MNN Mod IV Exam PDF

Maternal-Neonatal Nursing Module IV Exam Chapter 9: The family after birth ❖ Puerperium: postpartum is 6 weeks following delivery; “fourth trimester” ❖ BUBBLEHE assessment o Breasts: breastfeed Q3-4 hours; if not breastfeeding, don’t even pump; educate about colostrum; nippl...

Maternal-Neonatal Nursing Module IV Exam Chapter 9: The family after birth ❖ Puerperium: postpartum is 6 weeks following delivery; “fourth trimester” ❖ BUBBLEHE assessment o Breasts: breastfeed Q3-4 hours; if not breastfeeding, don’t even pump; educate about colostrum; nipples may be cracked and dry which is super painful ▪ Educate about wearing bras for support, or even elastic binders to suppress lactation ▪ If not breastfeeding, educate about avoiding nipple stimulation (don’t let water hit them during the shower and don’t let clothes rub against ‘em) o Uterus: observe height, firmness, and location; watch for blood clots o Bladder: observe for distension which could increase risk of hemorrhage o Bowel: observe for flatus, bowel sounds and defecation o Lochia: watch for trickle of bright red blood (indicates hemorrhage) o Episiotomy ▪ Use REEDA ▪ Ice pack for first 12-24 hours to reduce swelling, then warmth can be applied to help with the healing process ▪ Perineal care after every void (pee or poop) o Hemorrhoids/lower extremities: hemorrhoids are normal within postpartum moms; assess strength in lower extremities ▪ Sitz baths and witch hazel pads can help with hemorrhoids o Emotions: educate about the importance of skin to skin and make sure mom feels comfortable interacting with baby; assess for PP depression Psychological Adaptation Nursing Responses Taking-In Mother is passive and willing to let other Provide time for rest; supply sufficient Phase people care for her; convos center on birth nutrition; allow new mom to vent and speak experience; little to no interest in learning up about her birthing experience; let her about infant care; focus is on fluids, rest, and share her disappointment as well as her joys food Taking-Hold Mom initiates action of caring for her newborn Be supportive and identify the support Phase baby; interested in her body functions and how system; educate about the importance of she will be able to provide help for her baby self-care which will lead to how she takes care of baby Letting-Go New parents work through giving up their Be supportive; give referrals to agencies for Phase previous lifestyle for this new one with a child; different programs (WIC, food stamps, moms may give up their ideal birth experience lactation consultants or nurses); reinforce and swap it with what truly happened; they newborn caregiving abilities give up the “fantasy child” and accept reality ❖ Nonreproductive system changes o Cardiovascular ▪ Cardiac output and blood volume temporarily increases due to blood that gets recirculated from placenta and uterus ▪ Higher risk of blood clot formation due to stasis in venous system Pulmonary embolus: dyspnea and tachypnea ▪ WBCs may increase due to inflammation, pain, and stress ▪ May become “chilled”; these tremors are related to the sudden release of pressure on the pelvic nerves and a vasomotor response involving epinephrine (adrenaline) during the birthing process Report if chills are accompanied with a fever after 24hr ▪ Blood pressure may drop (orthostatic hypotension) due to resistance of blood flow within in the vessels; may feel faint or dizzy and are at risk for passing out o Integumentary ▪ Hyperpigmentation will disappear as hormone levels decrease ▪ Striae (stretch marks) will fade to silver o Musculoskeletal ▪ Abdominal wall has stretched greatly and may look “dough-like” and will be extremely weakened ▪ Diastasis recti (longitudinal muscles that extend from chest to symphysis become separated) ▪ Hypermobility of the joints will stabilize within 6 weeks PP ▪ Center of gravity will return to normal once uterus returns to normal size pre-pregnancy o Immune ▪ Rh- moms should receive RhoGAM within 72 hours PP to prevent blood incompatibilities ▪ Rubella vaccine if indicated ❖ Adaptation of nursing care after cesarean birth o Monitor abdominal dressing ▪ Horizonal is most common ▪ REEDA (redness, edema, ecchymosis, discharge, approximation) o Lochia may generally be less than vaginal delivery o Assess urinary catheter/foley ▪ Usually removed within 24hr after delivery ▪ Observe urine output for amount, color, and blood ▪ Signs of UTI: fever, dysuria, urgency of urination o Respiratory care ▪ Auscultate lung sounds each shift ▪ If bedridden, educate about taking 2 deep breaths and turning from side to side every 2 hours (will help get secretions expelled) ▪ Educate about splinting with a pillow to minimize pain when coughing ▪ Educate about incentive spirometry  o Prevent risk of thrombophlebitis ▪ c-section mommas are at the greatest risk ▪ Possible prophylactic heparin anticoagulation therapy ▪ Educate about early ambulation and possible compression therapy o Pain management ▪ Crucial to reduce her stress and anxiety ▪ Use the 1-10 pain scale rating ❖ Lactation phases of milk production 1: Colostrum (first few days) -contains antibodies, proteins, vitamins A & E, essential minerals, lower in calories, and has a laxative effect 2: Transitional milk (7-10 days after birth) -fewer immunoglobulins, fewer proteins, but increased lactose, fat, and calories 3: Mature Milk (14 days after birth) -bluish color, 20 kcal/oz, contains all the nutrients the infanct needs, antibodies are passed from mom ❖ Afterpains: intermittent uterine contractions may cause afterpains (similar to menstrual cramps) o Occur more often in multiparas or if women have an overdistended uterus o Breastfeeding mothers (due to suckling that causes contractions, thanks to oxytocin- released from posterior pituitary gland) o DO NOT use aspirin (it interferes with blood clotting) ❖ Breastfeeding o Positions: center nipple to nose of newborn and aim to the roof of their mouth so that their lower jaw latches on first o Techniques: mother should hold her breast in a C position; newborns lips should flare outward; will have to arouse sleepy babies o Suckling pattern: newborns will swallow with every suck (drinks approx 0.14 mL) o Removal of infant from breast: mother should use her finger to break the seal o Evaluating intake: newborns should nurse 10-15 minutes per breast for 8-10 times a day; should have 6-8 wet diapers per day for sufficient output o Frequency and duration: every 2-3 hours for newborns o Hunger cues: hand to mouth movements, sucking motions, rooting movements, mouth and tongue movement, clenched fists, kicking legs, crying (late hunger) o Breast engorgement: apply cold packs between feedings and heat just before feedings to reduce discomfort; manual massage to expel all extra milk for the breastfeeding session; DON’T use soap and wear supportive bras 24/7 ❖ Bottle feeding o DON’T heat in microwave; instead, run through warm water or use bottle warmer o DON’T prop bottle because the infant can aspirate if you’re not paying attention ❖ Postpartum Self care o Follow-up: 2 weeks then 6 weeks o Nutrition: 500 additional calories, high fiber foods, prescribed prenatal vitamins  o Moderate exercise o Hygiene: daily showers, NO douching or use of tampons, perineal care o AVOID coitus until episiotomy is fully healed and lochia flow has ceased o Danger signs: fever >100.4, persistent lochia rubra or foul-smelling lochia, bright red blood, prolonged afterpains, constant backache, UTI signs, pain/redness/tender at calf, localized breast tenderness or redness, suture separation or discharge, prolonged and pervasive feelings of depression Chapter 10: Nursing care of women with complications after birth ❖ Hemorrhage o Types ▪ Vaginal: >500 mL ▪ Cesarean: >100 mL o Major risk: hypovolemic shock ▪ Body’s response: tachycardia is first sign; along with hypotension ▪ PP mom’s have low pulse so report 100bpm o Early postpartum hemorrhage: within 24 hours ▪ Causes Uterine atony: soft and high fundus that’s difficult to feel, heavy lochia, bladder distension and may displace to one side o Due to use of oxytocin during labor, tocolytics (magnesium sulfate), or low placental implantation Lacerations: continuous bright red trickle of blood, firm fundus o Due to rapid labor, forceps or vacuum use Hematoma: blue or purplish mass on vulva, severe and poorly relieved pain or pressure in vulva or pelvis or rectum, large amount of blood lost in tissue spaces o Due to prolonged or rapid labor, or large infants o Late postpartum hemorrhage: after 24 hours but before 6 weeks postpartum ▪ Causes Retention of placental fragments: can cause clot formation Subinvolution of uterus: slower than expected return of uterus to normal/nonpregnant size; fundal height is greater than expected o Interventions ▪ Monitor pad saturation If saturated in 15 minutes to 1 hour after delivery, report to HCP immediately Weigh pads to determine blood loss (1g=1mL blood lost) ▪ Educate importance of keeping bladder empty Distension leads to uterine atony and hemorrhage ▪ If mom develops hemorrhagic complications, place on NPO ❖ Thromboembolic disorder: venous thrombosis (blood clot in vein) o 3 types ▪ Superficial venous thrombosis (SVT):  ▪ Deep venous thrombosis (DVT): ▪ Pulmonary embolism: dramatic signs and symptoms that include sudden chest pain, cough, dyspnea, decreased LOC, heart failure symptoms o Treatment ▪ Subcutaneous or IV anticoagulation drugs (Heparin) o Anecdotes ▪ For warfarin: Vitamin K ▪ For Heparin: Protamine Sulfate o Interventions ▪ Educate pregnant women NOT to cross their legs ▪ Monitor for s/s of PEs ▪ Early ambulation or ROM exercises ▪ Elevate lower extremities ▪ Anti-embolic stockings ▪ Educate about signs of excessive bleeding and how to prevent it Soft bristly toothbrushes o Treatment ▪ Culture and sensitivity (C&S) ▪ IV antibiotics ▪ May be placed on bedrest ❖ Endometritis: tender and enlarged uterus o S/S: prolonged and severe cramps, foul-smelling lochia, fever and other signs of infection, uterine subinvolution o Treatment/nursing care ▪ C/S of uterine cavity ▪ Antibiotics ▪ Educate about progression of lochia and proper hygiene care ▪ Analgesics for pain ▪ Monitor for absent bowel sounds, distension, and N/V ❖ Mastitis: breast infection that can occur 2-3 weeks after birth o S/S: red tender and hot breasts, edema and heavy feeling, purulent drainage o Treatment/nursing care ▪ Antibiotics, incision and drainage of abscess ▪ Teach effective feeding techniques ▪ Warm shower before nursing and moist heat applications Heat promotes blood flow and comfort ▪ Massage affected area ▪ Frequent and regular pumping intervals If not pumping, have mom use cold packs to help dry up her milk o Education ▪ Wash hands thoroughly before breastfeeding ▪ Nipple exposure to air helps tremendously ▪ Ensure proper latch ▪ Encourage complete emptying to reduce milk stasis  ▪ Maintain a regular schedule of feeding ▪ Massage distended areas as newborn nurses ▪ Report redness and fever to HCP ▪ Ice packs and moist heat will help relieve discomfort ❖ Postpartum depression: depressive illness that can start within 2-4 weeks after delivery o If the woman seems depressed, act on it; take it seriously o Treatment ▪ Combo of psychotherapy and antidepressants ▪ Light therapy (phototherapy) ▪ CAM modalities ❖ Postpartum blues (baby blues): periods of let down and joyful moments too o Also known as an “adjustment reaction” o Psychosis: serious impairment of one’s perception of reality Chapter 12: The term newborn ❖ Newborn vital signs o Respirations: 30-60 (will be irregular; count for 1 full minute) o Pulse: 110-160 (count apical for 1 full minute) o Temperature: 97.7- 98.6 (take axillary) ❖ Reflexes o Rooting: infant’s head turns in the direction of anything that strokes their cheek o Palmar grasp: newborn with grasp tightly to objects that are place in their hands o Sucking: will suck on finger or nipple when it meets their mouth o Moro: sudden jarring movement that causes extension and abduction o Babinski: spread of toes when one stokes the sole of their foot o Dancing or stepping: prancing movements of legs when infant is help upright ❖ Head o Fontanelles ▪ Anterior: diamond shaped ▪ Posterior: triangular ▪ Bulging: increased ICP (hydrocephalus, meningitis, intracranial hemorrhage) ▪ Sunken: decreased ICP (dehydration) ▪ Large/delayed closure: congenital hypothyroidism, rickets, increased ICP o Molding: due to head fitting through birth canal ▪ Caput succedaneum: collection of fluid under scalp due to edema; will make head appear longer than normal; crosses suture lines; ▪ Cephalohematoma: lump on one side of head; NO cross of suture lines o Measure circumference: top of eyebrow to widest part of occiput ❖ Thermoregulation o Hypothermia leads to hypoglycemia o Less brown adipose tissue o Mechanisms of head loss ▪ Radiation: through scalp (keep a hat on infant) ▪ Convection: through body (keep covered)  ▪ Conduction: through surfaces (never place them bare on tables) ▪ Evaporation ❖ Bowel and urinary function o Meconium: mix of amniotic fluid and secretions; can be dark green-black; will be thick and sticky; passe 8-24 hours after birth o Transitional stool: loose and greenish yellow with mucus o Bottle fed babies will have more solid bowel movements ❖ Hypoglycemia: may occur with micro/macrocosmic babies and hypothermic infants o S/S: lethargy, poor feeding, tachycardia, jitters, irregular body temp, apnea, weak or high pitch cry, restlessness, irritability, pale or blue o Medical emergency o Testing: stick side of heel ❖ Respiratory o Mucus from nose or mouth is normal o Suction bulb: squeeze to create pressure- place in mouth first then the nose ❖ APGAR: appearance, pulse, grimace (reflex irritability), activity, respirations o Obtained 1 minute after delivery then again after 5 minutes o Sternal retractions are reported immediately o Scoring ▪ Severy depressed: 0-3 ▪ Moderately depressed: 4-6 ▪ Excellent condition: 7-10 ❖ Circumcision o Gomco clamp: petroleum jelly to protect it from moisuture ▪ Monitor for bleeding, infection, and irritation ▪ Record voids o Plastibell: use of a fitted plastic ring that will fall off within 5-8 days ▪ Do not remove it earlier ▪ Notify HCP if it hasn’t fallen off after 8 days or if swelling has increased o Circumcised hygiene ▪ Wash area with warm water ▪ Avoid alcohol wipes ▪ DO NOT remove yellow crusts ▪ Apply diaper loosely ▪ Report redness, bleeding, or any drainage ▪ Make sure there are at least 6 wet diapers per day o Uncircumcised hygiene ▪ Avoid pulling back the foreskin forcefully ▪ Wash with water ▪ Smegma are normal (white lumps) ❖ Skin o Lanugo: fine hairs: will disappear within 1st week of life o Vernix caseosa: cheese-like substance that covers skin; made of protein, water, barrier lipids, and antimicrobial agents; will shed within 2-3 days  o Milia: tiny pinpoint pimples that will disappear within a few weeks; DO NOT attempt to squeeze them out o Cutis marmorata: lace-like red or blue pattern on surface of skin of newborn; response to low environmental temp; wrap warmly o Acrocyanosis: normal finding of blue extremities due to sluggish bloodflow ▪ Pallor IS NOT normal o Mongolian spots: dark blue or slate gray discoloration around lumbosacral area; often times is associated with child abuse o Desquamation: peeling of skin during early weeks of life o Jaundice: due to excessively rapid destruction of RBCs ▪ Physiological: appears after 24 hours of birth ▪ Pathological: appears within 24 hours of birth; stools may be clay or white colored; urine may stain clothes yellow ❖ Interactive bath o Hold infant like a football to wash head ▪ Wash hair last due to thermoregulation issues o Wash from dirtiest to cleanest ▪ Start with eyes then face (water only) o Wear gloves o Make sure vitals are stable o Make sure infant is dry and wrapped