maternity exam 2 study guide
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| Dyspareunia: | Difficult or painful coitus
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| Involution: | Retrogressive changes that return the reproductive organs, particularly the uterus, to their non-pregnant size and condition
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| Kegel exercises: | Alternately contracting and releasing pelvic floor muscles to strengthen muscles surrounding the urinary meatus and vagina
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| Lactation: | Secretion of milk from the breasts
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| Prolactin: | Hormone that stimulates milk production
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| Puerperium: | Period from end of childbirth until involution is complete -- ~ 6 weeks
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| Lochia Alba: | white, cream-colored vaginal discharge
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| Lochia Rubra: | Reddish or red-brown vaginal discharge
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| Lochia Serosa: | Pink or brown-tinged vaginal
discharge
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| Taking in/Taking hold/Letting go: | 1st, 2nd, 3rd phases of maternal adaptation, each with specific behaviors
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| Attachment: | Strong ties from infant to parent (other)
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| Bonding: | Strong ties from parent to infant
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| En face: | Position with mother facing infant
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| Fingertipping: | 1st tactile experience w/mom touching infant
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| 4th Trimester: | 1st 12 weeks after birth
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| Postpartum blues: | Temporary, self-limiting period of tearfulness experienced by new moms
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| Mastitis Etiology Clinical signs and symptoms Therapeutic management | Etiology
Usu 2-4 weeks after birth
Staph aureus or strep
Engorgement; stasis of milk
Clinical signs and symptoms
Flu-like; fatigue; aching; fever, chills, malaise
Therapeutic management
Antibiotics
Pump/b’feed; ice packs; breast support
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| Mastitis (cont’d) Nursing considerations | Nursing considerations
Teaching
Completely empty breast at each feeding
B’feed, pump more, especially on affected breast
Massage affected area
Support, encouragement for new moms who are trying to b’feed
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| Endometritis Etiology Clinical signs and symptoms | Etiology
Endomyometritis or
Metritis w/pelvic cellulitis
Clinical signs and symptoms
Fever, usu w/in ~36 hrs of birth, chills, abdominal pain, foul smelling lochia
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| Endometritis (Cont’d) Therapeutic management | Therapeutic management
IV antibiotics; Prevent infection from spreading
Sometime prophylactically before cesarean
Improvement usu w/in 2 days
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| Endometritis (Cont’d) Complications Nursing considerations | Complications
May spread to fallopian tubes or ovaries, resulting in sterility
Peritonitis may occur
Nursing considerations
Fowler’s to promote drainage
Medication
VS q2, while fever
Warm blanket; cool compress; hot/cool drinks
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| 1st, 2nd, 3rd phases of maternal adaptation, each with specific behaviors | Taking in/Taking hold/Letting go:
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| Taking in/Taking hold/Letting go? | 1st 24 hrs: Passive; preoccupied with own needs; elated, or very quiet
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| Taking in/Taking hold/Letting go? | After first 24 and for several days: Demonstrates autonomy for her own care; teaching time; easily feels overwhelmed
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| Taking in/Taking hold/Letting go? | Before d/c: Parents focus on giving up the “ideal” birth and the “ideal” infant Not the sex hoped for
Fantasy baby doesn’t match real infant
Feelings of loss and grief
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| Verbalize attachment | Attachment – development of ties between infant and another
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| Verbalize bonding | Bonding – immediate attraction of Parents to Infants
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| PP assessment of the mother (BUBBLEHE) | BUBBLEHE
Breast,Uterus,Bowel,Bladder,Lochia,Episiotomy/incision, Homan’s sign & Pedal,pulses, Emotions
OTHER Assessments
Vital signs, Lungs & heart, neurological system, CVA tenderness, Rest & sleep,Nutrition
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| Care Post Cesarean Birth – 1st 24 | Major abdominal surgery, Pain relief 1st 24, Respirations:Pulse ox – 1st 24, Q15 x 1st hr,Q 30 x 3-6 hr, Qh x 24 hrs ≤12-14 bpm – notify, Bowel sounds, Surgical dressing, REEDA, I&O, 1st 24
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| Care Post Cesarean Birth – 1st 24 continued | Pain management
Anesthesiology
Turn, cough Q2, while awake
Flex feet, knees
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| ,Sedatives | Used in early latent phase
Relieves anxiety & induces sleep
Augments analgesics
Decreases nausea
Can cause resp depression in infant in active labor
Minimal analgesic effect
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| Name sedative Too much = floppy NB Diazepam (Valium) Lorazepam ( Ativan) | Benzodiazepines
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| Valium is a popular _______ Used to treat _______ Some _______ have undesirable amnesic effect E.g., Low Apgar scores if given within 5 min of birth Usually not used in _______________ | benzodiazepine; anxiety; benzodiazepines; childbearing women
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| Drugs that occupy receptors and activate them | Agonist
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| Drugs that occupy receptors but do not activate them. They block receptor activation by agonists. | Antagonists
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| Name the analgesic? No amnesic effects Stimulate opioid receptors Create euphoria Decrease GI emptying Increase N&V; may inhibit bowel & bladder Dizziness Bradycardia Tachycardia Hypotension Resp depression | Opioid Agonist
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| Name the analgesic? Hydromorphone hydrochloride (Dilaudid) Meperidine (Demerol) Fentanyl (Sublimaze | Opioid Agonist
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| Name the analgesic? Stimulates certain receptors & blocks others Analgesia without resp depression Less N&V May have more sedation Used more often than the opioid agonist analgesics | Agonist-Antagonist
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| Name the analgesic? Stadol (Butophanol) Full term Early labor, 1-2mg IV/IM, no nasal spray, repeat 4h Not effective alone for pain associated with delivery If used in conjunction affects might be potentiated Not a lot of research | Agonist-Antagonist
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| Nubain Placental transfer is rapid; high (1:0.4-1:6) NB brady, r depression, apnea, hypotonia | Agonist-Antagonist
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| APGAR | Appearance; skin color-Pulse-Reflexes-Activity; muscle tone-Respiration; Crying
7-10 = Normal newborn; good condition
<7 = Neonate needs assistance making transition.Apgar may be repeated at 10 min after interventions
May have 3 readings, e.g., 4/7/9
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| ~ 72 – 96 hrs after birth Common if born h <38 wks, GA | Physiologic jaundice
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| A yellow, lipid-soluble pigment “Conjugated” in liver (converted from fat to water-soluble) Is toxic in unconjugated form; diff to excrete = build up Becomes visible ~ 5-7mg/dL; Head to toe ~ peaks days 4-5; can continue to show later in BF infants | Bilirubin
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| What type of jaundice? Nonpathologic (transient) Appears ~ day 2 Normal phenomenon Totals usu not above 12 mm/dL | Physiologic
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| What type of jaundice? Destruction of RBCs (1st 24 h) NOT Nl = Rises faster, higher Blood incompatibility Infection Tx = light therapy | Nonphysiologic
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| What type of jaundice? Early or late Not good feeders (lack colostrum) May supplement feedings | Breastfeeding (Early)
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| What type of jaundice? After 3-5 days Last weeks – months Cause unknown Increase feedings/lights Breast pump | Breastfeeding (True)
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| Bilirubin moves from bloodstream to brain | Krenicterus
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| Preventing High Bilirubin Levels | Prevent cold stress
Encourage early feeding, especially breastfeeding
Monitor stools
No stooling in 24 h is reported
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| Onset less than 24 hrs Erythroblastosis fetalis (hemolytic DZ of NB) Maternal/fetal blood incompatibility Rh Infection Toxoplasmosis, rubella, CMV – (congential,Postnatal infection,Increased hemolysis Treatment:Increase fluid intake,Phototherapy | Non-Physiologic/Pathologic Jaundice
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| Rare in US: Neuro damage,Athetosis,Spasticity,Hearing defects,Mental defects Causes Extreme prematurity Hemolytic dz; Sepsis Hypothyroidism Maternal DM Excessive bleeding | Kernicterus (Bilirubin Encephalopathy)
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| Assessment of Gestational Age | Ballard Score
Scoring
Gestational age and infant size
Small for gestational age (SGA)
Large for gestational age (LGA)
Appropriate for gestational age
Monitor for complications common to age and size of infant
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| Assessment of Gestational Age: | Ballard Score
Neuromuscular
Square window
Arm recoil
Popliteal angle
Scarf sign
Heel to ear
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| Assessment of Gestational Age: | Ballard Score
Physical characteristics
Skin ; Lanugo
Plantar surface
Eyes and ears
Genitals
Chest
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| Verbalize Large for gestational age (LGA) | Weighing 4000 g (~ 8.8 lbs) or more at birth
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| Treatment for meconium aspiration | Suction of head? No Suctioning? (debatable)
Direct tracheal suctioning if infant is not vigorous (HR>100)Amnioinfusion-infused normal saline or ringer's lactate. Warmed, humidified oxygen,, or extensive respiratory support with mechanical ventilation. NO
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| What Makes a Newborn ‘At-Risk?’ | Minority
Maternal SES
Limited access
Environ dangers
Neighborhoods
Preexisting mat problems
Mat factors (age/ parity)
Medical conditions r/t pregnancy
Pregnancy complications
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| Nipple Problems | Nipples
Inverted,
Flat,
Everted
Causes the infant difficulty in latching
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| Etiology of a boggy fundus: Most common reasons | Atony, clot, full bladder, retained placental tissue fragments
Subinvolution of uterus
Hemmorage
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| Bilirubin and Jaundice: Patient teaching | UV light, more frequent feedings
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| Methods of heat loss in the newborn | Four methods:
-Conduction
-Convection
-Evaporation
-Radiation
*hypothermia can lead to death
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| Immunities in the NB | IgG (G=Given) crosses the placenta
-Passive acquired immunity
IgM (M=mine,all mine) infant develops on his own
-Active immunity occuring- 18 mos
IgA (A=also a gift) immunity transferred through breastmilk
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| Reflexes of the newborn | Reflexes: indicate neurological integrity
-Rooting
-Sucking
-Palmar grasp
-Plantar grasp
-Tonic neck
-Moro
-Stepping
-Babinski's
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| Cephalohematoma vs. Caput | Caput crosses suture line; covers everything. Cephalohematoma stops at suture line; its under the periostium
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| When to call for help | Signs/symptoms of concern, Fever, Localized pain, redness in a breast. Persistent abdominal tenderness. Frequency/urgency/ burning on urination. Redness/drainage/foul odor or separation of incision
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| When to call for help continued | Abnormal changes in lochia Increased amt Sudden bright red blood Passage of large clots
Foul odor Tenderness/warmth in legs
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| Discharge instructions | Topics
Involution
Hand washing
Breast care
Suppressing lactation
Care of the incision
Perineal care
Don’t touch the perineal side of the pad with hands
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| Discharge instructions continued | Kegel exercises
Rest & sleep
Feeding schedules
Nutrition
Exercise
Sexual activity
F/u appointments
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| Normal RR? Abnormal RR? | -30-60
-below 30 above 70
tachy- 60-70
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| PP hemorrhage: Who’s at risk? | Uterine atony
Overdistention of uterus
Multifetal births
Macrosomic infant
Polyhydramnios
Trauma
Prolonged labor
Assisted birth
Previous hemorrhage
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| PP hemorrhage: When to call for help | Bright red blood
Foul smelling discharge
Fever
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| Vaccines that mom’s receive after giving birth | Rhogam
Blood product
Rubella, if mom is not immune
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| Care Post Cesarean Birth – 1st 24 | Major abdominal surgery
Pain relief
1st 24
Respirations
Pulse ox – 1st 24
Q15 x 1st hr
Q 30 x 3-6 hr
Qh x 24 hrs
≤12-14 bpm – notify
Lung sounds?
Bowel sounds
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| Care Post Cesarean Birth – 1st 24 cont | Surgical dressing
REEDA
I&O
1st 24
Pain management
Anesthesiology
Turn, cough Q2, while awake
Flex feet, knees
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| Cesarean Care – After 24 hours | IV/Foley are d/c
Dressing is removed
Clear liquids - soft/regular diet
Provide help w/ambulation
Assist with feedings
B’feeding may be v. painful
Pillow on the lap
Side lying position
Abdominal distention
Watch fizzy drinks
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| Cesarean Care – After 24 hours cont | Ambulation
Simethicone (order)
Suppositories (order)
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| Blood vessels in eye are damaged usu r/t O2 use. May result in visual impairment or blindness in preterm infants. Occurs more often in premature infants weighing 1500g or less. | Retinopathy Of Prematurity ROP:
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| Serious; inflammatory; gut. A serious inflammatory condition of the intestinal tract that may lead to cellular death of areas of intestinal mucosa. | Necrotizing enterocolitis NEC
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| Thought to be caused by immaturity of the intestines. Signs include increased abdominal girth caused by distention, increased gastric residual, decreased or absent bowel sounds, respiratory difficulty, apnea, bradycardia, hypotension. | Necrotizing enterocolitis NEC
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| Early unlimited contact between parents and infants Assist the parents in unwrapping the baby to inspect their body. Inspection fosters identification and allows the parents to become acquainted with the “real” baby. | Promoting attachment and bonding
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| Position the infant in an en face position and discuss the infant’s ability to see the parent’s face. Point out the reciprocal bonding activities of the infant: “Look how she holds your finger” | Promoting attachment and bonding continued
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| Assist mom in putting infant to breast if she plans to breastfeed. Reassure that many infants do not latch onto breast at 1st. If formula feeding, assist in positioning reassure her that holding and cuddling the infant provide comfort and security. | Promoting attachment and bonding continued
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| Model behavior by holding the infant close, making eye contact with infant, and speak in high pitched, soothing tones. Encourage the parents to take as much time as they wish with the infant | Promoting attachment and bonding continued
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| Point out the characteristics of the infant in a positive way: “She has such pretty little hands” | Promoting attachment and bonding continued
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| Provide comfort and ample time for rest because mother must replenish her energy and be relatively free of discomfort before she can progress to initiating care of her infant. | Promoting attachment and bonding continued
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| SGA/LGA infants: Special needs-793 | -SGA-hypoglycemia, early and more frequent feedings, temp regulation and respiratory support, observe for jaundice in infants with polycythemia
-LGA-assess for injuries, hypoglycemia, polycthemia
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| Factors that help establish neonatal circulation (Areas where pressure increases vs. decreases to begin newborn respirations) ___PO2 levels;___ pulmonary resistance;___ pressure in R. atrium; ___ pressure in L. atrium; ____ systemic vascular resistance | Increased PO2 levels
Decreased pulmonary resistance
Decreased pressure in R. atrium
Increased pressure in L. atrium
Increased systemic vascular resistance
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| If dura is unint. punctured with the needle used to introduce the epidural catheter, leakage of CSF can occur, which may result in postdural puncture (“spinal”) headache. (postural spinal HA). | Postdural punctures
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| It is worse when a woman is upright and may disappear when she is lying flat. | Postdural pucture headaches
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| Treatmeant for postural puncture headaches (4) | Treatments- 1.Bed rest with oral or IV hydration. 2. Caffeine is another oral therapy. 3.A blood patch. 4. Epidural injections of dextran, sterile saline, or fibrin glue created from pooled human plasma
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| Patient care postural puncture | Patient care-assess mother’s VS and FHR
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| Name method of heat loss? Can occur during birth or bathing from moisture on skin, as a result of wet linens or clothes, and from insensible water loss | Evaporation
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| Name method of heat loss? Wet diaper, regurgitated milk on shirt, hair wet from bath, insensible water loss from lungs | Evaporation
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| Name method of heat loss? Occurs when the infant comes in contact with cold objects or surfaces such as a scale, a circumcision restraint board, cold hands, or a stethoscope | Conduction
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| Name method of heat loss? Cold hands, metal scale with thin paper liner | Conduction
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| Name method of heat loss? Occurs when drafts come from open doors, air condition, or even air currents created by people moving about | Convection
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| Name method of heat loss? Open door to hall Blanket loss or off Air condition | Convection
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| Name method of heat loss? Heat is lost by this method when infant is near cold surface. Thus, heat is lost from the infant's body to the sides of the crib or incubator and to the outside walls and windows | Radiation
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| *Hormone; ant pituitary; promotes milk production | Prolactin:
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| Secreted during pregnancy; days 7-10 after birth | Colostrum:
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| Swelling of the breasts from stasis | Engorgement:
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| First breast milk received in a feeding | Foremilk:
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| Last breast milk received; contains highest fat | Hindmilk:
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| *Hormone; post pituitary; stimulates milk let-down | Oxytocin:
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| Infection of the breast | Mastitis:
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| Appears ~ 2 weeks of lactation | Mature milk:
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| > 90 percentile @ birth | LGA:
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| Breathing stops > 20 secs AND cyanosis or bradycardia | Apneic spells:
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| Requires O2; chronic | Bronchopulmonary dysplasia (BPD):
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| Elasticity of lungs and thorax Corrected age: Chronologic age – Wks premature | Compliance:
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| Failure to grow appropriately | Intrauterine growth restriction (IUGR):
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| Serious; inflammatory; gut | Necrotizing enterocolitis:
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| Surfactant resulting in atelectasis, hypoxia, hypercapnia | Resp distress syndrome (RDS):
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| Weighing <2500 g (5.8 lbs at birth) | LBW:
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| Birth wt >90 percentile | Macrosomia:
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| Resistance of lungs/thorax to expansion | Noncompliance:
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| Bleeding around/into ventricles of brain | IVH:
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| Born >42 weeks; | Posterm:
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| born <38 weeks, GA | Preterm:
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| Blood vessels in eye are damaged usu r/t O2 use | Retinopathy Of Prematurity ROP:
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| <10th percentile | SGA:
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| Cessation last 5-10 seconds and then 10-15 seconds of rapid resp. NO change in HR or color | Periodic breathing:
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| Problems common to multiparous women during the postpartum period | After pains are more severe. The uterus may take longer to return to normal size due to multiple pregnancies.
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| Problems common to multiparous women during the postpartum period continued.. | Caesarian deliveries may have more complications due to repeated C-sections and scar tissue and adhesions. Multiparous women are at greater risk for hemorrhage due to boggy uterus.
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| How respirations are initiated at birth Normal RR? | Normal RR?First 30 minutes: Time of reactivity, Tachypnea (60-70 bpm), Cyanosis/Acrocyano sis, Crackles. Once established: 30-60 bpm, irregular and shallow, symmetric.
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| How respirations are initiated at birth Abnormal RR? | Abnormal RR?
Respirations <30 or >70 per minute at rest, dyspnea, cyanosis, nasal flaring/grunting. (Occurs after respiratory transition)
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| D/C instructions for new parents 1. S/S of infection-for mom 2. When to call the physician-for mom o | 1/2 Fever, Localized pain/redness in a breast (mastitis),Persistent abnormal tenderness, Frequ/urgency/burning on urination (UTI),Redness/drainage/foul odor or separation of incision (infection),
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| D/C instructions for new parents continued 1. S/S of infection-for mom 2. When to call the physician-for mom | 1/2 Abnormal changes in lochia (increased amount, sudden bright red blood, large clots, odor) (hemorrhage),Tenderness/warmth in legs
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| D/C instructions for new parents continued 3. Accepted weight loss in the NB- 4.# of kcal/day needed in the newborn- 5.Getting rid of excess fluid in the mouth- | 3. Accepted weight loss in the NB- <10% of birth weight
4. # of kcal/day needed in the newborn- 110-120 kcal/kg daily (FT)
5. Getting rid of excess fluid in the mouth-Use a bulb syringe
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