Professional Documents
Culture Documents
Version 1
1. Basic nursing skills/safety/newborn radiant warmer temperature probe
If the infant does not remain w/the mother during the 1st 1-2 hours after birth, the
infant is placed under a radiant warmer or incubator until body temperature stabilizes
Skin temperature is used as the point of control maintained b/t 36 and 37
A thermistor probe (automatic sensor) is placed on the upper quadrant of the
abdomen immediately below the right or left costal margin
o Probe ensures detection of minor temperature changes before a dramatic
change in temperature develops
o Probe needs to be checked periodically to make sure it is in contact w/infants
skin
2. Med administration math
3. Med administration math
4. Antepartum contractions action
Frequent position changes
Encourage voiding minimum q2 hours
Encourage deep cleansing breaths
Provide pharmacological and non-pharmacological comfort measures
Provide maternal/fetal monitoring
Discourage pushing until fully dilated
5. Antepartum CST
Contraction stress test (CST) purpose is to identify the jeopardized fetus that is
stable at rest but showed evidence of compromise after stress. Woman is seated and
reclined (semi-Fowler). She is monitored electronically w/fetal ultrasound transducer
and uterine tocodynamometer. Tracing is observed for 10-20 minutes for baseline rate.
Two methods of the CST are the nipple-stimulation contraction test and the more
common oxytocin stimulated contraction test. If no late decelerations are observed w/
contractions, the findings are considered negative. Repetitive late decelerations (50%
or more of contractions) render a positive result
6. Antepartum fundal height action
Used as one indicator of fetal growth
Provides a gross estimate of the duration of pregnancy
o The height of the fundus in cm is approximately the same as the number of
weeks of gestation
Measurement is made from the upper border of the symphysis pubis to the upper
border of the fundus
Woman should have emptied her bladder and be lying supine with knees in flexed
position
The recommended weekly weight gain for overweight women during the 2nd
and 3rd trimester is 0.3 kg/week, and 0.2 kg for obese women
Encourage women to quit or cut down if they smoke and to avoid second hand smoke
Not preventable, do not douche, wear perineal pads, wipe from front to
back, report to PCP if accompanied by pruritus, foul odor, or change in
character or color
16. Antepartum Intrapartum UTI
UTIs are a common medical complication of pregnancy; about 20% of all pregnancies
Instruct women taking ABX to finish the entire course of meds, take meds on time and
around the clock so the medication levels remain constant
o Many women will develop a yeast infection while taking ABX b/c the ABX kills
normal flora. We should encourage them to include yogurt, cheese, or milk
containing active acidophilus while on their ABX regimen
UTI prevention
o Wipe from front to back
o Cotton crotch underwear
o Avoid tight-fitting clothes
o Limit time spent in damp exercise clothes
o Avoid bath salts/bubble baths
o Avoid colored/scented toilet tissue
o Dont wait to void
o Void before and after intercourse and before going to bed at night
o Drink at least 8 glasses of water daily
!
Relief
o
Avoid fatigue
Conscious relaxation
Rest
o
o
o
A sterile speculum examination and a Nitrazine (pH) and fern test can confirm that the
membranes have ruptured (procedure for test on p437)
Active phase (4-7cm dilation) - more rapid dilation and increased rate of
descent
2nd stage of labor - from the time the cervix is fully eaced and dilated to the birth of
the fetus
o
o
Nursing interventions
o Change maternal position (side-lying, knee chest)
o Discontinue oxytocin if infusing
o Administer oxygen at 8-10 L/min by nonrebreather
o Notify PCP
o Assist w/vaginal examination to assess for cord prolapse
o Assist w/birth if pattern cannot be corrected
Infants born w/vacuum assistance are usually born w/caput in area where the
cup was applied
Treatment
o When indicated, administer phenobarbital, diazepam or other meds per order
to decrease CNS irritability and control seizure activity
o Treatment may be needed for 2 weeks or more
Blood gas analysis RDS would reveal low oxygen and excessive acid
Asymptomatic at birth; mental and motor delays, short stature, coarse, dry skin
and hair, hoarse cry, constipation
Diagnosis
o Heelstick - blood spot T4 or TSH or both can be used in neonatal screening for
CH
Treatment
o Maintain L-thyroxine levels in upper half of normal range
o Periodic bone age to monitor growth
If not breast feeding encourage snug, support bra b/c it limits milk production and
decreases discomfort
The nurse should remain w/the woman and let her express her fears
o Explanations to reduce her fear can be eective
o Avoid belittling their fears; dont tell them not to worry
Interventions
o Assess level of anxiety
o Remain w/patient as much as possible
o Elicit patients feelings about surgery
o Explain preoperative and postoperative procedures
o Reduce unnecessary stimuli
Version 2
1. Nutrition/newborn/postpartum vegetarian breast feeding
Choose foods high in iron, protein, and calcium
o Iron - dried beans and peas, lentils, whole-grain products, dark leafy green
vegetables, and dried fruit
o Protein eggs and dairy products, soy products and meat substitutes,
legumes, lentils, nuts, and seeds
o Calcium dairy products, juices, cereals, soy milk, soy yogurt, and tofu
Supplements; B12 and in some cases Vitamin D
2. Med administration intrapartum pain control deep breathing
Breathing techniques provide distraction, thereby reducing the perception of pain
All patterns begin w/a deep, relaxing, cleansing breath to greet the contraction and
end w/another deep breath to gently blow the contraction away.
Slow paced breathing is initiated when the woman can no longer walk or talk through
contractions
o Aids in relaxation and provides optimum oxygenation
o As contractions increase in frequency and intensity, a shallower and faster than
normal rate of breathing should be tried
Patterned paced (pant-blow) breathing is suggested during the transition phase
3. Med administration math ml/hr
4. Med administration math
5. Med administration/newborn/legal/ethical immunize NB
Rubella/varicella
o Informed consent for rubella and varicella vaccination in the PP period includes
information about possible side eects and the risk of teratogenic eects.
o Women must understand that they must practice contraception to prevent
pregnancy for 1 month after being vaccinated
Rh Immune Globulin, RhoGAM
o Obtain informed consent (per protocol), explain procedure, purpose, and
possible side eects
o Verify correct dosage and confirm lot number and womans identity before
injection w/another RN
HB
o Parental consent must be obtained before administration
6. Antepartum 2nd trimester no fetal movement
If woman is concerned about lack of fetal movement she can perform a daily fetal
movement count aka kick count
o Woman should count kicks a few times a day for periods of 60 minutes
If renal function declines, all of the magnesium sulfate will not be adequately excreted
resulting in magnesium toxicity
Symptoms of mild toxicity
o Lethargy
o Muscle weakness
o Decreased or absent DTRs
o Double vision
o Slurred speech
Symptoms of increasing toxicity
o Maternal hypotension
o Bradycardia
o Bradypnea
o Cardiac arrest
If magnesium toxicity is suspected
o D/C magnesium infusion immediately
o Give calcium gluconate or calcium chloride IV
Treatment
!
Penicillin
Tocolytics are medications given to arrest labor after uterine contraction and cervical
change have occurred
o Magnesium sulfate is the most commonly used tocolytic agent b/c maternal/
fetal adverse reactions are less common that w/beta-adrenergic agonists
o Beta-adrenergic agonists (terbutaline - m/c) were widely used in the past
o Calcium channel blockers (Nifedipine) oral administration, low incidence of
maternal and fetal side eects; use is increasing
o Maternal fever
o Maternal or fetal infection
o Parasympatholytic drugs (atropine)
o sympathomimetic drugs (terbutaline)
o Maternal hyperthyroidism
o Fetal anemia
o Drugs (caeine, cocaine, methamphetamines)
Clinical significance
o Tachycardia is abnormal when associated w/late decelerations, severe variable
decelerations, or absent variability
Nursing interventions
o Depend on cause: reduce maternal fever w/antipyretics and cooling measures;
O2 at 8-10 L/min by nonrebreather may be of some value
Candidates for home therapy include healthy and active infants w/no signs/symptoms
of complications
Fiber optic bilirubin blankets are often used
Home care nurse assesses infants response to therapy via weight, feeding, output,
and temperature stability
Leakage of CSF from the site of puncture of the dura mater is thought to be the major
causative factor in postdural puncture headache
Assuming an upright position triggers or intensifies the headache
Assuming a supine position provides relief
Headache usually begins within 2 days of puncture and may persist for days/weeks
B Breasts
! Size/shape
! Abnormalities, reddened areas, or engorgement
! Presence of breast fullness d/t milk presence
! Nipples for cracks, fissures, soreness, or inversion
! Little change the 1st day; colostrum is present and may leak
U Uterus
! Palpate for firmness
! Location of fundus; normal finding in 1st 24 hours is midline at level of
umbilicus, involutes 1cm/day
B Bowel
! Bowel sounds in all 4 quadrants should be active in all quadrants
! Bowel movement (by day 2 or 3 after birth is normal)
B Bladder
! Ability to void spontaneously
! Distention
! Pain/burning during urination
! Does pt. feel like she is emptying bladder completely?
L Lochia/legs
! Lochia
Color of lochia
o Day 1-3; nubra (dark red)
o Day 4-10; serosa (brownish red/pink)
o After day 10; alba (yellowish white)
Amount; scant to moderate - > 1 pad/hr indicates PPH
Clots anything > 1cm is abnormal
Odor foul may indicate infections
! Legs
Deep tendon reflexes 1+ to 2+
Peripheral edema can you see/feel ankle bones?
E Episiotomy/laceration/Perineum
! Episiotomy/laceration
Edges approximated
! Perineum
Redness, edema, ecchymosis, and discharge
Level of pain
H Hemorrhoids
! If present; should be soft and pink
! Takes up to 6 weeks to decrease in size
E Energy level/emotions
! Able to care for self/infant; able to sleep
! Exited, happy, interested or involved in infant care
Epidural blood patch the womans blood is injected slowly into the lumbar epidural
space, creating a clot that patches the tear or hole in the dura mater
Blood patch is nearly complication free
Maternal infection w/HSV-2 can have adverse eects on both mother and fetus
o Viremia (virus in the blood) occurs during the primary infection
o Primary infections during 1st trimester are associated w/increased miscarriage
rates
Most severe complication of HSV is neonatal herpes, potentially fatal/severely
disabling disease
No known cure
Antiviral meds to partially control symptoms include acyclovir, Val acyclovir, and
famciclovir
o Safety of these antivirals has not been established; however may be used to
reduce the symptoms if benefits to the woman outweigh the potential harm to
the fetus
49. Newborn thrush
Oral candidiasis is characterized by white plaques on the oral mucosa, gums, and
tongue
Infants who are sick, debilitated, or receiving ABX are more susceptible to thrush
Interventions
o Maintenance of scrupulous cleanliness to prevent reinfection
o Careful hand hygiene
o Proper cleanliness of equipment and environment
Infant is treated w topical application of 1 ml Nystatin over surface of oral cavity four
times a day
o To prevent relapse therapy should be continued for at least 2 days after lesions
disappear
If infant is BF, the mother is also treated w/topical antifungal preparation such as
Nystatin applied to the nipples
50. Antepartum teaching childbirth education
Health promotion
o The nurse should stress healthy behaviors that promote the health of the
pregnant woman and her fetus
Preparation for pregnancy and birth
o Nurses should provide anticipatory teaching about physical/emotional
changes, danger s/s to report, various birthing options
o Use a variety of educational methods, such as pamphlets and videos, and
have the client verbalize and demonstrate learned topics
Common discomforts of pregnancy
o P 354-5
Danger signs to report
o Gush of fluid from the vagina (rupture of amniotic fluid) prior to 37 weeks
gestation
o Vaginal bleeding (placental problems such as abruption or previa)
o
o
o
o
o
o
o
o
o
o
o
o
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Urination with burning, pain, frequency, urgency; urine that is cloudy or has
blood
Psychosocial problems
o Postpartum depression is when the client feels apathy toward the infant,
cannot provide self- or infant-care, or has feelings that she might hurt herself or
her infant
Follow up
o The client should be discharged with an appointment set for a postpartum
follow-up visit or a number to call and schedule an appointment
o Following a vaginal delivery the follow up visit should take place in 6 weeks
o Following a cesarean birth the visit should take place in 2 weeks
Reorganization phase
o Search for meaning
o Reduction of distress
o Reentering normal life activities w/more enthusiasm
o Can make plans, including discussion about another pregnancy