Maternity Study Guide 1 PDF

Study Guide 1 1)​ Describe legal and ethical issues that influence the nursing care of childbearing families. a.​ ANA: 9 Provisions in code of ethics, practice standards. 1)​ Compassion 2)​ Commitment 3)​ Advocates 4)​ Accountability 5)...

Study Guide 1 1)​ Describe legal and ethical issues that influence the nursing care of childbearing families. a.​ ANA: 9 Provisions in code of ethics, practice standards. 1)​ Compassion 2)​ Commitment 3)​ Advocates 4)​ Accountability 5)​ Personal growth 6)​ Effort 7)​ Research 8)​ Human rights and disparities 9)​ Justice b.​ AWHONN (Association of Women’s Health, Obstetric, & Neonatal Nurses) -​ Protection of individual nurses’ rights to choose to participate in any reproductive health care service or research activity -​ Nurses must consider access to affordable and acceptable health care services as a basic human right -​ Plays significant roles in advancing nursing practice and improving outcome for women and newborns c.​ State Nursing Practice Acts -​ Laws put in place by states to govern the practice of nursing within the particular state -​ Scope of practice -​ Licensure requirements -​ Standard of practice -​ Education programs -​ Grounds for disciplinary procedures 2) Define ethical terms: a.​ Beneficence: kindness and charity, which requires action on the part of the nurse to benefit others b.​ Nonmaleficence: nonmaleficence requires that nurses avoid causing harm to patients c.​ Fidelity: the fidelity ethical principle can best be described by keeping your word to patients d.​ Veracity: being completely truthful with clients, families, coworkers e.​ Autonomy: the right of self determination, or the right of the individual to make their own choice  f.​ Justice: patients have a right to fair and impartial treatment, which means no matter what a patient’s insurance status or financial resources may be, or what gender identification, age, or ethnicity they are, they have the right to fairness in nursing decisions g.​ Breach of privacy: HIPAA violations h.​ Malpractice: improper, illegal, or negligent professional activity or treatment i.​ Informed consent: educates a patient about risks, benefits, and alternatives of a given procedure or intervention before undergoing it 3) Discuss the impact of culture when caring for the childbearing family. a.​ How to assess? What is cultural humility? Assess (covered later on) Cultural humility: ways people build trusting relationships with each other and acknowledges that everybody has their own individual experiences, beliefs, values, & identities -​ 4 core tenets 1)​ Critical self reflection and lifelong learning 2)​ Recognizing and mitigating inherent power imbalance 3)​ Creating beneficial partnerships 4)​ Creating institutional alignment and accountability 4) Describe evidence-based practice in nursing, including a rationale for its use. a.​ Define EBP (pg. 30) EBP: integrating best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care 5) Discuss current trends in maternal and infant health outcomes. a.​ Define infant mortality: death before age of one b.​ Define maternal mortality: death of a woman during pregnancy or within 42 days of pregnancy termination caused by conditions aggravated by the pregnancy c.​ Trends/issues: issues include teen pregnancy, tobacco, electronic cigarette use, substance use, medications, obesity, violence, STIs, climate change, depression, mood disorders, racism, & health disparities during pregnancy 6) Discuss AWHONN’S Perinatal Quality Measures (pg. 33) -​ Using evidence based education and practices -​ Nursing shapes the environment 7) Examine healthy people 2030 goals related to maternal and infant care (table 1-6). -​ Reducing rate of maternal mortality -​ Reducing rate of infant mortality -​ Reducing rate of preterm births  -​ Increase the proportion of women delivering a live birth who had a healthy weight prior to pregnancy -​ Increase the proportion of women are screened for postpartum depression at their postpartum checkup -​ Increase the proportion of infants who are breastfed Module 2 (chp. 12, 13, 16) 1)​ Describe the basic physiologic, emotional, and psychological changes that occur during the postpartum period. a.​ Rubin’s Taking In, Taking Hold, Letting Go (Table 13-1) 1)​ Taking in phase: -​ First 24-48 hours after birth -​ Woman focused on her own personal comfort and physical changes -​ Woman relives and speaks of the birth experience -​ Woman adjusts to psychological changes -​ Woman is dependent on others for her and her infant’s immediate needs -​ Woman has a decreased ability to make decisions -​ Woman concentrates on personal physical healing 2)​ Taking hold phase: -​ 24-48 hours post birth and can last weeks -​ Movement between dependent and independent behaviors -​ Focus moves from self to the infant -​ Woman begins to be independent -​ Woman has increased ability to make decisions -​ Woman is interested in the infant’s cues and needs -​ Woman gives up the pregnancy role and initiates taking on the maternal role -​ Woman is eager to learn -​ Excellent time to initiate postpartum teaching -​ Woman begins to like the role of mother -​ Woman may have feelings of inadequacy & being overwhelmed -​ Woman needs verbal reassurance that she is meeting her infant’s needs -​ Woman may show S/S of baby blues & fatigue -​ Woman begins to let more of the outside world in 3)​ Letting go phase: -​ Movement from independence to the new role of mother if fluid and interchangeable with the taking-hold phase -​ Grieving and letting go of old relationship behaviors in favor of new ones -​ Incorporating the infant into her life -​ Separates newborn’s entity from her own -​ Accepting the infant as the child really is  -​ Giving up fantasy of what it would or could have been -​ Independence returns; may return to school or work -​ May have feelings of grief, guilt, or anxiety -​ Reconnection & growth in relationship with partner b.​ Define postpartum blues versus postpartum depression Postpartum blues Postpartum depression -​ First few weeks postpartum -​ Major depressive disorder with -​ Woman feels sad & cries easily but is peripartum onset able to take care of herself & her -​ 10-20% of women have depression or infant anxiety during pregnancy or Causes postpartum period, making this the -​ Changes in hormonal levels most common complication of -​ Fatigue childbirth -​ Stress from taking on the new role of -​ Important to ask about mood mother -​ Characterized by severe depression S/S that occurs within 6-12 months -​ Anger postpartum -​ Anxiety -​ Depressed mood or a loss of interest -​ Mood swings for 2 weeks in addition to four of the -​ Sadness following symptoms -​ Weeping -​ Significant weight loss or gain: -​ Difficulty sleeping a change of more than 5% of -​ Difficulty eating body weight in a month Nursing actions -​ Insomnia or hypersomnia -​ Explain this occurs in the majority of -​ Changes in psychomotor postpartum women activity -​ Explain the importance of rest in -​ Decreased energy or fatigue reducing stress -​ Feelings of worthlessness or -​ Explain to the woman’s partner in the guilt importance of emotional & physical -​ Decreased ability to support during this period of time concentrate; inability to make -​ Explain that the woman of family decisions should seek assistance from the -​ Decreased interest in normal health-care provider if the symptoms activities persist beyond 4 weeks or if symptoms Risk factors concern the woman or her family, as -​ History of depression she may be experiencing postpartum -​ Depression or anxiety during depression pregnancy -​ Inadequate social support -​ Poor quality relationship with partner -​ Life and childcare stresses -​ Complications of pregnancy or childbirth  -​ Low level of support from mother or mother figure -​ Low socioeconomic status -​ History of childhood sexual abuse -​ Domestic or intimate partner violence Assessment findings -​ Sleep and appetite disturbances -​ Fatigue greater than expected -​ Despondency, uncontrolled crying, anxiety, fear, or panic -​ Inability to concentrate -​ Feelings of guilt, inadequacy, or worthlessness -​ Inability to care for self or baby -​ Decreased affectionate contact with infant -​ Decreased responsiveness to infant -​ Thoughts of harming baby -​ Thoughts of suicide Nursing actions -​ Education and support! c.​ Define the characteristics of a normal postpartum assessment -​ Vital signs, pain, breath, & heart sounds -​ Laboratory findings, such as CBC, rubella status. & Rh status -​ Vaccination status, including tetanus, diphtheria, & acellular pertussis (Tdap); influenza; pneumococcal; Covid 19 vaccine -​ Breasts -​ Uterus -​ Bladder -​ Bowel -​ Lochia -​ Episiotomy, lacerations, perineum, hemorrhoids -​ Lower extremities -​ Emotions, bonding with infant, fatigue, psychosocial factors d.​ Red flags in the assessment -​ Systolic BP under 90 or over 160 -​ Diastolic BP over 100 -​ HR under 50 or over 120 -​ RR under 10 or over 30 -​ Oxygen sat at room level under 95% -​ Oliguria, mL/hr for over or equal to 2 hours under 35  -​ Maternal agitation, confusion, or unresponsiveness -​ Woman with preeclampsia reporting an unremitting headache or shortness of breath e.​ Vital sign changes -​ Pulse and BP should be within normal ranges -​ After delivery, blood pressure may have a 5% transient elevation -​ Bradycardia may occur post delivery and in the early postpartum period (considered normal) -​ No tenderness or sensation of warmth -​ Orthostatic hypotension may occur first postpartum week -​ Oxygen remains over 95% -​ RR should be within 12-20 bpm and clear (normal) f.​ Lab values Expected assessment findings -​ Blood loss is within normal ranges -​ Hemoglobin and hematocrit within normal ranges 2) BUBBLE HEB– describe the pertinent assessment information below. a.​ Breast -​ After delivery, estrogen and progesterone decrease and prolactin increases -​ Prolactin stimulates breast milk production -​ Infant suckling causes posterior pituitary to release oxytocin, resulting in milk ejection reflex -​ Breast fullness is normal -​ Breast tissue may be swelling, but it is soft & nontender -​ 3rd day postpartum: both breastfeeding & non breastfeeding women will experience primary breast engorgement→ large, firm warm, and tender, possible w/ throbbing -​ Subsides within 24-48 hours 1)​ Colostrum (yellowish fluid) comes before milk production -​ Higher in protein and lower in carbs that breast milk -​ Contains immunoglobulins G and A, which provides protection for newborn during early weeks of life -​ Continues for 5 days to 2 weeks post delivery 2)​ Mature milk -​ Contains proteins, carbs, fats, minerals, vitamins, hormones, and immunoglobulins -​ Composition of breast milk changes during the deeding and throughout the course of feedings during the day -​ First 24 hours postpartum: breasts are soft and nontender -​ Day 2 postpartum: breasts are slightly firm and nontender -​ Day 3 postpartum: breasts are firm, tender, and warm to touch  -​ Assess breastfeeding nipples for signs of irritation and tissue breakdown (latching issues) -​ Mastitis: an infection of the breast -​ Typically occurs 3-4 weeks postpartum -​ Infection caused by bacteria entering cracks of nipples and associated with milk stasis, engorgement, long intervals between feedings, stress, and fatigue -​ Fever, chills, malaise, and flu like symptoms -​ Unilateral breast pain, redness, and tenderness -​ Treatment: empty the affected breast, antibiotics after culture, adequate nutrition, and hydration -​ Continue to breastfeed or pump -​ Apply moist heat to the affected breast Breast Care Assessment Findings -​ Breast engorgement 1)​ Physiological: breasts are swollen 2)​ Pathological: breasts are hard, swollen, red, tender, or painful, warmful to the touch, throbbing sensation in the breasts, elevated temperature, can cause difficulty latching -​ Treatments for breastfeeding women: -​ Frequent feedings to empty breasts and prevent milk stasis -​ Warm compresses to the breast and breast massage to facilitate the flow of milk before feeding sessions -​ Express milk by breast pump or manually if the infant is unable to nurse -​ Ice packs after feedings to reduce inflammation and discomfort -​ Analgesics for pain management -​ Wear supportive bra -​ Prevention and treatments for non breastfeeding women -​ Wear a supportive bra -​ Avoid stimulating the breast -​ Ice packs to the breast -​ Analgesics for pain management -​ Subsides within 48-72 hours -​ Plugged milk ducts are associated with inadequate emptying of the breasts and stasis of the milk -​ Symptoms: palpation of tender breast lumps the size of peas -​ Treatments: frequent feedings, changing infant feeding positions, application of warm compresses before feeding sessions, massaging the breasts before feeding session -​ Continued milk stasis or unresolved plugged milk ducts can lead to mastitis and potential breast abscess -​ Educate woman to wear a supportive, but non restrictive bra -​ Instruct woman to examine her nipples before feedings for signs of irritation  -​ After feeding, woman should expose her nipples to air -​ Improper latch should be adjusted to decrease nipple tissue breakdown -​ Instruct woman to feed infant frequently on demand or express milk if has engorgement -​ Wash hands frequently and keep breasts clean to prevent infection -​ Provide information on mastitis b.​ Uterus -​ Begins process of involution to return to its prepregnant size, shape, and location -​ Happens through uterine contractions, atrophy of the uterine muscle, & decrease in size of uterine cells -​ Involution happens 6-8 weeks post delivery -​ Primiparous women do not experience discomfort due to uterine contractions because the uterus remains contracted -​ Multiparous women or breastfeeding women may experience afterpains caused by strong contractions for the first few days -​ Afterpains are caused to the uterus working to remain contracted and/or the increase of oxytocin released in response to infant suckling -​ Intensity of afterpains decrease after 3rd postpartum day -​ Uterine contractions decrease chances of PPH b/c contracted uterine muscles compress open vessels at the placental site to decrease the amount of blood loss Nursing Actions -​ Assess the uterus for location, position, and tone of the fundus -​ First hour: every 15 mins -​ Second hour: every 30 mins -​ Next 22 hours: every 4 hours -​ After first 24 hours: every shift -​ Risk for PPH highest in the first hour following delivery 1)​ Primary PPH: occurs in the first 24 hours after birth 2)​ Secondary PPH: occurs from 24 hours to 12 weeks post delivery (prominent first 7-14 days) -​ Instruct woman to void before palpating the uterus -​ Woman should be supine and flat -​ Remove her peripads to evaluate lochia at the same time the fundus is palpated -​ Support lower uterine segment by placing one hand just above the symphysis pubis -​ Give oxytocin per the physician’s or midwife’s postpartum orders to support contraction of the smooth muscle -​ Uterus shifted to the side indicates an overdistended bladder Expected findings -​ Immediately after birth: midway between the umbilicus and symphysis pubis and is firm & midline  -​ Few hours later: at the umbilicus -​ Within 12 hours: level of the umbilicus or 1 cm above the umbilicus and is firm and midline -​ 24 hours after birth: 1 cm below the umbilicus and is firm and midline -​ Uterus descends 1 cm per day -​ By day 14, fundus has descended into pelvis and is not palpable Subinvolution is failure of the uterus to descend or involute as expected, which can be caused by retained placental fragments, infection and overdistended uterus. FUNDAL MASSAGE: for a boggy uterus, use palm of hand in circular motion until firm and reevaluate within 5-10 mins… if uterus does not respond to massage, follow the standing order for oxytocin and notify MD c.​ Bowel -​ GI muscle tone and motility decrease post birth with a return to normal bowel function by the end of the 2nd postpartum week -​ Constipation due to decreased Gi motility from the effects of progesterone -​ Decreased physical activity, dehydration, fluid loss from labor, fear of having bowel movement after perineal lacerations or episiotomy -​ Hemorrhoids -​ Appetite (exceptionally hungry first few days postpartum and can be on a regular diet unless otherwise stated) -​ Weight loss Nursing actions -​ Assess bowel sounds at each shift -​ Notify the physician or midwife if bowel sounds are faint or absent -​ Assess for constipation -​ Bowel movements will usually return 2-3 days -​ Decreased frequency of bowel movements and passage of hard, dry stools indicate constipation -​ Instruct woman to increase fluid intake and increase fiber and roughage in the diet to decrease constipation (water and prune juice) -​ Implement personal strategies to help with constipation -​ Encourage ambulation -​ Administer a stool softener or laxative per orders -​ Assess for hemorrhoids -​ Assess appetite -​ Ask woman if she is nauseous or has vomited Patient education -​ Instruct woman to increase fluid intake and fiber and roughage in diet  -​ Provide nutritional education (especially important for breastfeeding mothers and women who had a C-section) -​ Breastfeeding moms need to increase daily caloric intake by 500-1,000 calories -​ Encourage the woman to ambulate to increase GI motility and decrease risk of gas pains -​ Instruct woman to increase fluid intake to a minimum of 10 glasses per day ​ d.​ Bladder -​ Women at risk for urinary complications after birth -​ Transient incontinence associated with impaired pelvic muscles function involving the urethra may occur in the first 6 weeks postpartum -​ Many factors associated with stress urinary incontinence: pregnancy, multiparity, perineal trauma, infant size, length of second stage labor, and pushing techniques that increase pressure on pelvic floor -​ Primary complications: bladder distention and cystitis Bladder distention: rapid bladder filling, incomplete emptying, and inability to void -​ Related to intravenous fluids in post delivery period, decreased sensation or uge to void b/c of anesthesia or analgesics, edema around urethra, perineal lacerations or episiotomy, operative vaginal delivery, or bladder trauma -​ Diuresis caused by decreased estrogen levels 12 hours after birth, aiding in elimination of excess tissue fluids -​ Urine output may be 3,000 mL or more per day during this time Nursing Actions -​ Assist woman to bathroom and encourage her to void within 2-4 hours post birth -​ Decreases risk of cystitis and prevents bladder distention -​ Assess for urinary disturbances -​ Measure urinary output post birth -​ Should be at least 300 mL within 2-4 hours of delivery -​ Under 150 mL calls for other measures (bladder scan using US, catheterization, peppermint oil to relax urinary sphincter) -​ Assess for frequency, urgency, and burning on urination (cystitis) Expected findings -​ Woman spontaneously voids within 2-4 hours post birth -​ Each voiding is at least 300 mL -​ Woman does not have frequency, urgency, and burning on urination -​ Instruct woman to increase fluid intake to a minimum of 10 glasses per day Cystitis: bladder inflammation or infection -​ Symptoms: frequency, urgency, pain, or burning on urination, suprapubic tenderness, hematuria, and malaise -​ Treatment: antibiotics, therapy, increased hydration, rest  e.​ Lochia Stage Time frame Expected findings Abnormal Lochia rubra Days 1-3 -​ Bloody with small -​ Large clots clots -​ Heavy amount: -​ Moderate to scant saturates pad within 1 amount hr -​ Increased flow on -​ Excessively heavy: standing or saturates pad within breastfeeding 15 mins -​ Fleshy odor -​ Foul odor (sign of infection) Lochia serosa Days 4-10 -​ Pink or brown color -​ Continuation of rubra -​ Scant amount stage after day 4 -​ Increased flow during -​ Heavy amount: physical activity saturates pad within 1 -​ Fleshy odor hr -​ Excessively heavy: saturates pad within 15 mins -​ Foul odor (sign of infection) Lochia alba Day 10 -​ Yellow to white in -​ Bright red bleeding color -​ Saturates pad within 1 -​ Scant amount hr (sign of possible -​ Fleshy odor late PPH) -​ Foul odor (sign of infection) f.​ Episiotomy -​ An incision made in the perineum by delivering provider to provide more space for the presenting part at delivery -​ Routine use of episiotomy is no longer typical, but may be used when clinical circumstances warrant -​ For example, if there is a need to deliver the fetus quickly due to fetal heart tracing concerns or shoulder dystocias -​ Most common type: midline (cut at 90 degree angle toward the rectum) and mediolateral (cut at 45 degree angle) -​ Midline episiotomies associated with higher risks of severe perineal trauma, including third and fourth degree lacerations -​ Mediolateral episiotomies protective against severe perineal trauma, but recent research argues neither helpful or harmful  -​ Midline incision that tends to heal more quickly and cause less pain than a mediolateral episiotomy -​ REEDA: redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration g.​ Homan’s -​ The pain and tenderness elicited on compression of calf muscles by squeezing the muscles or by dorsiflexion of the foot -​ Positive Homan’s sign is calf pain at dorsiflexion of the foot -​ Associated with the presence of thrombosis -​ Supine, knee bent, dorsiflex ankle h.​Hemorrhoids -​ Women commonly develop hemorrhoids during pregnancy or the birthing process -​ Often slowly resolve but can be painful -​ Some hemorrhoids can persist postpartum -​ Hemorrhoids may increase in size during labor and cause discomfort in the postpartum period -​ Instruct woman to lie on her side, then separate her buttocks to expose the anus -​ If hemorrhoids are present: -​ Encourage the woman to avoid sitting for long periods of time by lying on her side -​ Witch hazel pads or topical anesthetics reduce discomfort -​ Sitz baths are helpful in promoting circulation and reducing pain i.​ Emotional Postpartum blues Postpartum depression Postpartum psychosis -​ First few weeks -​ Major depressive -​ Brief psychotic postpartum disorder with disorder with -​ Woman feels sad & peripartum onset peripartum onset cries easily but is able -​ 10-20% of women -​ Relatively rare to take care of herself have depression or -​ Onset of symptoms is & her infant anxiety during rapid and can occur as Causes pregnancy or early as 2-3 days after -​ Changes in hormonal postpartum period, childbirth levels making this the most -​ Presence of at least -​ Fatigue common complication one or more of the -​ Stress from taking on of childbirth following symptoms: the new role of mother -​ Important to ask about -​ Delusions S/S mood -​ Hallucinations -​ Anger -​ Characterized by -​ Disorganized  -​ Anxiety severe depression that speech -​ Mood swings occurs within 6-12 -​ Grossly -​ Sadness months postpartum disorganized -​ Weeping -​ Depressed mood or a or catatonic -​ Difficulty sleeping loss of interest for 2 behavior -​ Difficulty eating weeks in addition to Require immediate medical Nursing actions four of the following attention and acute inpatient -​ Explain this occurs in symptoms psychiatric treatment the majority of -​ Significant -​ Women with postpartum women weight loss or preexisting BPD have -​ Explain the gain: a change highest risk importance of rest in of more than Risk factors reducing stress 5% of body -​ Women with bipolar -​ Explain to the weight in a disorder woman’s partner in month -​ Personal or family the importance of -​ Insomnia or history of bipolar emotional & physical hypersomnia disorder or affective support during this -​ Changes in disorder period of time psychomotor Assessment findings -​ Explain that the activity -​ Paranoia associated woman of family -​ Decreased with the baby should seek assistance energy or -​ Mood swings from the health-care fatigue -​ Extreme agitation provider if the -​ Feelings of -​ Depressed or elated symptoms persist worthlessness moods beyond 4 weeks or if or guilt -​ Distraught feelings symptoms concern the -​ Decreased about ability to enjoy woman or her family, ability to infant as she may be concentrate; -​ Confused thinking experiencing inability to -​ Strange beliefs postpartum depression make -​ Disorganized behavior decisions Medical Management -​ Decreased -​ Hospitalization to interest in psych unit normal -​ Psych eval activities -​ Antidepressant and Risk factors antipsychotic drugs -​ History of depression -​ Psychotherapy -​ Depression or anxiety -​ Electroconvulsive during pregnancy therapy -​ Inadequate social Nursing Actions support -​ Review risk factors -​ Poor quality and history relationship with -​ Educate parents on partner early signs of PPD -​ Life and childcare -​ Early detection and  stresses treatment= prevention -​ Complications of -​ Resources and pregnancy or education childbirth -​ Antidepressants and -​ Low level of support telecommunication from mother or therapy are most mother figure effective interventions -​ Low socioeconomic for PPD status -​ History of childhood sexual abuse -​ Domestic or intimate partner violence Assessment findings -​ Sleep and appetite disturbances -​ Fatigue greater than expected -​ Despondency, uncontrolled crying, anxiety, fear, or panic -​ Inability to concentrate -​ Feelings of guilt, inadequacy, or worthlessness -​ Inability to care for self or baby -​ Decreased affectionate contact with infant -​ Decreased responsiveness to infant -​ Thoughts of harming baby -​ Thoughts of suicide Nursing actions -​ Education and support! j.​ Bonding -​ Affected by time, proximity of parent and infant, whether the pregnancy is planned or wanted, and the ability of parents to process through the necessary development tasks of parenting  -​ Factors affecting: -​ Knowledge base of couple -​ Past experience with children -​ Maturity and educational levels of the couple -​ Type of extended support system -​ Maternal or paternal expectations of the pregnancy -​ Maternal or paternal expectations of the infant -​ Cultural expectations Bonding behaviors -​ En face -​ Calls the baby by name -​ Cuddles the baby close to their chest -​ Talks or sings to the baby -​ Kisses the baby -​ Breastfeeds the baby or holds the baby close when bottle-feeding -​ Parents respond to the infant’s cry -​ The infant responds to the parents’ comforting measures -​ Parents stimulate and entertain the infant while awake -​ Parents become “cue sensitive” to the infant’s behavior Risk factors for Delayed Bonding -​ Maternal illness during pregnancy or postpartum period -​ Neonatal illness that requires separation of the infant from the parents -​ Prolonged or complicated labor and birth that exhausts both partner and mother -​ Fatigue related to lack of rest and sleep -​ Physical discomforts experienced by women post birth -​ Age and development age of the woman, such as adolescents -​ Outside stressors, like finances, poor social support system, or need to return to work soon after birth Promote bonding and attachment -​ Initiating early and prolonged contact between the parent and infant -​ Initiate rooming in or couplet care -​ Providing positive comments to parents regarding their interactions with the infant -​ Encourage mothers to breastfeed -​ Encourage women and partners to talk about their birth experience and feelings regarding becoming parents -​ If separated due to maternal illness or neonatal complications -​ Recommend the family members take pictures of the infant and bring them to the mother to keep in her room -​ Assisting parents to the NICU or nursery so that they can see and touch their infant  -​ Providing opportunities for parents to care for their infant in the NICU or nursery -​ Instructing the woman on breast milk pumping and encouraging her to bring breast milk to the NICU for use with her infant -​ Informing parents that they can call the NICU or nursery anytime of the day or night and talk with the nurse 3) Discuss appropriate comfort measures to promote birth parent well-being. a.​ Pharmacological vs. non pharmacological Pharmacologic Non-pharmacologic -​ NSAIDs (ibuprofen or motrin) -​ Ice packs -​ Give with full glass of water -​ Warm compresses and food or milk to decrease -​ Aromatherapy GI upset -​ Sitz baths -​ Be careful with asthma, nasal -​ Repositioning polyps, or allergies to aspirin -​ Walking -​ PO 400-600 mg every 4-6 -​ Showering hours PRN -​ Topical treatments, such as witch -​ Acetaminophen 650 mg every 4 hours hazel pads and anesthetic sprays PRN applied to localized perineal -​ Opioid analgesics are reserved for discomfort severe pain that persists the previously -​ Cotton nightwear listed interventions -​ Cold decreases welling -​ Heat facilitates healing and circulation 4) Discuss the nursing care of the mother after a Cesarean birth. -​ Recovery period is longer than vaginal delivery due to the tissue trauma related to surgical intervention -​ Usual hospital stay is 3 days, with full recovery from surgery taking 6 weeks or longer -​ Main complications: infection, hemorrhage, thromboembolism -​ Wound infections present with erythema, discharge and induration of the incision -​ Generally develops 4-7 days post op -​ When infection develops within 48 hrs, usually group A or B hemolytic streptococcus -​ General complications: PPH, anemia due to blood loss, DVT, pulmonary embolism, paralytic ileus, hematuria related to bladder trauma, infections, severe headache due to anesthesia -​ Keep eye on vitals -​ Oliguria less than 30 mL/hr for 2 hours is a huge red flag Immediate post op (first 2 First 24 post op hours Post Op 24 hours to discharge hours) -​ LOC -​ Monitor VS every -​ Assess every 4 hours -​ Assess every 15 mins hour for first 4 hours, -​ Assess incisional site (VS, color, cardiac then every 4 hours for drainage & signs monitoring, O2 sat, until stable, and then of infection sensory motor every 8 hours until -​ Up independently function, presence or discharge -​ Encourage women to absence of oozing on -​ Monitor RR and ambulate for bowel dressing, fundal sedation level b/c of movement and reduce height, tone location, morphine every hour risk of blood clots & lochia) for first 24 hours -​ May require minimal -​ Assess every hour for -​ Assess pain assistance with peri the first 4 hours -​ Assess abdominal care and ADLs (urinary output, dressing for bleeding -​ Education on bladder distention, or discharge discharge I&O) -​ Monitor I&Os and -​ Assist to bathroom -​ Assess newborn every ability to void and measure voiding 30 mins -​ Monitor for signs of at least 2 times after -​ Bedrest PPH catheter is removed -​ Educate and emphasis -​ Review labs for H&H -​ Administer ordered on skin to skin contact and CBC meds -​ Monitor I&O -​ Monitor for signs of -​ Diet as tolerated -​ Couple may be infection -​ Information on anxious and excited -​ Complete post nutrition in (same for all) anesthesia postpartum recovery -​ Address concerns and assessments & breastfeeding questions (same for -​ Adverse reactions to all) morphine -​ Patient desires and -​ Bedrest for first 6-12 safety should guide hours, then assisted on practice (same for all) short walks and may -​ Provide opportunities sit in chair for short for family to be with periods of time baby (same for all) -​ Assist for peri care -​ Administer meds as and ADLs ordered -​ Educate on care -​ Treat morphine side during postpartum effects, such as period pruritus and nausea or -​ Remove foley catheter vomiting generally 12 hrs post -​ Ice chips, clear fluids, op IV fluids -​ Assist woman to BR -​ Assist mother to -​ Administer meds as breastfeed ordered (stool -​ Anesthesia provider softeners, Rhogam, responsible for rubella, anticoags) prescribing pain meds -​ Advance to regular  diet -​ Assist with breastfeeding -​ Administer pain meds 5) Outline discharge planning and home care of the postpartum family a.​ Shaken baby syndrome -​ Leading cause of death in babies under 2 -​ Pediatric abusive head trauma (AHT) -​ Education -​ How shaking causes injury to the infant’s brain and eyes -​ Long term effects of AHT -​ Stages of infant and childhood development -​ Stress reduction -​ Asking for help is okay b.​ SIDS/Back to Sleep/Safe Sleep -​ Teach all caregivers about sleep safety, such as placing infants on their backs to sleep, avoiding loose bedding, and not bed-sharing -​ Place infants on their back for all sleep -​ Once infants can turn on their own from back to front, it is safe to leave them in the position they assume -​ Infants should not be swaddled once they can move around and appear to be close to rolling over (usually around 2 months) -​ Use a firm sleep surface made for infants, covered by a fitted sheet -​ Keep soft objects, toys, and loose bedding out of infant’s sleep area, including bumper pads -​ Do not use blankets -​ Do not let them bed-share in a bed, couch, lounge chair -​ Should sleep in their own bed in the same room as the parent for at least first 6 months of life -​ No smoking, drugs, alcohol around baby -​ Pacifiers are protective against SIDS and should be offered, but not forced -​ Do not overbundle during sleep -​ Provide tummy time when baby is awake -​ Keep objects out of reach -​ Water temperature for bathing should be 100 F to 100.4F, or 37.8C to 38C -​ Water heater thermostat at 120 F or lower -​ Do not cook or drink hot liquids while holding infant -​ Cover electrical outlets -​ Car seats  -​ Fall prevention -​ Poisoning prevention c.​ Breastfeeding vs. Formula Feeding Breastfeeding Formula Feeding Newborn Benefits -​ Feed atleast every -​ Reduced risk of gastroenteritis, respiratory syncytial virus, 3-4 hrs otitis media, necrotizing enterocolitis, SUID -​ Consume 0.5 to 1 -​ Decreased risk of asthma, atopic dermatitis, cardiovascular oz every feeding disease, celiac disease, inflammatory bowel disease, & for first few days obesity -​ Increases to 2-3 Mother benefits oz by day 4 -​ Decreased blood loss -​ Then 32 daily oz -​ Decreased infection -​ Feed 2.5 oz for -​ Increased weight loss every 1 lb of -​ Decreased risk of diabetes, metabolic syndrome, baby weight per osteoporosis, autoimmune diseases, & ovarian and breast day cancers Benefits -​ Reduces anxiety and stress -​ Partner can assist Contraindications -​ Mother can run -​ Newborns with galactosemia errands or work -​ Active and untreated TB without having to -​ Active herpes simplex lesions on a breast pump -​ Receive treatment with radiation -​ Decreases -​ Receive treatment with antimetabolites or frequency of chemotherapeutic agents feedings -​ Use illicit drugs Disadvantages -​ Are HIV positive -​ Increased cost to Most important component of breast milk= fat purchase Stages of Breast Milk -​ Prepare formula 1)​ Colostrum and clean bottles -​ Present in breast beginning in 2nd trimester -​ Lack of mother’s -​ Higher levels of protein, lower levels of fat, carbs, antibodies and calories -​ Possible formula -​ High levels of IG G and A intolerance, but -​ Produced in small amounts there are -​ Newborn will consume 7-14 mL the first day of life hypoallergenic per feeding formulas -​ Stomach capacity size of marble -​ Parents should -​ Serves as laxative to assist in passage of meconium select BPA free 2)​ Transitional milk bottles easy to -​ Gradually changes from colostrum to mature milk clean -​ Decreasing levels of protein -​ Silicone or rubber -​ Increasing levels of fats, carbs, and calories nipples cleaned  -​ Lasts until day 12 with soapy warm 3)​ Mature milk water -​ Arrives about 12 days after birth -​ Slow, medium, -​ Composed of 20% solids and 80% water fast nipples -​ Contains about 22-23 calories per ounce -​ Hold head higher -​ Whiter, thinner, watery, has bluish cast than body close -​ Foremilk: produced and stored between feedings to body and is released at beginning of feeding, dilute and -​ Burp newborn satisfies thirst halfway through -​ Hindmilk: produced during feeding session, and at the end of received toward end of feeding and has a higher fat feeding by content tapping or patting Mammogenesis: breast changes that occur during pregnancy b/c of the back for a few estrogen and progesterone mins Lactogenesis I: pregnancy until postpartum day 2 -​ Discard unused -​ Transition from pregnancy to lactation formula -​ Mammary secretory cells stimulated by prolactin to produce milk Lactogenesis II: day 3-8 post birth prompted by placenta expulsion and decrease in progesterone Galactopoiesis: day 9 post birth until cessation of lactation -​ Maintenance period of lactation Involution: less demand for breast milk Latching the Newborn -​ Wait til baby’s mouth is wide open then bring them to the areola Feeding cues -​ Every 2-3 hrs -​ Licking or smacking their lips -​ Extending their tongue -​ Putting hand to their mouth -​ Sucking on their fingers -​ Turning their head to their mother’s voice -​ Entering a quiet alert stage Latch Audible swallowing Type of mother’s nipple Comfort Hold or position -​ Days 3 to 4, should transition from meconium to yellowish color and have 5-6 wet diapers and 2-3 soiled diapers for adequate feeding Storage -​ Can be stored at room temp for 6-8 hrs -​ In the fridge for 7-8 days -​ In the freezer for 6 months  -​ In a deep freezer for 6-12 months 6) Identify risk factors related to domestic violence (pg. 600 & 636) -​ A validated screening tool should be used for IPV and SA -​ Women should be screened for IPV in private during annual physicals, initial prenatal visits, and each trimester and postpartum checkup -​ Women should be asked about their sense of feeling safe in their home and relationship -​ Teach safe and healthy relationship skills to adolescents to reduce IPV Risk Factors -​ Low self esteem -​ Low academic achievement -​ Being an adolescent or young adult -​ Alcohol or drug abuse -​ Having few friends -​ Marital conflict -​ Dominance and control of the relationship by one partner over the other 7) Identify characteristics of a battered and batterer. a.​ Identify cycles of violence Tension-Building Phase Batterer -​ Moody, nitpicking, isolates, withdraws affection, yelling, drinking or drugs, threatens, destroys property Battered -​ Attempts to calm them, nurtures, steps away from family and friends, pacifies, keeps kids quiet, agrees, withdraws, tries to reason, cooks favorite dinner, general feeling of walking on eggshells Explosion Phase Batterer -​ Hitting, choking, humiliation, imprisonment, rape, use of weapons, verbal abuse, throwing things Battered -​ Protects self and children, calls police, tries to stay calm, tries to reason, leaves, fights back “Honeymoon” or Batterer “Remorse” Phase -​ I’m sorry, begs for forgiveness, promises to get counseling, sends flowers/presents, I’ll never do it again, declares love Battered -​ Agrees to stay, attempts to stop legal proceedings, sets up counseling appts, feels happy and hopeful Module 3 (chapters 3, 4, & 5) 1)​ Define terminology related to the menstrual cycle. a.​ Ovarian cycle: the maturation of ova and consist of the follicular phase, ovulatory phase, & luteal phase b.​ Follicular: begins the first day of menstruation and lasts 12-14 days -​ The graafian follicle matures under the two pituitary hormones: luteinizing hormone and follicle-stimulating hormone -​ Maturing graafian follicle produces estrogen c.​ Ovulatory: begins when estrogen levels peak and ends with the release of oocyte (egg) from the mature graafian follicle -​ Release of the oocyte is referred to as ovulation -​ Estrogen levels decrease and progesterone levels increase -​ Next, LH levels surge 12-36 hours before ovulation d.​ Luteal phases: begins after ovulation and lasts approximately 14 days -​ The cells of the empty follicle morph to form the corpus luteum -​ Produces high levels of progesterone and low levels of estrogen -​ If pregnancy occurs, the corpus luteum releases progesterone and estrogen until the placenta matures enough to assume this function -​ Pregnancy → corpus luteum releases progesterone and estrogen until placenta matures enough to assume this function -​ Not pregnant → corpus luteum degenerates, resulting in a decrease in progesterone and the beginning of menstruation e.​ Uterine cycle: the same as the endometrial cycle, which pertains to the changes in the endometrial of the uterus in response to the hormonal changes that occur during the ovarian cycle, including proliferative phase, secretory phase, menstrual phase f.​ Proliferative: follows menstruation and ends with onset of menstruation -​ Endometrium becomes thicker and more vascular in preparation for implantation -​ Changes in response to the increasing levels of estrogen produced by the graafian follicle g.​ Secretory: begins after ovulation and ends with the onset of menstruation -​ Endometrium continues to thicken -​ Primary hormone is progesterone, which is secreted from the corpus luteum -​ Pregnancy → endometrium continues to develop and begins to secrete glycogen, the energy source for the blastocyst during implantation -​ Not pregnant → the corpus luteum begins to degrade and the endometrial tissue degenerates  h.​ Menstrual: occurs in response to hormonal changes and results in the sloughing off and expulsion of the endometrial tissue i.​ Ischemic phases: 28th day of the cycle, lasts a few hours for a maximum of one day -​ Occurs when the fertilized egg has not fertilized -​ Mucosal tissue is infiltrated by lymphocytes and leukocytes j.​ Ovulation: the release of the oocyte, which happens in the ovulatory phase of the ovarian cycle k.​ Conception: known as fertilization, occurs when a sperm nucleus enters the nucleus of the oocyte -​ Occurs in the outer third of the fallopian tube -​ Fertilized oocyte is called a zygote and contains 46 chromosomes -​ Needed for conception: -​ Ovulation occurs and the mature ovum enters the fallopian tube -​ Sperm cells are deposited in the vagina and travel to the fallopian tube -​ One sperm cell is able to penetrate the mature ovum 2) Outline the menstrual cycle and the hormones that influence the cycle. a.​ Estrogen -​ Increases uterine size -​ Increases breast development -​ Increases blood flow -​ Prevents further follicular development during pregnancy b.​ Progesterone -​ Relaxes smooth muscle -​ Maintains uterine lining for implantation -​ Thermogenic during ovulation c.​ Luteinizing hormone -​ Stimulates ovulation of the mature ovum in the nonpregnant state -​ Secreted by the anterior pituitary d.​ Follicular stimulating hormone -​ Initiates maturation of the ovum, which is necessary for conception -​ Suppressed during pregnancy -​ Secreted by anterior pituitary e.​ Human placental lactogen -​ Growth promoting -​ Milk producing (lactogenic) -​ Acts as antagonist to insulin f.​ Oxytocin  -​ Stimulates uterine contractions -​ Stimulates the milk ejection reflex -​ Secreted by the posterior pituitary g.​Prolactin -​ Affects breast growth and milk production h.​HCG -​ Prevents involution of the corpus luteum, which maintains production of progesterone until the placenta is formed -​ Used to detect early pregnancy initially high in early pregnancy then diminishes 3) Describe the fertilization process. There are two fallopian tubes, or oviducts, that partially surround the ovary. Fimbriae stick out of the lateral ends that create a current pulling the ovum into the tube. Peristaltic waves created by the fallopian tube’s smooth muscle contractions move the ovum through the tube and into the uterus, where the medial end of the tube lies. Fertilization occurs when a sperm nucleus enters the nucleus of the oocyte, which usually happens in the outer third of one of the fallopian tubes. There are 3 conditions needed for fertilization to occur: ovulation and the mature ovum enters the fallopian tube, sperm cells are deposited into the vagina and travel to the fallopian tube, and one sperm cell is able to penetrate the mature ovum. 4) Discuss the characteristics of the fetal membranes, amniotic fluid, placenta, and umbilical cord. a.​ Placenta: what 4 hormones, what happens there? -​ Placenta is formed from both fetal and maternal tissue -​ The placental membrane separates the maternal and fetal blood and prevents fetal blood from mixing with maternal blood, but allows for the exchange of gasses, nutrients, and electrolytes -​ Metabolic and gas exchange -​ Hormone production 1)​ Estrogen: stimulates enlargement of breasts and uterus 2)​ Progesterone: facilitates implantation and decreases uterine contractility 3)​ hCG: stimulates corpus luteum to continue to secrete estrogen and progesterone until placenta is mature enough to do so (high in early pregnancy then declines) 4)​ hPL: promotes fetal growth by regulating available glucose and stimulates breast development in preparation for lactation b.​ Amniotic fluid: what is normal? -​ Contained within the amniotic sac -​ Clear and mainly composed of water, but also contains proteins, carbs, lipids, electrolytes, fetal cells, lanugo, & vernix caseosa  -​ During first trimester, amniotic membrane produces it, then for second and third trimester, the fetal kidneys produce it -​ Peaks at 800-1,000 mL around 34 weeks gestation and decreases to 500-600 mL at term -​ Functions: -​ Cushions fetus from sudden maternal movements -​ Prevents developing human from adhering to the amniotic membranes -​ Allows freedom of fetal movement, which aids in symmetrical musculoskeletal development and prevents adhesions to self or the amniotic membrane -​ Provides a consistent thermal environment c.​ AFI (Amniotic Fluid Index) -​ Peaks at 800-1,000 mL around 34 weeks -​ 500-600 mL at term d.​ Oligohydramnios -​ A decreased amount of amniotic fluid (less than 500 mL at term or 50% reduction of normal amount) e.​ Polyhydramnios -​ An excess amount of amniotic fluid (1,500-2,000 mL) f.​ Umbilical cord– 2 arteries, 1 vein -​ Connects the fetus to the placenta -​ Has 2 arteries and one vein -​ The arteries carry deoxygenated blood -​ The vein carries oxygenated blood -​ These vessels are surrounded by a collagenous substance that protects the vessels from compression called Wharton’s jelly -​ Usually inserted in the center of the placenta and is about 55 cm long 5) Outline the stages of fetal development a.​ Organogenesis: the formation and development of body organs -​ The first 8 weeks of gestation b.​ Teratogens: the developing human is most vulnerable to teratogens during organogenesis -​ Drugs, viruses, infections, or other exposures -​ Different degrees of damage 6) Apply the nursing process to assist with common problems and discomforts of pregnancy (pg. 83 Table 4-4) Generalized or -​ Fatigue (first and third trimesters) multisystem -​ Reassure woman of normalcy of her response -​ Encourage extra rest and focus on growing healthy baby -​ Enlist support and assistance from friends and family -​ Encourage optimal diet  -​ Insomnia (throughout pregnancy) -​ Instruct woman to implement sleep hygiene measures -​ Create comfortable sleep environment -​ Teach breathing exercises and relaxation techniques or measures -​ Evaluate caffeine use -​ Emotional lability (throughout pregnancy) -​ Reassure normalcy of response -​ Encourage adequate rest and optimal nutrition -​ Communication w partner and support system -​ Refer to pregnancy support group Breasts -​ Tenderness, enlargement, upper back pain (throughout pregnancy) -​ Encourage well-fitting, supportive bra -​ Leaking of colostrum (starting second trimester) -​ Recommend soft cotton breast pads if leaking Uterus -​ Braxton-Hicks contractions (mid pregnancy) -​ Reassure occasional contractions are normal -​ Instruct the woman to call her provider if contractions become regular and persist before 37 weeks -​ Ensure adequate fluid intake -​ Recommend a maternity girdle for uterus support Cervix and vagina -​ Increased secretions and yeast infections (throughout pregnancy) -​ Daily bathing -​ Cotton underwear -​ Wear panty liner and change pad frequently -​ Tell woman to avoid douching or using feminine hygiene sprays -​ Inform provider if discharge changes in color or accompanied by foul odor or pruritus -​ Dyspareunia (throughout pregnancy) -​ Suggest alternative positions for sexual intercourse and alternative sexual activity to sexual intercourse Cardiovascular -​ Supine hypotension (mid pregnancy) -​ Instruct women to avoid the supine position -​ Advise her to lie on her side and rise slowly -​ Orthostatic hypotension -​ Advise woman to keep her feet moving when standing and avoid standing for prolonged period -​ Instruct woman to rise slowly from a lying position to sitting or standing to decrease the risk of a hypotensive event  -​ Anemia (throughout pregnancy) -​ Encourage women to include iron rich foods in daily dietary intake and take iron supplementation -​ Dependent edema in lower extremities or vulva (late pregnancy) -​ Wear loose clothing -​ Use a maternity girdle -​ Avoid prolonged standing or sitting -​ Dorsiflex feet periodically -​ Elevate legs when sitting -​ Position on side when lying down -​ Varicosities (later pregnancy) -​ Instruct woman for dependent edema -​ Suggest woman to wear support hose -​ Lie on back with legs propped against a wall in about a 45 degree angle to spine periodically throughout day -​ Instruct woman to avoid crossing her legs when sitting Respiratory -​ Hyperventilation and dyspnea (throughout pregnancy) -​ Instruct woman to slow down respiration rate and depth when hyperventilating -​ Encourage good posture -​ Instruct woman to stand and stretch, taking a deep breath, periodically throughout the day; also stretch and take a deep breath periodically throughout the night -​ Suggest sleeping semi sitting with additional pillows -​ Nasal and sinus congestion and epistaxis (throughout pregnancy) -​ Suggest woman try a cool-air humidifier -​ Instruct women to avoid use of decongestants and nasal sprays and instead of using normal saline drops Renal -​ Frequency and urgency or nocturia (throughout pregnancy) -​ Encourage women to empty bladder and wipe front to back -​ Stress importance of maintaining adequate hydration and reducing fluid intake only near bedtime -​ Instruct to urinate after intercourse -​ Teach woman to notify provider if painful or bloody urination -​ Encourage Kegel exercises; wear perineal pad if needed GI -​ Nausea or vomiting in pregnancy (first two trimesters) -​ Avoid causative factors -​ Encourage women to eat small frequent meals, eat at a slow pace, eat crackers or dry toast before rising or whenever nauseous, drink cold carbonated drinks, avoid fluid intake with meals, eat ginger flavored lollipops or  peppermint candies, brush teeth after eating, wear P6 acupressure wrist bands, take vitamins at bedtime with a snack, suggest vitamin B6 -​ Increase or sense of increase in salivation (first trimester) -​ Suggest use of gum or hard candy or use astringent mouthwash -​ Bleeding gums (throughout pregnancy) -​ Encourage women to maintain good oral hygiene (brush gently with soft toothbrush, perform daily flossing), maintain optimal nutrition -​ Flatulence (throughout pregnancy) -​ Maintain regular bowel habits, encourage in regular exercise, avoid gas producing foods, chew food slowly and thoroughly, use the knee chest position during periods of discomfort -​ Heartburn (later pregnancy) -​ Eat small frequent meals, maintain good posture, maintain adequate fluid intake, but avoid fluid intake with meals, avoid fatty or fried foods, remain upright for 30-45 mins after eating, refrain from eating at least 3 hours -​ Constipation (throughout pregnancy) -​ Maintain adequate fluid intake, engage in regular exercise such as walking, increase fiber in diet through vegetables, fruits, & whole grains, maintain regular bowel habits, maintain good posture and body mechanics -​ Hemorrhoids (later pregnancy) -​ Avoid constipation, instruct women to avoid bearing down with bowel movements, instruct woman in comfort measures, elevate hips and lower extremities during rest periods, gently reinsert hemorrhoid into the rectum while doing Kegel exercises MSK -​ Low back pain, joint discomfort, or difficulty walking (late pregnancy) -​ Utilize proper body mechanics, good posture, pelvic rock and tilt exercises, supportive shoes with low heels, apply warmth or ice to painful areas, maternity girdle, use massage, relaxation techniques, sleep on firm mattress -​ Diastasis recti (late pregnancy) -​ Gentle abdominal strengthening exercises -​ Proper technique for sitting up from lying down -​ Round ligament spasm and pain (late 2nd and 3rd trimester) -​ Lie on side and flex knees to abdomen -​ Bend toward pain -​ Do pelvic tilt and pelvic rock exercises -​ Use warm baths or compresses  -​ Use side-lying in exaggerated Sim’s position with pillows -​ Use a maternity belt -​ Leg cramps (throughout pregnancy) -​ Dorsiflex foot to stretch calf muscle, apply warm baths or compresses to affected area, change position slowly, massage affected area, engage in regular exercise and muscle conditioning Integumentary -​ Striae (stretch marks) (later pregnancy) -​ Reassure woman that there is no method to prevent them -​ Suggest maintaining skin comfort -​ Good weight control -​ Dry or skin pruritus (later pregnancy) -​ Use tepid water for baths and showers ad rinse with cooler water -​ Avoid hot water -​ Use of lotions, oatmeal baths, and nonbinding clothing may lessen itching -​ Skin hyperpigmentation -​ Limit sun exposure -​ Wear sunscreen -​ Acne -​ Only use products developed for the face only Neurological -​ Headaches and syncope -​ Adequate hydration -​ Rise slowly from sitting to standing -​ Avoid supine position from mid pregnancy onward -​ Advise woman to lie on her side and rise slowly to decrease risk of hypotensive event 7) Discuss cultural considerations during the care of a pregnant client a.​ How to assess? -​ What is the woman’s predominant culture? Is there anything she wants to observe about her culture’s traditions? -​ What language does the client speak at home? What are the styles of nonverbal communication? -​ How does the woman’s culture influence her beliefs about pregnancy and childbirth? A state of health or illness? Attitudes towards age at time of pregnancy? -​ What does childbirth mean to the woman? -​ Prescriptions, restrictions, taboos, dietary particles, expressions of emotion? -​ What support is given during pregnancy, childbirth, and who gives the support?  -​ How does the woman interpret and respond to experiences of pain? Will she want pain medication? -​ Are there culturally defined expectations about male-female relationships and relationships outside the culture? -​ What is the educational background? -​ How does the patient relate to people outside of her cultural group? Does she prefer a caregiver of the same cultural background? -​ What is the role of religious beliefs related to pregnancy and childbirth? -​ How are decisions made, and by who? -​ Concept of time -​ How is the newborn viewed? Patterns of infant care? Relationships with extended family? b.​ How to support and respect? -​ Enhance clear effective communication -​ Greet respectfully -​ Demonstrate empathy, interest, and inclusion -​ Listen actively and sincerely -​ Emphasize the woman’s strengths -​ Respect functional and neutral practices -​ If proposed practices are nonfunctional, work with the woman and her support network to bring about negotiation -​ Accommodate or negotiate cultural practices and beliefs as appropriate -​ Identify who the patient calls “family” -​ Determine who the decision makers are -​ Provide an interpreter when necessary and when patient requests -​ Recognize that a patient agreeing and nodding yes to the nurse’s instruction or questions may not always guarantee communication, but instead indicate confusion -​ Use nonverbal communication and visual aids in an applicable way -​ When providing patient education, include family and elicit support, and encourage questions to verbalize concerns -​ Demonstrate how scientific and folk practices can be combined to provide optimal care 8) Identify the physiologic changes that occur during pregnancy. a.​ Reproductive Increased estrogen -​ Tenderness, fullness, and tingling & progesterone -​ Increase in weight of breasts by 400 g levels -​ Enlargement Increased blood -​ Darkening of the areola and nipple supply to breasts to -​ Striae prepare for -​ Prominent veins caused by twofold increase in blood supply lactation Increased in -​ Increased growth of mammary glands prolactin -​ Increase in lactiferous ducts and alveolar system -​ Colostrum, a yellow secretion rich in antibodies, begins to be produced as early as 16 weeks Increased levels of -​ Hypertrophy of uterine wall estrogen & -​ Softening of vaginal muscle & connective tissue in preparation progesterone for expansion of tissue to accommodate passage of fetus through the birth canal -​ Uterus contractility increases in response to increased estrogen, leading to Braxton-Hicks contractions -​ Hypertrophy of cervical glands lead to formation of mucus plug, the protective barrier between uterus or fetus and vagina -​ Increased vascularity and hypertrophy of vaginal and cervical glands leads to increase in leukorrhea -​ Cessation of menstrual cycle (amenorrhea) and ovulation Enlargement & -​ Uterus size increases 20x stretching of uterus -​ Weight of uterus increases from 70 g to 1,100 g -​ Capacity increases from 10 mL to 5,000 mL Expanded -​ Blood flow to the uterus is 500-600 mL/min at term circulatory volume -​ Goodell’s sign: softening of the cervix leads to increased -​ Hegar’s sign: softening of the lower uterine segment vascular congestion -​ Chadwick’s sign: bluish coloration of cervix, vaginal mucosa, & vulva Acid pH of vagina -​ Acid environment inhibits growth of bacteria -​ Acid environment allows growth of Candida albicans, leading to increased risk of candidiasis (yeast infection) b.​ Cardiovascular Decrease in peripheral vascular resistance -​ Decrease in blood pressure in the first trimester Increase in blood volume 30-50% -​ Hypervolemia of pregnancy Increase in cardiac output 30-50% -​ Increased resting heart rate by 10-20 bpm BMR increased 15% by third trimester -​ Increased stroke volume by 25-30% Increase in peripheral dilation -​ Systolic murmurs, loud and wide S1 split, loud S2, obvious audible S3 Increase in RBC 30% -​ Anemia due to hemodilution caused by Increase in RBC volume by 20-30% increase plasma volume being larger than Increase in plasma volume by 40-60% increase in RBCs  -​ Results in decreased hemoglobin and hematocrit values Increase in WBC count -​ Values up to 16,000 mm3 Increase demand for iron -​ Iron deficiency anemia: hemoglobin