-4 hours after delivery of the placenta ○ Interventions: Monitor lochia: expecting moderate amount, red color, no large clots Assess fundus: firm, midline, near or at umbilicus Bladder status and voiding Promote bonding with baby ___________________________________________________________________________ 11. Know about pain control during labor Especially when it’s appropriate to use opioids → First stage of labor ○ Usually given in the early part of active labor Avoid giving within 1-4 hrs of expected delivery Crosses placenta and can cause neonatal respiratory depression if the baby is born with peak opioid concentration in system ○ Contraindicated for respiratory disorders (asthma) ○ Hold for RR < 12 bpm Patient education about opioids Will cause drowsiness - don’t get up without assistance Side effects can include nausea, vomiting, constipation, confusion Sedating effects may help her rest between contractions May decrease frequency + duration of uterine contractions Crosses the placenta → alter baby’s HR (slows + decreases variability) ___________________________________________________________________________ 12. Rupture of membranes – What the characteristics of the fluid should be Should be clear to slightly yellowish ○ Blood-stained: could indicate placental abruption or trauma ○ Meconium-stained (green): suggests fetal distress ○ Cloudy/Purulent = Infection  MIld musty odor (foul odor is indicative of infection - chorioamnionitis) Alkaline pH compared to vaginal secretions ___________________________________________________________________________ 13. Bonding vs. attachment Bonding ○ Parents’ feeling → baby One direction ○ Develops during the first 30-60 minutes after birth ○ Initiated when mom caresses infant Attachment ○ Baby’s feeling ←→ caregiver feeling ○ Reciprocal: Baby attaches to parent and parent attaches to baby ○ Child’s attachment influences the way they view the world and future relationships Infant’s first developmental task: trust vs. mistrust Secure attachment develops when infant’s needs are continually met ___________________________________________________________________________ 14. Episiotomy care Proper cleansing to prevent infection ○ Use peri bottle to cleanse multiple times per day Promote measures to soften stools - prevents straining/tearing/pain Comfort Measures: ○ Ice pack first 24 hrs to reduce edema/inflammation - decreases capillary permeability + reduces nerve conduction Also prevents hematoma formation when applied in 4th stage (recovery) Instructions: on for 20 mins, off for 10 mins ○ Peri Bottle: plastic squeeze bottle filled with warm water Spray over perineal area after each voiding and before applying a new peri pad Make sure pt educated on spraying from front to back ○ Sitz bath - room temp water Used after the first 24 hrs as sub for ice pack Also reduces local swelling and pain Educate to cleanse before using (shower or peri bottle) ○ Local anesthetics and/or analgesic meds for pain ___________________________________________________________________________ 15. Education on birth control after you have a baby Menstruation returns ~7-9 weeks after birth if not lactating ○ If lactating: depends on frequency + duration of breastfeeding (2-18 months) Ovulation can occur before your first menstruation returns Dispel the myth that you can’t get pregnant while breastfeeding - They need to be aware that it’s definitely possible ○ If using breastfeeding as contraception, need to ensure you breastfeed every 4 hours during the day and every 6 hours at night No breaks from this schedule! ___________________________________________________________________________ 16. Know about postpartum depression (Domestic violence + other risk factors) Postpartum Depression occurs within 1st year of birth + usually won’t resolve w/o intervention Risk factors for Perinatal mood disorders: ○ Decreased social support system ○ Anxiety about new role as parent; low self-esteem ○ Individual socioeconomic factors ○ History of previous depressive disorder ○ Unintended pregnancy ○ Thyroid imbalance, diabetes, infertility ○ Complications/difficulty with breastfeeding ○ Younger age ___________________________________________________________________________ 17. Education on breastfeeding in general Should feed baby 8-12 times in the first 24 hrs ○ After that, feed on demand Educate parents to keep track of how many wet diapers ○ When baby is getting enough, should be ~6-8 per day Normal stool for breastfeeding infant = yellow-gold, loose, stringy-pasty, sour smell Proper latch: To prevent soreness, newborn should take in part of areola as well, not just tip of the nipple ○ If correct, newborn’s nose, cheeks, and chin should all be touching the breast ___________________________________________________________________________  18. Signs of postpartum hemorrhage + education Saturating pad completely in 15 mins ○ Blood pooling under mom Constant oozing, trickling, or frank flow of bright red blood from vagina Passing large clots (larger than a quarter) Return to previous lochial stage ○ Lochia serosa → Lochia Rubra Uterine atony - hypotonic or boggy Tachycardia + Hypotension Oliguria Pallor of skin + mucous membranes ○ Cool and clammy Education: ○ Most often caused by uterus not contracting back down (atony) ○ Risk Factors: Precipitous labor (lasts less than 3 hours) Prolonged 3rd stage of labor (lasts more than 30 mins) Placenta previa or placental abruption Labor induction or augmentation ___________________________________________________________________________ 19. Everything about uterine atony Uterus unable to contract back down May lead to postpartum hemorrhage Assessment findings: ○ Uterus is larger than usual, boggy, w/ possible lateral displacement on palpation ○ Irregular or excessive bleeding ○ Pallor, tachycardia, hypotension Risk factors for atony: ○ Retained placental fragments ○ Precipitous or prolonged labor ○ Oxytocin induction or augmentation of labor ○ Overdistention of the uterine muscle: Multiparity or multiple gestation Polyhydramnios Macrosomia  ○ Magnesium sulfate admin as tocolytic ○ Anesthesia/Analgesia admin ○ Trauma from operative delivery Forceps-assisted Vacuum-assisted Cesarean ___________________________________________________________________________ 20. Kegels Pelvic Floor exercises Helps with or prevents urinary incontinence (stress incontinence) Muscles used to stop urine stream mid-flow Do them multiple times per day ___________________________________________________________________________ 21. PEs/DVTs education Prevention of DVTs: ○ Ambulation ASAP! ○ Graduated compression stockings + Sequential compression devices ○ Prevent venous pooling: Avoid putting pillows under knees Avoid crossing legs for long periods Don’t leave legs up in stirrups for long periods ○ Pad stirrups to reduce pressure in popliteal area ○ Avoid standing or sitting in one position for prolonged periods ○ Increase fluid intake to prevent dehydration Signs/Symptoms (PE): ○ Sudden death possible ○ Chest pain ○ SOB/dyspnea ○ Hypoxia Signs/Symptoms (DVT): (unilateral) ○ Calf pain/tenderness ○ Warmth/Redness ○ Edema ○ Venous distention Care: ○ Treat DVTs with heparin to prevent progression of thrombosis to PE ___________________________________________________________________________  22. Signs of hypovolemic shock – always a risk Diaphoresis, tachycardia, anxiety Cool extremities, cap refill increase Oliguria Postural hypotension if moderate, hypotension if severe Agitation/confusion if severe ___________________________________________________________________________ 23. Signs of infection Fever above 38°C or 100.4°F Chills Increased abdominal pain Change in color or odor of lochia Increased redness, warmth, swelling, or drainage from a wound site ___________________________________________________________________________ 24. Know about erythromycin and vitamin k Vitamin K (thighs) ○ Injected at birth to stimulate clotting factors w/o: risk of VKDB - Vitamin K Deficient Bleeding (life-threatening) Onset usually w/in first 7 days - may begin in otherwise healthy babies up to 6 months old ○ Vitamin K not produced by newborn’s GI tract until ~day 7 ○ IM route into vastus lateralis (thigh muscle) ○ Education point: if parents refuse K, baby can’t get circumcised Erythromycin (eyes) ○ Prophylactic antibiotic ointment applied to eyes Prevents ophthalmia neonatorum Can cause blindness Caused by gonorrhea or chlamydia bacteria Infections may be transmitted during descent through birth canal ○ Typically given within the first hour of life ___________________________________________________________________________ 25. What elevated bilirubin looks like in a newborn Jaundice ○ Yellowing of skin, mucus membranes, sclera - usually on face first ○ Light colored stools + dark urine ○ Feeding difficulties + drowsiness ___________________________________________________________________________  26. Need to know about meconium Meconium = newborn’s first stool ○ Thick, Dark Green, Sticky ○ Usually passed within 48 hrs of birth May be passed before birth, in the womb Possible causes for passing meconium in utero: ○ Transient hypoxia, Cord compression ○ Prolonged pregnancy ○ Intrauterine growth restriction ○ Maternal HTN, diabetes ○ Chorioamnionitis ○ Breech presentation If meconium present in amniotic fluid (apparent during rupture of membranes), priority is preventing meconium aspiration during the birth ○ Suction after the head is born before the infant takes its first breath ○ Possibly also direct tracheal suctioning after birth if low Apgar score ○ Amnioinfusion may be done beforehand to dilute moderate to heavy meconium released in utero For Meconium Aspiration Syndrome (MAS): See #57 ___________________________________________________________________________ 27. Know all the fun stuff about thermoregulation Baby maintains body temp through: ○ Flexed posture (holding limbs close to trunk - curled up) ○ Brown Fat: Special type of adipose - highly vascular - that generates heat that warms the blood that flows through it Brown fat oxidizes in response to cold exposure, the oxidative metabolism generates a ton of heat Remember that baby can’t shiver Heat loss can lead to cold stress  Types of heat loss: ○ Conduction When objects are in direct contact w/ each other Baby placed on a cold surface, or touched with cold object ○ Evaporation Body heat is lost when a liquid evaporates off baby’s skin ○ Convection Heat flows from body surface to surrounding cool air Prevent by wrapping baby so less of their skin is exposed to the air ○ Radiation When a cold surface is close to baby’s body, but not directly touching it Heat flow: Baby → Cold air pocket → Cold solid surface How do we keep baby warm? ○ Dry immediately after birth Evaporation ○ Skin-to-Skin contact w/ mom as soon as possible ○ Wrap in warmed blankets Convection ○ Delay initial bath until baby’s temp stable Evaporation ○ Avoid placing newborn in drafts or near air vents Convection ○ Avoid placing crib near cold outer walls/windows Radiation ○ Place newborn under temperature-controlled radiant warmer ___________________________________________________________________________ 28. Surfactant - What does it do + What happens if they’re missing it Surfactant: phospholipid that helps with alveoli expansion by reducing surface tension ○ When missing: atelectasis likely - increases work of breathing Leads to hypoxemia + respiratory acidosis Respiratory Distress Syndrome (RDS) caused by surfactant deficiency ___________________________________________________________________________ 29. Reflexes for babies Step Reflex ○ Hold newborn upright w/ feet touching flat surface → baby makes stepping movements ○ Birth → 1 month Sucking + Rooting ○ Stroke cheek or edge of mouth → baby turns toward that side and sucks ○ Birth → 3-4 months (could be up to a year) Tonic Neck (Fencer position) ○ Turn newborn’s head quickly to one side → baby’s arm and leg on that side extend while the opposite side’s arm and leg flex ○ Birth → 3-4 months Palmar Grasp ○ Place finger in newborn’s hand → fingers curl to grasp ○ Lessens by 3-4 months old Moro ○ Triggered when baby is startled or thinks it’s falling ○ Reaches arms out ○ Birth → 6 months (less prominent after 8 weeks) Plantar Grasp ○ Place finger at base of newborn’s toes → toes curl down to grasp finger ○ Birth → 8 months Babinski ○ Stroke outer edge of sole of the foot, moving up toward toes → toes fan out ○ Birth → 1 year ___________________________________________________________________________ 30. Skin findings (Stork bites, milia, etc.) A) Stork Bite ○ AKA Salmon Patch ○ Flat pink or red patch ○ Usually on back of neck, forehead, eyelids, nose, upper lip ○ Usually disappear w/in the first few years of life  B) Milia ○ Tiny white elevated spots ○ Disappear within the first month ○ Due to immature sebaceous glands C) Mongolian spots ○ Flat, blue-gray, blue-green, or brown spots ○ Normally on back and butt ○ Due to abnormal collection of melanocytes ○ Usually fade ~2-3 years D) Erythema Toxicum ○ Newborn rash - Harmless ○ Shows up on day 2-3 ○ Disappears around 1-2 weeks old ○ Red blotches w/tiny white or yellow “pimple” in center E) Port wine stain ○ AKA Nevus Flammeus ○ Flat pink or red discoloration ○ Most common on face/neck ○ May grow in size or become darker or thicker over time ○ Caused by abnormally developed blood vessels in skin ○ Don’t go away on their own - cosmetic issue only F) Strawberry Hemangioma ○ Raised red/purple benign tumor made of blood vessels clumped together under skin ○ Grows rapidly during first year ○ Most will fade, but it may take several years ○ Only need removal if very large/interferes w/ function G) Harlequin Sign ○ Due to immature circulation ○ Newborn who has been laying on their side will appear red on the dependent side of the body and pale on the upper side ○ Not an issue, resolves itself ___________________________________________________________________________ 31. Acrocyanosis Cyanotic hands, feet, and perioral area (lips) Normal finding at birth Typically resolves in 24-48 hrs ___________________________________________________________________________  32. Rh (–) mom interventions Rh-negative mom should receive RhoGAM at 28 weeks + again within 72 hrs after childbirth if Rh-Positive baby ○ RhoGAM prevents development of antibodies that would attack Rh-positive RBCs → hemolytic disease of the newborn otherwise likely in 2nd Rh+ exposure Indirect Coombs test: Determines whether there are antibodies against Rh factor in the mother’s blood ___________________________________________________________________________ 33. PROM + PPROM (+ Nursing interventions and teachings) Premature/Prelabor rupture of membranes (PROM): Assess for signs of labor beginning Discharge home if labor hasn’t begun within 48 hrs ○ Send pt with prophylactic ABX, activity restriction, and instructions for infection prevention ○ Daily temperature checks + fetal kick counts ○ Avoid any touching of breasts (could stimulate labor) ○ Do not insert anything into vagina (no tampons, no sex) May induce labor if fetal lungs mature enough Increases risk of infection ○ Assess for any signs of active infection Increased maternal temp and HR Cloudy/Foul-smelling amniotic fluid Fetal tachycardia (above 160 bpm) ○ No unsterile digital cervical exams until active labor! PPROM: Preterm Premature/Prelabor Rupture of Membranes ○ Rupture prior to labor onset + less than 37 weeks gestation ○ May give corticosteroids to mature fetal lungs + attempt to delay labor to give them time to develop further ___________________________________________________________________________ 34. Everything about miscarriages (Spontaneous vs elective abortion) Abortion = Loss before 20 week gestation ○ Spontaneous abortion = miscarriage ○ Elective abortion = procedure Bleeding in first trimester - report to HCP and come into office immediately ○ Instruct to bring in any passed clots/tissue fragments she can for analysis ___________________________________________________________________________ 35. Placental abruption + placenta previa + uterine rupture Placental Abruption ○ Separation of the placenta from the uterine wall prematurely ○ VERY high risk of maternal-fetal mortality Baby no longer receives blood from placenta once it’s detached If mom’s bleeding is severe (hemorrhage) → shock → death ○ Signs/Symptoms: Severe abdominal pain, back pain common as well Uterine tenderness/rigidity Usually Dark red vaginal bleeding (sometimes bright red) Patient may have rigid, board-like abdomen due to accumulation of blood in the abdomen s/s of hemorrhagic shock (pallor, tachypnea, hypotension+tachycardia) ○ Treatment: Emergency C-Section Nothing can be done for abruption other than delivering the baby and stopping the bleeding Nursing care for hemorrhagic shock: IV fluids, blood products, oxygen Avoid manual vaginal exams! ○ Risk Factors: Preeclampsia, gestational HTN Seizure activity Maternal age above 34 Uterine rupture Trauma Smoking or cocaine Infection Placenta Previa ○ Placenta implants very near to or over the cervical os ○ Can cause bleeding during the 3rd trimester ○ Signs/Symptoms: Painless, bright red vaginal bleeding ○ Risk Factors:  Previous C-section Infertility treatments Short interval between pregnancies Maternal age above 34 Uterine fibroids/scarring Uterine Rupture ○ Uterine wall tears - may be a complete tear where uterine contents spill into the abdominal cavity Possible for the baby to move into the abdomen when it’s time to deliver ○ Typically happens during a vaginal birth after cesarean (VBAC) when scars from previous C-section tear during labor Can also happen if scars from other uterine or abdominal surgeries are present ○ Leads to catastrophic hemorrhage + fetal anoxia ○ Often marked by sudden fetal bradycardia ○ Treatment = rapid surgery ○ Risk factors: Uterine scars Prior cesarean births Prior rupture Trauma Prior invasive molar pregnancy History of placenta percreta or increta Malpresentation Cocaine use ___________________________________________________________________________ 36. Magnesium sulfate (When it’s given and why) Depresses the CNS to prevent seizures for patients with eclampsia or severe preeclampsia ○ If seizure has occurred, it can be given to prevent another Continued for at least 24 hrs Standard seizure prophylaxis for HELLP Syndrome Also given as tocolytic to stop preterm labor ○ Off-label use  Toxicity = absence of deep tendon reflexes, decreased respiration, dysrhythmias, ALOC ○ Treat with calcium gluconate or calcium chloride ___________________________________________________________________________ 37. Cervical cerclage Prophylactic procedure for Cervical Insufficiency (premature cervical dilation) Surgical reinforcement of the cervix with a heavy ligature placed submucosally around the cervix to strengthen it and prevent dilation Best results: placed at 12-14 weeks Removed at 36-38 weeks of gestation or when spontaneous labor occurs ___________________________________________________________________________ 38. HELLP Syndrome Note: HELLP syndrome is diagnosed by laboratory tests H: Hemolysis: resulting in anemia and jaundice EL: Elevated liver enzymes LP: Low platelets (less than 100,000/mm3), resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly DIC Severe variant of gestational HTN/preeclampsia/eclampsia Management: ○ Stabilization of blood pressure ○ Seizure prevention w/ magnesium sulfate ○ Steroids for fetal lung maturity if necessary ○ Birth of infant and placenta ○ Treat coagulopathies that accompany HELLP Increased risk of complications: ○ Cerebral hemorrhage ○ Retinal detachment ○ Hematoma/Liver rupture ○ DIC ○ Placental abruption ○ Eclampsia ○ Acute renal failure ○ Pulmonary edema ○ Maternal death ___________________________________________________________________________ 39. Anemia (Iron-Deficiency) Assessment Findings: ○ Fatigue ○ Weakness ○ Malaise ○ Anorexia ○ Susceptibility to infection (frequent colds) ○ Pale mucous membranes ○ Tachycardia ○ Pallor Abnormal lab results: ○ low hemoglobin ○ low hematocrit ○ low serum iron ○ low serum ferritin Teaching Guidelines: ○ For best absorption, take iron supplements with Vitamin C Empty stomach = better absorption, but can take with meals if GI side effects bother you ○ Increase exercise, fluids, and high-fiber foods to reduce constipation ○ Foods rich in iron: Meats Green leafy veggies Legumes, Peanut butter Dried fruits Whole grains/whole-wheat fortified breads and cereals ___________________________________________________________________________ 40. Diabetes → Infant of a diabetic mother Very high risk for hypoglycemia (due to hyperinsulinemia) Also increased risk for: ○ Preterm birth ○ Macrosomia ○ Asphyxia ○ Respiratory distress (RDS)  ○ Hypocalcemia ○ Hyperbilirubinemia ○ Polycythemia ○ CNS or Cardiac abnormalities Care: ○ Correct hypoglycemia + hypocalcemia ○ Start phototherapy for jaundice ○ Administer fluids ○ Maintain oxygen/ventilation if compromised ○ Prevent hypoglycemia by initiating oral feedings within 1 hour of birth Breastmilk or formula Repeat every 2-3 hrs Monitor blood glucose via heel stick ___________________________________________________________________________ 41. Risk factors for developing herpes in the newborn What’s the #1 risk factor? → Mother has primary infection near delivery Transmission associated with significant acute + chronic morbidity and mortality If mom has primary HSV infection around time of delivery→ 30-50% risk of transmission (primary = first/initial outbreak) ○ If she has an active recurrent flare-up → 1-3% risk Majority of mother-to-child transmission of HSV infection occurs as a result of exposure to virus shed from the genital tract as a neonate passes through the birth canal ___________________________________________________________________________ 42. Different drugs ppl take that cause issues Alcohol → Fetal alcohol syndrome/spectrum disorders ○ Growth restriction, craniofacial structural anomalies, CNS dysfunction Tobacco/nicotine → impaired oxygenation, low birth weight, SGA, Preterm ○ Increased risk for sudden infant death syndrome + chronic resp. Illness Marijuana → SGA + Fetal growth restriction common ○ No identified teratogenic effects/malformations Methamphetamines → Infant may be born with withdrawal symptoms ○ High-pitched cry, jitteriness, agitation, poor feeding and sleep ○ Increased risk for preterm birth and low birth weight  Cocaine → preterm/low birth-weight, learning/memory issues ○ GU, Cardiac, and CNS defects ○ Prune belly syndrome Heroin → Baby born dependent on heroin ○ Risk of transmission of Hep B/C + HIV if mom shared needles ○ Stillbirth, fetal growth restriction, Preterm birth, Newborn mortality ○ Abrupt cessation of heroin use may lead to intrauterine death or preterm Methadone → Improvement in many of the detrimental fetal effects associated with Heroin use, but increased severity + longer period of withdrawal (long ½ life) ○ Seizures, usually severe, occur around 2 - 3 weeks of age ○ Increased rate of SIDS ___________________________________________________________________________ 43. Know about HIV + pregnancy HIV can be transmitted to the baby before birth, during birth, or through breastfeeding Mom needs to take antiretroviral medication continually during pregnancy ○ During labor, an antiretroviral is given IV until birth ○ An Antiretroviral is given to the newborn within 6-12 hrs of birth and continued for 6 weeks ___________________________________________________________________________ 44. Fetal demise (How you take care of a pt that loses their baby) Therapeutic communication + common sense? Use the word “died” and avoid euphemisms to facilitate coping ___________________________________________________________________________ 45. Umbilical cord prolapse Umbilical cord protrudes through the cervix/precedes the presenting part of the fetus Results in cord compression + compromised fetal circulation (Emergency!) Nursing Care: ○ Call for help immediately! (But do NOT leave the patient) ○ Use a STERILE-GLOVED hand, insert 2 fingers, lift the presenting part of the fetus off of the cord Stay in this position until the birth of the baby  Prepare for immediate birth (vaginal if fully dilated, cesarean if not) ○ Apply a warm, sterile, saline-soaked cloth to the visible portion of the cord to prevent drying and maintain blood flow ○ Reposition patient to a position that will relieve pressure on the cord: Knee-chest Trendelenburg Modified lateral semi-prone recumbent ○ Look for variable decelerations (indicates fetal hypoxia) ○ Oxygen via mask to improve fetal oxygenation ○ IV access + fluid bolus ___________________________________________________________________________ 46. Vacuum extraction (What your care will be/All the things about it) Suction-attached cup on top of baby’s head provides traction/rotation to deliver Indicated for: ○ Prolonged 2nd stage of labor ○ Distressed FHR pattern ○ Failure of presenting part to fully rotate and descend in pelvis ○ Limited sensation and inability to push effectively ○ Presumed fetal jeopardy or fetal distress Risk for cephalohematoma Risk of tissue trauma to mother and baby ___________________________________________________________________________ 47. Different birthing positions Standing ○ Takes advantage of gravity during and b/w contractions ○ Helps fetus line up with angle of maternal pelvis ○ Makes contractions feel less painful + be more productive Walking ○ Same advantages as standing ○ Helps fetus move through the birth canal Standing + leaning forward (on partner, bed, or birthing ball) ○ Same advantages as standing ○ May feel more restful than standing ○ Can be used with electronic fetal monitor Slow dancing  ○ Apparently this is a thing too Lunge - step lunge-foot up on a chair seat ○ Widens one side of the pelvis ○ Encourages rotation of baby Sitting upright or Semi-sitting: Head of bed at 45 degree angle ○ Helps promote rest ○ Has more gravity advantage than lying down ○ Can be used w/electronic fetal monitor Sitting on toilet or commode ○ Same advantages of sitting upright + may help relax the perineum for more effective bearing down On all fours - hands and knees ○ Helps relieve backache ○ Assists rotation of baby in posterior position ○ Allows for pelvic rocking + body movement ○ Relieves pressure on hemorrhoids ○ Allows for easy vaginal examinations Side-Lying ○ Convenient for different medical interventions ○ Restful position - good for conserving energy ○ Helps lower elevated bp ○ Useful for slowing a rapid 2nd stage ○ Avoids vena cava syndrome Squatting ○ Takes advantage of gravity ○ Requires less bearing-down effort ○ Widens pelvic outlet ○ Pressure evenly distributed to perineum Reduces need for episiotomy ○ May help fetus turn + move down in a difficult birth ○ Helpful if woman feels no urge to push ___________________________________________________________________________ 48. Babies that are over- gestational age (What are the risk factors for a 42-weeker) Risk factors: ○ Previous post-term birth  ○ Maternal obesity ○ First time pregnant ○ Advanced maternal age ○ Genetic predisposition Fetal risks: ○ Macrosomia ○ Shoulder dystocia ○ Brachial plexus injuries ○ As placenta ages, its perfusion decreases Less efficient at delivering nutrients/oxygen to fetus ○ Amniotic fluid volume begins to decline after 38 weeks May lead to oligohydramnios → fetal hypoxia/cord compression ___________________________________________________________________________ 49. How can you tell if a newborn is dehydrated Sunken eyes Few or no tears when crying Dry diaper for 6 or more hours Fontanelle looks sunken Dry or sticky mouth Tachycardia Irritability ___________________________________________________________________________ 50. Everything about RDS Caused by surfactant deficiency in the lungs ○ Surfactant: phospholipid that helps with alveoli expansion by reducing surface tension When missing: atelectasis likely - increases work of breathing Leads to hypoxemia + respiratory acidosis Signs/Symptoms in a baby: ○ Shallow + rapid respiration Tachypneic w/ RR > 60 bpm ○ Expiratory grunting ○ Nasal flaring ○ Sternal retractions ○ Prolonged expiration ○ Inspiratory lag ○ Cyanosis  ○ Auscultation = Fine crackles Care for RDS: ○ Meds: end in “-actant” + restore surfactant to baby’s lungs ○ Suction ○ ET tube placement ○ Vent support to correct resp. Acidosis Metabolic acidosis possible - admin bicarb instead ○ Maintain thermoregulation, oxygenation, and hydration __________________________________________________________________________ 51. Risk factors for small-for-gestational-age Definition of SGA = At or below the 10th percentile/has intrauterine growth restriction Risk Factors: ○ Advanced maternal age ○ Maternal HTN/Preeclampsia/Diabetes/Autoimmune diseases ○ Smoking ○ Low socioeconomic status, no prenatal care ○ Substance abuse ○ Maternal nutrition Malnutrition or obesity ○ Placenta previa ○ Placental insufficiency ○ Multiple fetal gestation ___________________________________________________________________________ 52. What would you suspect for neurologic impairment Sorry, I literally don’t understand this vague ass question so I’ll just list a bunch of possibly related stuff Brachial plexus injury from birth trauma (often involving shoulder dystocia) ○ Erb palsy possible (unilateral arm: may be stiff/crooked, flaccid, weak) Also breech birth ○ Klumpke palsy possible (Claw hand sign, difficulty w/ hand movements) Facial nerve injury from birth trauma ○ Often from foceps ○ Asymmetrical facial droop - causes difficulty nursing Intraventricular/periventricular hemorrhage  ○ Brain bleed (around or into ventricles) due to fragile cerebral vessels ○ Most common in infants born before 33 weeks ○ Signs/Symptoms Sometimes none - found incidentally in imaging Possible: respiratory distress, seizures, stupor Bulging fontanelle ○ Long term effects dependent on area, size, and pressure of hemorrhage Neural tube defects ○ Spina bifida (occulta, meningocele, myelomeningocele) Myelomeningocele may involve: paralysis, incontinence, hydrocephalus ○ Anencephaly - not compatible with life ___________________________________________________________________________ 53. Everything with large for gestational age babies Risk factors: ○ Maternal diabetes or obesity ○ Multiparity ○ Prior LGA ○ Postdate gestation ○ Genetics Common characteristics and problems: ○ Large body, full-faced ○ Poor motor skills ○ Difficulty regulating behavioral states ○ Hypoglycemia ○ Polycythemia ○ Hyerbilirubinemia ○ Birth trauma (due to macrosomia) ___________________________________________________________________________ 54. Back into jaundice – teachings for phototherapy Promote breastfeeding to make sure newborn is well-hydrated and fed → stooling frequently to promote bilirubin elimination as phototherapy breaks it down Avoid routine supplementation with water or dextrose+water (unless baby is dehydrated)  ○ They don’t reduce serum bilirubin and might interfere w/breastfeeding Don’t want them to fill up on water b/c breastfeeding will promote stool For effective phototherapy, the light has to touch as much of the baby’s skin as possible ○ Newborn should be naked and turned frequently ○ Eyes must be covered to prevent damage Closely monitor: body temperature, fluid + electrolyte balance, urine output + specific gravity (for hydration status), stool frequency/consistency Observe skin integrity Remove baby from light every 4 hrs to unmask their eyes + check for inflammation/injury ○ Take axillary temperature @ every 4 hr mark as well Common side effects: ○ Frequent, loose stools May be green from excess bile flow ○ Increased insensible water loss: contributes to dehydration, may need to address ○ Transient maculopapular skin rash - not a concern ○ Bronze discoloration - harmless + temporary - not a concern ○ Dehydration - assess for carefully and frequently - major concern ○ Elevated temperature - track carefully ___________________________________________________________________________ 55. Necrotizing enterocolitis (NEC) Inflammatory disease of the bowel ○ Causes ischemic + necrotic injury in the GI tract Associated with significant acute and chronic morbidity and mortality Usually occurs b/w 3-12 days of life (but sometimes weeks later) Highest risk = Preterm NICU babies who are formula fed ○ Newborns who are exclusively breastfed have reduced risk of NEC Other risk factors: ○ Preterm labor or prolonged rupture of membranes ○ Preeclampsia ○ Maternal sepsis or amnionitis ○ Uterine hypoxia ○ Patent ductus arteriosus, congenital heart diseases ○ Low birth weight  ○ Low apgar scores ○ GI infection ○ Hypoglycemia, Hypothermia ○ Respiratory Distress Syndrome (RDS) Patho not fully understood, but there are 3 Pathologic Mechanisms believed to lead to NEC: ○ Bowel hypoxic-ischemia events, perinatal stressors During stress, oxygen is shunted away from the gut → brain/heart Leads to ischemia + intestinal wall damage ○ Bacterial flora - abnormal colonization Due to preterm’s underdeveloped immune defense + mucosal barrier function ○ Formula feeding High solute feedings allow bacteria to flourish Signs/Symptoms: ○ abdominal distention and tenderness ○ bloody stools ○ feeding intolerance (bilious vomiting) ○ Diarrhea and vomiting ○ Sepsis ○ Lethargy ○ Apnea ○ shock Management: ○ Maintenance of fluid + nutritional status (IV fluids + TPN) ○ Bowel rest + antibiotic therapy ○ Surgery (bowel resection) with proximal enterostomy (usually temporary) ○ Supportive care + family education ___________________________________________________________________________ 56. Cephalohematomas + Caput Succedaneum Cephalohematoma ○ Doesn’t cross the suture line ○ Hematoma ∴ gathering of blood ○ Caused by excessive pressure on the scalp - difficult deliveries Commonly caused by vacuum extraction  Caput Succedaneum: Newborn Conehead ○ Typically crosses suture line ○ Swelling that contains serous fluid ○ Caused by pressure squeezing on the head by the uterus or vagina during a head-first delivery Commonly caused by long delivery - prolonged pressure ___________________________________________________________________________ 57. Meconium aspiration (Findings + Care) Meconium Aspiration Syndrome (MAS) ○ Can cause respiratory failure ○ Meconium aspiration induces: Airway obstruction Surfactant dysfunction Hypoxia Chemical Pneumonitis ○ Severe MAS can lead to persistent pulmonary HTN and Death Treat with surfactant + inhaled nitric oxide ○ Findings: Respiratory distress Fine crackles on auscultation Cyanosis Barrel-shaped chest Green-stained amniotic fluid, fingernails, skin, or umbilical cord CXR = Patchy, fluffy infiltrates; hyperaeration w/atelectasis ○ Care: Suction mouth, trachea, and nose as needed Keep newborn warm to conserve energy and prevent cold stress Handle baby as little as possible to decrease oxygen requirement Cluster care to allow for rest Administer exogenous surfactant if necessary ___________________________________________________________________________ ___________________________________________________________________________ Extra Notes: Newborn Vital Signs: Temperature ○ F: 97.7 - 99.5 ○ C: 36.5 - 37.5 Heart Rate ○ 110 - 160 bpm ○ May increase to 180 while crying Respirations ○ 30 - 60 bpm at rest ○ Increases while crying Blood Pressure ○ 50 - 75 (Systolic Range) ○ 30 - 45 (Diastolic Range)