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Postpartum 68WM6 *

Postpartum 68WM6 Medications and Nursing Phase 2

How long is the puerperium and what happens during that time? Period from the end of childbirth until the involution of the reproductive organs is complete. (6 weeks) placenta-ovulation returns.
What is involution? Is the process that results in the return of the reproductive organs to their non pregnancy size.
When is a temperature considered abnormal postpartum? If temperature persists at 100.4 for longer than 24 hours or exceeds 100.4 it is considered abnormal.
What hormone is responsible for stimulating milk production postpartum? Prolactin
What is the hormone that causes milk ejection? Oxytocin
How long does it take for lactation to be suppressed? 5 days
Nipple trauma should suggest what nursing intervention? Lactation referral could indicate a bad latch. Avoid soap on nipples keep them dry. Lanolin or express a small amount of colostrum.
Nursing intervention for psychological adaptation should be to? Kegel Exercise to strengthen pubococcygeal muscles. Mother must be taught to take care of herself. Use good hand washing. Breast care. Incision/episiotomy care. REST
Danger signs for postpartum psychological disorders include? Passive reactions, either verbal or nonverbal. Hostile reactions. Disappointment over the sex of the baby. Lack of eye contact. Non-supportive interaction between parents.
The birth of an infant requires the reorganization of roles and relationships within the family, what is the role of the mother? Primary caregiver to the infant. Loss of freedom. Must be sensitive to concerns.
The birth of an infant requires the reorganization of roles and relationships within the family, what is the role of the father? Must involve from birth to develop a bond. Eager to help, but lack confidence. Must be included in teaching.
Sibilings adaptation depends on developmental level. How might the toddler, infant, preschooler, school age child adapt? Toddler may think the Infant is competition, may have sleep problems, may experience regression. Preschooler may look more than touch, and the school age may easily adapt.
During the Postpartum Period if the fundus is not firm, and massaging and breast feeding does not increase the muscle tone the nurse should prepare to give? An oxytocic medication. Most common: Pitocin. Methergine. Usually administered IV
Which drug is given to an Rh negative mom who has an RH-positive infant? Rhogam
The criteria for discharge is? No complications. Normal assessments. Immunizations given if needed. Discharge teaching given. Demonstration of readiness to take care of self and baby is evident. Support person is available.
Patient teaching done at discharge should include? Uterine Massage. Lochia norms. Involution. Care of abdominal incisions. Breast care. Bowel and urinary functions. Nutrition.Rest and sleep. Exercise. Sexual activity. Follow-up appointments. Medications. Emotional responses. Infant care and feeding.
Why are babies given vitamin K? To prevent hemolytic disease.
The patient should notify the physician of? Fever. Localized redness, swelling or pain in either breast that is not relieved by support or analgesics. Persistent abdominal tenderness. Feeling of pelvic fullness or pressure. Persistent perineal pain. Frequency, urgency or burning on urination.
Report to provider if the lochia is? Foul smelling, bright red discharge. Clots are passed which are larger than the size of your fist. Pad is saturated in less than one hour.*
REEDA stands for? Episiotomy: Redness. Edema. Ecchymosis. Discharge. Approximation.
Lochia rubra Blood content; bright red colored for the first couple days.
Lochia serosa Pink to brown discharge lasting the first postpartum week.
Lochia alba Slightly yellow to white discharge which lasts 10 days to 2 weeks.
Name 3 signs of hypertonic uterine activity that would tell you to stop pitocin? Significant change in fetal heart rate, contractions less than two minutes apart with a increase of 50-65 mmhg, or lasting longer than 60-90 seconds.
Name 3 contraindications to starting pitocin? Hypoglycemia, hypersensitivity, 1st/2nd stage labor.
Why is recording I&O important for the patient on oxytocin? Water intoxication is a common side effect of oxytocin.
What are the 3 processes of involution? muscle contraction, catabolism, epithelial regeneration
How much should the fundus descend per day postpartum? 1 cm
Fundus should be back in the pelvic cavity by what day postpartum? day 10
These mothers are more likely to experience intense afterpains? multiparas who breastfeed
Why is urinary retention commonly a problem in postpartum women? decreased urge to void and pain from birth trauma
Breastfeeding can delay the onset of these two natural processes postpartum? ovulation and menstration
Normal WBC level in a postpartum woman? 14000-16000
Why should we give the premie a pacifier during tube feeding? It stimulates the sucking reflex, helps prepare the infant for nippling, is comforting and helps the infant associate sucking with feeding
Breastfeeding can delay the onset of these two natural processes postpartum? ovulation and menstration *
Normal WBC level in a postpartum woman? 14000-16000 *
How long does it take for menses to resume in nonbreastfeeding women? 7-9 weeks
How long does it take for menses to resume in breastfeeding women? 12-18 months
How much weight does a woman usually lose during childbirth? 10-12 lbs
How much weight does a woman usually lose during involution of the uterus? 5-8 lbs
Are tachy or bradydysrhythmias common in pospartum? bradydysrhythmias due to increased intravascular volume
This technique can be used to stimulate uterine contractions? fundal massage
Priority assessments following C section? Respiratory, GI, and wound assessments
To prevent pneumonia following a C section what should be done? turning coughing, deep breathing and early ambulation, IS
To prevent lactation in a woman who does not intend to breastfeed what interventions are approbriate? snug bra, avoid nipple stimulation
Early Hemorrhage Hemorrhage occurs within 24 hours of delivery.
Two causes of early uterine hemorrhage is? Uterine Atony and Trauma
Factors that increase uterine atony? Over-distension of the uterus from causes such as multiple gestations. A large infant. Hydramnios. Intrapartum factors. Augmented labor with oxytocin. DIC.
Clinical signs of uterine atony? The woman's uterus is difficult to palpate, and when found, it is boggy (soft). The fundal height is high, often above the umbilicus. If bladder is full, the fundus is high and off to one side or the other instead of being midline. Lochia will increase
Management of uterine atony? Nurses are responsible for the initial management of uterine atony. If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus
What drugs can be used to stop postpartum hemorrhage? oxytocin cytotec methergrine prostin
oxytocin (Pitocin) Often increases uterine tone and controls bleeding (rapid infusion).
methylergonovine (Methergine) Raises the blood pressure and should not be given to a woman who is hypertensive (IM).
prostaglandin (Hemabate, Prostin) Is given intramuscularly or into the uterine muscle if oxytocin is ineffective.
misoprostol (Cytotec) Is a less expensive drug that also may be used to control bleeding.
If massaging and pharmacological measure do not stop postpartum hemorrhage what might be necessary? Hysterectomy
Cervical lacerations typically occur? During the second stage of labor
Predisposing risk factors for lacerations? Rapid labor and use of forceps
Signs and symptoms of uterine lacerations? Lochia is a brighter red and flows in a continuous trickle. The uterus is usually firm.
Hematomas resulting from birth trauma are usually where? The vulva or inside the vagina.
Hemotomas usually result from? Prolonged or rapid labor. Large baby. Use of forceps or vacuum extract.
Medical management of hematomas includes? Small hematomas usually resolve without treatment. Large hematomas may require incision and drainage of the clots. Bleeding vessel is ligated or area packed.
What should the nurse inspect in hematomas? Inspect the perineum to determine whether a laceration is visible or if examination of the vaginal walls and cervix is warranted by the provider.
Late Postpartum Hemorrhage Hemorrhage that occurs later than 24 hours after delivery. Typically it occurs without warning 7 to 14 days after delivery
Most common causes of late postpartum hemorrhage is? Subinvolution (delayed return of the uterus to its nonpregnant size and consistency). Fragments of placenta that remain attached to the myometrium when the placenta is delivered.
Medical management of late postpartum hemorrhage? Oxytocin, Methergine, and prostaglandins are the most commonly used pharmacologic measures. Sonography can identify placental fragments that remain in the uterus. Dilation and curettage may be necessary to remove fragments. Antibiotics for infection.
Nursing interventions for postpartum late hemorrhage? Monitor BP, assist with ambulation, encourage rest, encourage diets high in iron.
Nursing interventions for hemovolemic shock? Monitor vital signs every 3-5 minutes, temperature, cap refill, SPO2 levels, Monitor I&Os. Teach patient to observe signs and symptoms of bleeding.
Subinvolution of the uterus can be cause by what two things? Retained placenta and pelvic infection
Signs and symptoms of subinvolution of the uterus? Prolonged discharge of lochia. Irregular or excessive uterine bleeding. Pelvic pain or feelings of pelvic heaviness. Backache, fatigue and persistent malaise.
Nursing interventions of subinvolution of the uterus include? Demonstrate how to locate and palpate the fundus and estimate fundal height. Explain the progressive changes of lochia from lochia rubra to lochia serosa and then to lochia alba. Report any deviation from the expected pattern or duration of lochia.
What is a major cause of maternal death in the US? Thromboembolic Disorders
Three major causes of thrombosis are? Venous Stasis. Hypercoagulation. Blood Vessel Injury.
What are the signs & symptoms of hemorrhage and what should be taught at discharge? Persistent red bleeding. Return of red bleeding after it has changed to serosa or alba.
Venous Stasis Result of compression of the large vessels of the legs and pelvis by the enlarging uterus.
Venous Stasis is most pronounced when? The pregnant woman stands for prolonged periods of time.
Prolonged time in stirrups for delivery and repair of the episiotomy can? Promote venous statis and increase the risk of thrombus formation.
Due to the changes in the coagulation and fibrinolytic systems that persist into the postpartum period results in a high risk for thrombus. True or False True
Thromboembolic Disorders Predisposing Factors Varicose veins. Obesity. History of thrombophlebitis. Use of oral contraceptives before pregnancy. Smoking. Women older than 35 years or who have had more than three pregnancies are also at increased risk.
Superficial Venous Thrombosis Clinical Signs and Symptoms Swelling of the involved extremity. Redness, tenderness and warmth. An enlarged, hardened, cordlike vein may be palpated. The woman may experience pain when walking. Often there are no signs at all.
Superficial Venous Thrombosis Therapeutic Management Analgesics, rest, and elastic support. Elevation of the lower extremity improves venous return. Warm packs may be applied to promote healing. Woman should avoid standing for long periods and should continue to wear support hose.
Deep Vein Thrombosis Clinical Signs and Symptoms Swelling of the leg. Erythema, heat or tenderness. Pedal edema. Positive Homan’s Sign Affected leg may become pale and cool to the touch with decreased peripheral pulses. Pain on ambulation. Chills, general malaise.
Diagnosis of DVT includes what procedures? Ultrasonography with vein compression. Doppler flow analysis. MRI may be used for pelvic veins.
Medical management for DVT? Heparin. Ambulate frequently and as early as possible. ROM should begin within 8 hours after childbirth. Antiembolism stockings or sequential compression devises Teach mother to avoid clothing that is constricting around the leg, and prolonged sitting
Nursing management for DVT? Palpate pedal pulses. Assess the affected and unaffected extremity for size and color and compare the circumference to obtain an estimation of the edema that may be present. Determine the degree of discomfort present and treat as ordered
Puerperal Sites for Infections? Episiotomy. Lacerations. Surgical incision. Uterus. Urinary tract. Breasts.
Endometritis An infection of the uterine lining, often at the site of the placenta.
Signs and Symptoms of endometritis? Fever, chills, malaise, lethargy and anorexia. Uterine tenderness. Abdominal pain and cramping. Foul-smelling lochia. Leukocytosis after the first day that does not decrease
Medical Management of endometritis? Culture and sensitivity of the uterine cavity. IV Antibiotics usually clindamycin plus gentamicin are often used until the woman has been afebrile for 48 hours. Analgesics such as antipyretics for fever.
Nursing Interventions for endometritis? Keep patient in Fowler's position Analgesics Antibiotics as ordered. Observe patient for: Spread of infection. Absent bowel sounds. Abdominal distention. Nausea/vomiting. Increasing abdominal pain.
Name two nursing interventions for UTIs? Teach mother to take all medications for the entire time it is prescribed. Encourage increased fluid intake to help dilute the bacterial count and flush the infection from the bladder.
Name two patient teaching to reduce reocurrance of UTIs? Teach mother to include measures to prevent urinary tract infection such as proper perineal care and urinating frequently.Teach patient which foods increase acidity of urine, such as apricots, cranberry juice, plums and prunes.
Postpartum factors that increase risk are? Hormonal fluctuations that normally follow childbirth. Medical problems during pregnancy or after childbirth such as preeclampsia. Personal or family history of depression or mental illness.
Marital dysfunction or lack of support. Anger or ambivalence about the pregnancy. Feelings of isolation, lack of support. Fatigue. Financial worries. Birth of an infant with illness or anomalies. Multifetal pregnancy. Are all risk factors for what? Postpartum Depression
Signs and Symptoms of postpartum depression? Lack of enjoyment in life and food. Disinterest in others including the newborn. Feelings of inadequacy, unworthiness, guilt, shame and inability to cope. Being withdrawn.
How is the family impacted by postpartum depression? Postpartum depression impacts and creates strain for the entire family. Communication is impaired. Infants of depressed mothers are at risk for later cognitive and behavioral problems
How should the nurse assess the patient for postpartum depression? Simply asking women if they are often sad or depressed and if they have felt a loss of pleasure or interest in things they once enjoyed may identify depression.
Nursing interventions for PPD? Observe for subjective symptoms such as apathy, lack of interest or energy, anorexia or sleeplessness. Focus on the frequency, duration, and intensity of the woman’s feelings to determine their severity.
What should the nurse teach the patient abour postpartum depression? Teach mothers the signs of postpartum depression and when they should seek help. Teach and model behavior to show the mother how to respond to their infants cues.
Postpartum Psychosis Signs and Symptoms Sleep disturbances, confusion, agitation, irritability. Hallucinations and delusions. Tearfulness. Preoccupation with guilt and feelings of worthlessness. Lack of appetite. Excessive concern with baby’s health. Withdrawn and loses touch with reality.
What might the infant and mother be at risk for if the mother is suffering from major depression? Death
What are the three types of mood disorders related to the postpartum period? Postpartum blues, depression & psychosis.
Postpartum psychosis is a not a medical emergency. True or False False postpartum psychosis is a medical emergency!
Bipolar disorder, a disorder characterized by episodes of mania and depression, increases the risk of developing what disorder in pregnancy? Postpartum Psychosis
How is the head assessed in a newborn? The head is palpated to assess the shape and identify abnormalities.
What is molding? Changes in the shape of the head to allow it to pass the birth canal. Caused by overriding of the cranial bones at the sutures and is common. The parietal bones often override the occipital and frontal bones, and a ridge can be felt at those areas
How long does it take for a infants head to return to normal shape? Resolves gradually within a few days-1 week
Seperations can indicate what? may be the temporary result of molding or, if it persists or widens, may indicate increased intracranial pressure.
Fontanelles Areas of the head where sutures between the bones meet.
Caput Succedaneum area of edema as a result of pressure against the mother’s cervix during labor.
Face Exam Assess for symmetry. Positioning of the facial features. Movement. Expression. A transient asymmetry from pressure may occur, lasting a few weeks of months.
Eye Exam Abnormalities/signs of inflammation. Symmetric and same size. Transient strabismus. Color. Pupils. Tears. Eyelid edema/hemorrhage. Visual acuity.
Ear and Nose Exam Ear: Placement, overall appearance, and maturity. Position. Hearing. Nose Patency, discharge and septal deviation.
Mouth Exam Assess visually and by palpation. Inspect for pink mouth, gums and tongue . Epstein's pearls.
Neck and Clavicles Visually assess neck. Check for clavicle fractures.
Assessment of Integumentary System Assess every inch of skin surface. Color: Pink or tan. Acrocyanosis.
Vernix Caseosa A thick white cream cheese-like substance. Preterm vs Postterm. Most vernix is removed during the first bath and the remaining vernix is absorbed by the skin.
Respiratory Exam Respirations: Assess at least once every 30 min. Noted Abnormalities. Lung sounds.
Signs and symptoms of RDS Tachypnea. Retractions.   Nostril flaring. Cyanosis. Grunting. Seesaw Respirations. Asymmetry. Choanal Atresia.
Tachypnea It is the most common sign of respiratory distress defined as a rate above 60 breaths/min. Is not unusual during the first hour after birth and during the second period of reactivity, but continued tachypnea is abnormal.
What are the three types of retractions? Substernal retractions area under the sternum retracts each inhalation. Intercostal retractions are present when the muscles between the ribs are pulled in.Supraclavicular retractions when the muscles above the sternum and around the clavicles are used.
Nasal Flaring A widening of the nostrils when the infant is receiving insufficient oxygen. Decreases airway resistance & increases the amount of air entering the lungs. Flaring may occur in the first hour after birth. Continued flaring indicates a more serious problem.
Central cyanosis involves the lips, tongue, mucous membranes, and trunk and shows true hypoxia. Indicates that not enough oxygen is reaching the vital organs and requires immediate attention.
Grunting Describes a noise made on expiration when air crosses partially closed vocal cords.
Persistent grunting is a common sign of respiratory distress syndrome and necessitates expanded assessment and referral for treatment. True or False True
Seesaw Respirations In the infant with severe respiratory difficulty, the chest falls when the abdomen rises and the chest rises when the abdomen falls, causing a seesaw effect. Infants without other signs of respiratory difficulty should not cause alarm.
Choanal Atresia One or both nasal passages are blocked or narrowed by bone or membrane that protrudes into the area Assessed by closing the infant’s mouth and occluding one nostril at a time. Significant because newborns are nose breathers for the 1st 3 weeks of life
Heart Sounds Auscultate for rate, rhythm, and presence of murmurs or abnormal sounds. Listen at the apex – 3rd or 4th intercostals space, slightly left of the midclavicular line. Assess with same frequency as respiratory rate.
When is BP performed on a newborn? Not normally part of assessment but can be ordered if doctor suspects heart anomaly. Should be assessed when infant is quiet.
Cap Refill on newborn After blanching, color should return in < 3 sec.
Meconium Stools First stools that are dark greenish-black, tarry, odorless, but very tenacious material. Should occur within 12 hours following birth.
Urine Exam Newborn voids within first 12 hours. Record first void. By 4th day of life, at least six wet diapers can be expected.
Female Genitalia In the full term infant, the labia majora should be large and completely cover the clitoris and labia minora.
Labia may be darker than the surrounding skin in a newborn baby why? a normal response to exposure to mother’s hormones before birth.
Edema of the labia and white mucous vaginal discharge are normal. True or False True
Pseudomenstration A small amount of bleeding may occur from the sudden withdrawal of maternal hormones at birth.
Scrotum Should be pendulous at term and may be dark brown from maternal hormones. Rugae (creases in the scrotum) are deep and cover the entire scrotum in the full-term infant.
Meatus Should be at the tip of the glans penis. Routine retraction of the foreskin of the newborn for cleansing is not recommended as it can cause damage.
Reflexes of the Newborn Rooting. Sucking. Moro Reflex. Palmar Grasp Reflex. Plantar Grasp Reflex. Tonic Neck Reflex. Babinski. Dance or Stepping Reflex.
Rooting Stimulated by touching the side of the newborn's cheek near the mouth. Infant turns head toward that side and opens the lips.
Sucking Stimulated by placing a nipple or gloved finger into the infant's mouth. Suck reflex is assessed for presence and strength.
Moro Reflex Occurs when the infant’s head and trunk are allowed to drop 30 degrees when the infant is in a slightly raised position. Infant’s arms and legs extend and abduct, with the fingers fanning open and thumbs and forefingers forming a C position.
Plantar Grasp Reflex Occurs when the area below the toes is touched. Infant’s toes curl over the examiner’s fingers.
Tonic Neck Reflex In a supine position, the infant's head is quickly turned to one side, arm and leg will extend on that side, and opposite arm and leg will reflex; posture resembles a fencing position.
How does a nurse differentiate acrocyanosis and central cyanosis? Acrocyanosis the mucosa are not blue.
What medications are used for Induction and augmentation of labor: Prostaglandins. Oxytocin.
What medications are used for Cervical ripening: Prostaglandins. misoprostol (Cytotec). Magnesium sulfate.
Prostaglandin Mechanism of action? Produces contractions similar to those occurring during labor at term by stimulating the myometrium (oxytocic effect). Initiates softening, effacement, and dilation of the cervix ("ripening"). Also stimulates GI smooth muscle.
Therapeutic Effect of Prostaglandin? Therapeutic Effects: Initiation of labor. Expulsion of fetus.
Prostaglandin Precautions Uterine scarring. ****Asthma. Hypotension Cardiac disease. Adrenal disorders. Anemia. Jaundice. Diabetes mellitus. Epilepsy. Glaucoma. Pulmonary, renal, or hepatic disease. Multiparity (up to 5 previous term pregnancies).
Elements of Nursing Assessment for Prostaglandin Administration Monitor uterine activity, fetal status, and dilation and effacement of cervix continuously throughout therapy. Assess for hypertonus, sustained uterine contractility, and fetal distress. Insert should be removed at the onset of active labor.
If no cervical/uterine response to initial dose of dinoprostone is obtained, repeat dose may be administered 6 hours
What systems are commonly treated with medications following birth? Reproductive System: hemorrhoids, perineal trauma, episiotomy, lacerations, or bowel elimination. Cardiovascular System: hypervolemia. GI System: constipation. Urinary System: urinary tract infection caused by urinary retention and overdistention.
Care of the newborn also occurs during the postpartum period. The newborn will be treated with what medications? Vitamin K1 (Phytonadione). Antiinfectives: Erythromycin Ophthalmic Ointment. Tetracycline. Vaccines: Hepatitis B Vaccine. Hepatitis B Immune Globulin (HBIG).
What is the normal dose of Vitamin K for newborns PO (Children >1 month): 2.5-5 mg/day.
Nursing Interventions for Vit K Administration Monitor for side effects and adverse reactions. Children may be especially sensitive to the effects of vitamin K, which may increase incidence of side effects. Neonates, especially premature neonates, may be more sensitive than older children.
When administrating Vit K which labs should be monitored? Lab Test Considerations: prothrombin time (PT) should be monitored prior to and throughout vitamin K therapy to determine response to and need for further therapy.
When administering Vit K what nursing implementations should be used? Administration of whole blood or plasma may also be required in severe bleeding because of the delayed onset of this medication. Phytonadione is an antidote for warfarin overdose but does not counteract the anticoagulant activity of heparin.
What should a nurse teach the parents regarding Vit K for newborns? Take medication as ordered. If a dose is missed, take as soon as remembered unless almost time for next dose. Notify doctor missed doses. Advise patient to report any signs of bleeding (bleeding gums nosebleed black tarry stools hematuria
Normal Temp Range for Newborn? Temperature: Axillary: 36.5-37.5 C (97.7-99.5 F). Rectal 36.5-37.6 C (97.7-99.7 F). Axilla is the preferred site.
Normal Heart Rate for Newborn? Heart Rate: Normal rate 120 to 160 beats/minute with normal activity. May rise to 180 beats/minute when the infant is crying, or drop to 100 beats/minute during deep sleep. Count apical pulse for a full minute.
Normal Respiratory Rate for Newborn? Normal rate is 30 to 60 breaths/minute. Chest should move symmetrically, although pattern and depth of respirations are irregular. Respirations should not be labored. Count rate for 1 full minute for accuracy
How should the LPN provide Eye Treatment? Erythromycin 0.5% ointment most commonly used.
Ongoing assessment of the newborn should include? Perform cord care. Preventing infant abduction. Nutritional Needs of the infant.
What is colostrum? First lactation fluid which is a thick yellow substance high in protein, minerals, fat soluble vitamins and immunoglobulins, which transfers some immunity to the infant. Its laxative effect speeds the passage of meconium.
What is transitional milk? Appears as the milk changes from colostrums to mature milk. Immunoglobulins and protein decrease, whereas lactose, fat, and calories increase.
What is mature milk and when is it established? Established by two weeks after delivery. Bluish in color and not as thick as colostrum
Why are infants more predisposed for heat loss? Skin is thin and blood vessels are close to the surface. Little subcutaneous or white fat. Percentage of subcutaneous fat is only half that of an adult. Newborns have three times more surface area to body mass than adults do.
What are the four methods of heat loss? Conduction Radiation Evaportation and Convection
What is the difference between bonding and attachment? Bonding: the rapid initial attraction felt by parents soon after childbirth. Attachment: process by which an enduring bond between a parent and child is developed through pleasurable, satisfying interaction
What are three nursing interventions which facilitate bonding? ASAP after delivery, allow parents to see and hold infant (dictated by the condition of the mother and baby); encourages parents to touch the baby. Encourage frequent contact. Observe and assess for signs of progressive bonding and attachment
How many identification bands are made for baby? 4
What level can jaundice be visiable in the face abdomen and feet? Jaundice becomes visible when it reaches 5 to 7 mg/dl. A rough guide to the total bili level is that jaundice of the: Face occurs at 5 to 7 mg/dl. Midabdomen at about 15 mg/dl. Soles of the feet at 20 mg/dl.
Physiologic Jaundice Is not present during the first 24 hours of life in term infants but appears on the second or third day after birth and is considered a normal phenomenon.
Pathologic Jaundice Appears during the first 24 hours after birth is generally from a pathologic process.
Clinical Jaundice Lasts more than 2 weeks in a full term infant
What are common causes of pathologic jaundice? Abnormalities causing excessive destruction of erythrocytes. Incompatibilities between: Mother’s and infant’s blood types. Infection. Metabolic disorders.
Pathologic Jaundice may result in? May lead to kernicterus. Those who survive may suffer from: Cerebral palsy. Mental retardation. Hearing loss. More subtle long-term neurologic and developmental problems.
Factors that increase hyperbilirubinemia? Hemolysis of excessive erythrocytes. Short red blood cell life. Liver immaturity. Lack of intestinal flora. Delayed feeding. Trauma resulting in bruising or cephalohematoma. Fatty acids from cold stress or asphyxia
Common risk factors for hyperbilirubinemia? Prematurity. Cephalohematoma. Bruising. Delayed or poor intake. Cold Stress. Asphyxia.Rh incompatibility. ABO incompatibility. Sepsis. Sibling with jaundice. Breastfeeding. Infection.
How should jaundice be assessed in a newborn? Blanch the infant’s skin on the nose or sternum. Determine how far down the body the jaundice extends.
What is the medical management of jaundice? Prevention of kernicterus. Phototherapy most common treatment and involves placing the infant under special fluorescent lights. Phototherapy can be delivered by use of “bili” lights or by use of a fiber optic blanket placed against the infant’s skin.
When are exchange transfusions performed on a jaundice baby? Performed when phototherapy cannot reduce high bili levels quickly.
What are some nursing interventions for jaundice babies? Maintain a neutral thermal environment. Provide optimal nutrition. Protect the eyes. Enhance response to therapy. Detect complications. Parent Teaching.
Which test diagnosis ABO incompatibility? Coombs Test
Erythema Toxicum Benign rash of unknown cause in newborns, blotchy red areas that may have white or yellow papules or vesicles in the center. Rash appears during the first 24 to 48 hours after birth, although occasionally not until 1 to 2 weeks
Where does Erythema Toxicum most commonly occurs? Most common over the face, back, shoulders, and chest.
What is the cause of Erythema Toxicum and when does it go away? Cause is unknown, but it occurs in 50% of full-term infants and disappears within hours or up to 10 days.
Mongolian Spots Bluish black marks that resemble bruises. Usually occur in the sacral area.
What babies does Mongolian Spots more commonly occur on? Frequently in newborns with dark skin.
Petechiae Pinpoint bruises that resemble a rash. Increased intravascular pressure. May indicate infection or a low platelet count.
Nervus Simplex Flat, pink, or reddish discoloration. Usually on face or neck. Color blanches. Disappear by 2 years of age.
Nervus Flammeus Known as port wine stain. Permanent, flat, dark, reddish-purple mark. Varies in size and location. Can be removed by laser surgery.
Nevus Vasculosus Known as strawberry hemangioma. Enlarged capillaries in the outer layer of skin. Dark red and raised with a rough surface. No treatment is necessary.
Cutis Marmorata Lacelike red or blue pattern. Cold stress, overstimulation, hypovolemia, or sepsis. May indicate a chromosomal abnormality.
Harlequin Color Change Deep red color over half of body with pallor on the other half of the body. Cause is unknown. Usually occurs with preterm infants who are placed on their side.
Bruises May occur on any part of the body. Bruising on the head. Document size, color, and location.
Acrocyanosis Hands and feet may appear slightly blue. Acrocyanosis is common during the first day and is a result of poor peripheral circulation.
Milia Pearly white pinpoint papules on face and nose of newborn. Due to clogged sweat and oil glands (sebaceous glands) not functioning normally. Disappear within a few weeks.
What should the nurse teach the parents about Milia? Educate parents not to attempt to "squeeze out" the white material because infection can occur.
Mongolian spots can be mistaken for what condition? Child Abuse
Circumcision Most common surgical procedure of the neonate. Reasons for choosing circumcision. Reasons for rejecting circumcision. Pain Relief.
What are the two methods of circumcision? Gomco clamp. Plastibell.
What are the nursing interventions associated with circumcision? Assist in decision making. Verify signed consent. NPO 2-4 hours before. Bulb syringe for secretions. Comfort measures. Gentle pressure for bleeding. Note first void. Parent teaching.
Gestational Age refers to the prenatal age of the developing baby (measured in weeks) calculated from the first day of the woman’s LMP; approximately 2 weeks longer than the fertilization age. An SGA, AGA or LGA infant may be preterm, term or post-term.
Preterm can be defined as? Less than 38 weeks gestational age.
Term can be defined as? 38-42 weeks gestational age
Postterm can be defined as? Beyond 42 weeks gestational age.
Ballard Score Used to assess gestational age. Focuses on physical and neuromuscular characteristics. Gives a score to each assessment area with the total score determining the gestational age of the infant.
Small for gestational age (SGA): size is below the 10th percentile.
Appropriate for gestational age (AGA): infant whose size is AGA falls between the 10th and 90th percentiles.
Large for gestational age (LGA): size is above the 90th percentile.
Extremely low birth weight (ELBW): weight is 1000g (2 lb 3 oz) or less at birth.
Very low birth weight (VLBW): weight is 1500g (3lb, 5 oz) or less at birth.
Low birth weight (LBW): weight is 2500 g (5 lb 8 oz) or less at birth and of any gestational age (not to be confused with preterm).
Why are preterm infants predisposed to fluid and electrolyte imbalance? Preterm infants lose fluid very easily.   Skin has little protective subcutaneous white fat. Kidney development incomplete. Electrolyte regulation imbalance
What are 3 nursing interventions for F&E problems? I & O. Urine specific gravity. Daily weights. Signs of dehydration or fluid overload must be carefully monitored by the nurse.
What is rentinopathy why is it cause and who does it occur in more commonly? Breakage of the retina's blood vessels resulting in disattachement of the retina. Infants of less than 28 weeks 1500 g or less. Exact cause unknown.
What is the medical and nursing management of retinopathy? Check pulse oximetry. Treatment: Consult with an ophthalmologist. Possible laser photocoagulation surgery. Cryotherapy. Reattachment of the retina.
Necrotizing Enterocolitis Exact causes unknown.   Blood is diverted from the GI tract. Other causes of decrease blood flow. Incidence much higher after infants have been fed.
What are the signs and symptoms of necrotizing enterocolitis? Abdominal distention. Increased gastric residuals. Decreased or absent bowel sounds. Vomiting. Bile-stained emesis or residuals. Bloody stools. Abdominal tenderness. Signs of infection.
How is necrotizing enterocolitis? Antibiotics. Parenteral nutrition to rest the bowel. NPO. Continuous or intermittent gastric suction. May need to surgically remove necrotic bowel and place an ostomy.
What are some nursing interventions for necrotizing enterocolitis? Early recognition of signs of NEC. Measure abdominal girth. Manage IV fluids and parental nutrition. Strict I&O. Position infant on the side to minimize effects of pressure on the diaphragm from distended intestines.
What is the definition of hydrocephalus? Condition caused by an imbalance in the production and absorption of CSF in the ventricles of the brain.
Pathophysiology of Hyrocephalus May be congenital or acquired. Symptom of an underlying brain disorder classified as noncommunicating or communicating.
Arnold Chiari Malformation Congenital anomaly in which the cerebellum and medulla oblongata extend down through the foramen magnum.
Dandy Walker Syndrome When the enlarged head involves a prominent occiput, the condition usually involves an atresia of the foramen of Lushka and Magendie.
Signs and Symptoms of Hydrocephalus Fontanel is full or bulging. Head is enlarged. Setting-sun is apparent.
Two factors influence the clinical picture of hydrocephalus are? Time of onset. Presence of preexisting structural lesions.
Diagnosis of Hyrdrocephalus is made how? Diagnosis is based on: Head circumference. Associated neurologic signs that are present and progressive. Other diagnostic studies are needed to localize the site of CSF obstruction
Primary diagnostic tools used in older children are? Primary diagnostic tools are CT and MRI.
Treatment of hydrocephalus goal is to: Relief of hydrocephalus. Treatment of complications. Management of problems related to the effect of the disorder on psychomotor development.
Medical treatment of hydrocephalus is? Direct removal of an obstruction (such as tumor). Placement of a shunt.
Preoperative nursing care for hydrocephalus? Observe carefully for s/s increasing intracranial pressure. Measure the head circumference daily at the point of largest measurement and record. Gently palpate fontanels and suture lines for size and signs of bulging, tenseness and separation.
PostOp Nursing Interventions for Hydrocephalus Position carefully on unoperated side to prevent pressure on the shunt valve and pressure areas. Keep flat. s/s of increased ICP, which indicates an obstruction of the shunt
Patient Teaching for Hydrocephalus Educate parents on shunt malfunction and infection. Teach parents how and when to "pump" the shunt by pressing against the valve behind the ear. Emphasize the importance of multidisciplinary care. Educate parents on support groups
What are the two classifications for hydrocephalus? Communicating and noncommunicating hydrocephalus.
Spina Bifida Midline defect involving failure of the bony spine to close.
Spina Bifida Occulta Defect that is not visible externally. Occurs most frequently in the lumbosacral area. Failure of the vertebral arch to close, usually without other anomalies. It is seen by a dimple on the back, which may have a tuft of hair over it
Spina Bifida Cystica Visible defect with an external saclike. protrusion. Are two major forms: 
Meningocele meninges and spinal fluid.
Meningomyelocele contains meninges, nerve roots, spinal cord, and spinal fluid.
Neural Tube Diagnostic Tools MRI. Ultrasound. CT. Myelography. Prenatal detection by elevated AFP, & fetal ultrasound. CVS: chorionic villus sampling.
Initial Care of Neural Tube Defects Prevention of infection. Neurologic assessment, including observation for associated anomalies. Dealing with the impact of anomaly on the family.
Medical Managment of Neural Tube defects? Most authorities believe that early closure, within the first 24 to 72 hours, offers most favorable outcome. Improved surgical techniques do not alter major physical disability, spinal defect, or chronic UTIs that affect these kids.
Nursing Interventions for Neural Tube Defects Note position and covering of the defect at birth. Observe movement below the defect Examine for a relaxed anus and dribbling of stool and urine Care of the sac Positioning Diapering skin care Postoperative nursing care Latex-free environment
Definition of Cleft Lip Minor notching of the lip or complete separation through the lip and into floor of nose. Caused from a failure of the maxillary and median nasal processes to fuse.
Definition of Cleft Palate Midline fissure of the palate that result from failure of the two sides to fuse. Only the soft palate or division of entire hard and soft palate.
What is the etiology of Cleft Lip/Palate May be an isolated anomaly, or may occur with recognized syndrome. May be exposure to teratogens. Alcohol. Smoking (twice the risk). Certain medications.
What is the medical management for CL / CP? Lip surgery is generally performed by 3 months. Further surgery may be needed at 4 to 5 years. Palate repair surgery is done in stages, depending on the degree, usually beginning before one year to minimize speech problems.
Why is long term care needed for CL/CP? Long-term follow-up is necessary for orthodontia, speech therapy, treatment of possible hearing problems, and potential for emotional and social adjustment difficulties
What are some nursing interventions for CL/CP? Feeding: the degree of cleft determines the approach to feeding. Experiment to find method that works best for individual infants. Breastfeeding. Soft preemie nipples. Large, soft nipples with enlarged holes. Special “cleft palate” nipples
What patient teaching should be done with PreOP CL/CP? Help parents deal with their disappointment over the infant with an obvious anomaly. Show them before and after pictures of plastic surgery.
PostOP nursing interventions for CL? Position infant on back or side postoperatively. Place infant in arm restraints.   Prevent infant from sucking and crying. Avoid injury to operative site. Prevent infection/scarring. Elbow restraints Provide appropriate pain relief and sedation
PostOP nursing interventions for CP? Lie on abdomen. May resume feeding. Oral packing. Clear to full liquids.
What patient teaching should be done with PostOP CL/CP? Teach parents feeding techniques. Prevent infections. Importance of regular follow-up. Psychosocial support. Developmental delays.
Talipes varus: an inversion or bending inward.
Talipes valgus: an eversion or bending outward.
Talipes equines: plantar flexion in which the toes are lower than the heel.
Talipes calcaneus: dorsiflexion, in which the toes are higher than the heel.
Hip Dysplasia Treatment Newborn-6 months? Hip joint is maintained by dynamic splinting in a safe position with the proximal femur centered in the acetabulum in an attitude of flexion.
Hip Dysplasia Treatment 6-18 months? This age-group the dislocation is not recognized until child begins to stand and walk. Gradual reduction by traction is used for about 3 weeks. Child then undergoes attempted closed reduction of the hip using general anesthesia.
If hip dysplasia is not reducible what is done? open reduction is performed and child is placed in hip spica for 2-4 months until hip is stable and a flexion-abduction brace is applied
Nursing Considerations for Hip Dysplasia? Teach parents how to use the Pavlik harness. Reduce irritation and to maintain cleanliness. Involve in age-group appropriate activities.
PKU A genetic disorder that causes central nervous system damage from toxic levels of the amino acid phenylalanine in the blood.
PKU Causes A deficiency of the liver enzyme phenylalanine hydrolase, which is needed to convert phenylalanine to tyrosine. It is an autosomal recessive disorder.
PKU Signs and Symptoms Feeding difficulties. Vomiting. Hypertonia. Irritability. Infant has eczema and musty odor of urine.
PKU Signs and Symptoms in Older Children Eczema. Hypertonia. Hyperactive behavior. Mental retardation. Seizures. Hypopigmentation of the hair, skin, and irises.
Medical Management of PKU Further evaluations. Low-phenylalanine diet. Special formula for infants. Diet is primarily fruits, vegetables, and starches with a phenylalanine-free protein supplement. Small amounts of phenylalanine are allowed.
PKU Nursing Considerations Ensure newborns are screened for PKU at the appropriate time. The optimal time is 24-48 hours post birth Assist parents in regulating the diet to meet infant’s changing phenylalanine needs.
Down Syndrome Most common chromosomal abnormality of a generalized syndrome. Trisomy 21 (nonfamilial trisomy 21). Translocation of chromosomes 15 and 21 or 22. Mosaicism.
Trisomy 21 Attributable to an extra chromosome 21. Occurs in about 95% of all cases.
Translocation of chromosomes 15 and 21 or 22 This type of genetic aberration is usually hereditary. Not associated with advance parental age.
Mosaicism Refers to cells with both normal and abnormal chromosomes. The degree of physical and cognitive impairment is related to the percentage of cells with the abnormal chromosome makeup.
Diagnostic Tools for Downs Syndrome Alpha-fetoprotein (AFP) screening.   Multiple Marker screening. Chorionic villus sampling. Amniocentesis. Nuchal translucency.
What does the head and face look like in a child with Downs Sydrome? Separated sagittal suture. Brachycephaly. Skull rounded and small. Flat occiput. Enlarged anterior fontanel. Face: flat profile.
When assessing the face what should a nurse look for as an indication of Downs Syndrome? Oblique palpebral fissures (upward, outward slant). Innerepicanthal folds. Speckling of iris. Short, sparse eyelashes. Nose: small, depressed nasal bridge (saddle nose).
An infant with Down Sydrome mouth may: High, arched, narrow palate. Protruding tongue that may be fissured at lip and furrowed on surface. Hypoplastic mandible. Downward curve (especially when crying). Mouth kept open.
What do the hands and feet look like in an infant with Down Syndrome? Broad, short stubby fingers. Incurved little finger. Transverse palmar crease. Increased ulnar loops on fingers. Feet: Wide space between big and second toes. Plantar crease between big and second toes. Broad, stubby, and short
Other problems that may occur in children with Down Syndrome are? Congenital heart malformation (septal defects). Respiratory tract infections. Dysfunction of immune system. Thyroid dysfunction (congenital hypothyroidism). Increased incidence of leukemia.
What are some nursing interventions appropraite for children with Downs Syndrome? Family support and education. Allow parents to express concerns. Involve parents in infant care to promote bonding. Involve siblings in infant care and include them in discussions. Refer parents to others for help or advice
PIVH Defined as bleeding around and into the ventricles of the brain.
PIVH Etiology Occurs most often in infants of less than 32 weeks or weight less than 1500g. First few days are the most common time for hemorrhage to occur. Results from rupture of the fragile blood vessels around the ventricles.
PIVH Pathophysiology Hypoxic injury to the vessels. Increased or decreased blood pressure. Increased or fluctuating cerebral blood blow. Rapid blood volume expansion. Hypercarbia. Anemia. Hypoglycemia
PIVH Signs and Symptoms Lethargy. Poor muscle tone. Deterioration of respiratory status with cyanosis or apnea. Drop in hematocrit levels. Decreased reflexes. Full or bulging fontanelles. Seizures.
PIVH Medical Management Ultrasonography on preterm infants. Treatment is supportive. Hydrocephalus may develop.
PIVH Nursing Considerations Care may increase cerebral blood flow and blood pressure. Be alert for early signs of PIVH. Care includes: Head circumference. Observation. Minimal handling. Reduced environmental stressors. Parental support and teaching
Infant of Diabetic Mother Risks Congenital anomalies: 3X more likely. Most frequent anomalies are: Cardiac. Urinary tract. Gastrointestinal. Neural tube defects. Caudal regression syndrome. Cardiomegaly is common and may lead to heart failure.
IDM Medical Management Includes controlling the mother’s diabetes throughout the pregnancy to decrease complications. Be prepared for shoulder dystocia or cephalopelvic disproportion and C- Section.
Nursing Considerations for IDM Signs of complications, trauma, and congenital anomalies at delivery and during transition. Respiratory problems. Hypoglycemia. Rapid respirations, low temp and poor muscle tone.
Nursing Interventions for IDM Monitor glucose levels. Feed infant early. Parental support.
What two complications are common in infants born to diabetic mothers? these infants are prone to hypoglycemia and jaundice as well as muscle and nerve injuries related to traumatic deliveries due to macrosomia.
How often should you check gastric residuals on gavage fed infants before every feeding.
Why are premies often gavage fed? nippling consumes a great deal of energy. Some premies have difficulty coordinating sucking, swallowoing and breathing and are unable to consume sufficient calories before they become fatigued and may be at risk for aspiration.
When should the plastibell fall off? in 5-8 days
What is “Doll’s eyes”? Doll’s eyes is the rolling motion of the eyes to the midline when the baby is turned on its side. This is abnormal in adults but normal in newborns due to poor control of the small ocular muscles.
Name 3 signs of mastitis? temp > 100.3, hot, red tender area on breast usually the upper outer quadrant often accompanied by a flu like malaise.
What is the difference between postpartum blues, postpartum depression and postpartum psychosis? Blues are mild and self-limiting Depression lasts longer than 3 weeks and includes physical and psychological signs of clinical depression. Psychosis is rare and involves loss of contact with reality, delusions.
What is erythroblastosis fetalis? hemolytic red cell breakdown in the fetus in response to blood incompatibilities between baby and mother. Severe cases can cause fetal kernicterus, CHF, asiites and death.
Nevus Flammeus port wine stain Permanent flat dark reddish purple birthmark
What are café au-lait spots? permanent light brown or tan birth marks that may occur anywhere on the body. >5 are associated with an increased risk for neurofibromatosis. P494 Murray
Created by: alexandra.bell
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