Ob Hesi Study Guide 723k2t

OB HESI STUDY GUIDE 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 w/infants skin 2. Med istration – math 3. Med istration – 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

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Woman should have emptied her bladder and be lying supine with knees in flexed position

7. Antepartum – gestational HTN • Gestational HTN - the onset of HTN w/out proteinuria after week 20 of pregnancy o Systolic > 140, diastolic > 90 • HTN should be recorded on at least two separate occasions at least 4-6 hours apart and within a 1-week period • Occurs more frequently in women w/multifetal pregnancies • Women w/gestational HTN have no evidence of preexisting HTN, and their BPs return to normal levels within 6 weeks after giving birth 8. Antepartum – indigestion – third trimester • It is common for indigestion to start in the 3rd trimester d/t the growing baby pushing the stomach upward toward the esophagus o Relief measures ! Wait at least an hour after meals before lying down ! Eat several small meals, take your time ! Avoid foods that cause indigestion (fried/greasy foods) ! Avoid caffeine/alcohol b/c they can aggravate indigestion ! Don’t smoke 9. Antepartum - infertility – drug therapy • Action is often directed at stimulating ovulation or enhancing ovulation so more oocytes mature • M/C medications include: clomiphene citrate, hMG, FSH, hCG, and GnRH o Prevalence of multiple pregnancies w/use of these meds is > 25% 10. Antepartum – pregnancy – weight gain • Maternal and fetal risks increase when mom is severely over or under weight • Underweight women are more likely to have preterm labor and to give birth to LBW infants • Obesity – increases likelihood of preeclampsia and gestational diabetes • Appropriate measure of evaluating weight gain is BMI o <18.5 = underweight o 18.5-24.9 = normal o 25-29.9 = overweight o 30 or > = obese • Pattern of weight gain o 1st trimester – average weight gain is 1-2kg o Thereafter the recommended weight gain increases to about 0.5 kg/week for an underweight woman and 0.4 kg/week for a woman of normal weight

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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

11. Antepartum – smoking in pregnancy • Smoking is associated w/an increased frequency of preterm labor, PROM, abruption placentae, Placenta Previa, and fetal death •

Encourage women to quit or cut down if they smoke and to avoid second hand smoke

12. Antepartum – supine hypotension • Supine hypotensive syndrome – when lying flat, a decrease in systolic of >30mmHg d/ t suppression of the vena cava, causes faintness o Common in the 2nd and 3rd trimester b/c of the increasing weight of the baby; lying in the supine position can cause compression of the inferior vena cava o Instruct client to use a side lying position with knees slightly flexed, and change positions slowly 13. Antepartum – triple screen • In the 2nd trimester, triple screening is available for fetuses w/Trisomy 21 and Trisomy 18 • Screen is performed at 16-18 weeks • Measures the levels of 3 maternal serum markers; MSAFP, unconjugated estriol, and hCG o Fetus w/Trisomy 21 – MSAFP and unconjugated estriol levels are low o Low levels of in all 3 markers are associated w/Trisomy 18 (Edward’s syndrome) 14. Antepartum – ultrasound at 20 weeks • Uses o Establish/confirm dates o Confirm viability o Detect polyhdraminos/oligohydraminos o Detect congenital anomalies o Detect intrauterine growth restriction o Assess placental placement o Used for visualization during amniocentesis 15. Antepartum – vaginal discharge – pregnancy • Leukorrhea o Hormonally stimulated cervix becomes hypertrophic and hyperactive, producing abundant amount of mucus

Not preventable, do not douche, wear perineal pads, wipe from front to back, report to P 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 Don’t 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 !

17. Intrapartum – back labor – relief • Physiology o

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Exaggerated lumbar and cervicothoracic curves caused by change in center of gravity d/t enlarging abdomen

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Maintain good posture and body mechanics

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Avoid fatigue

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Wear low heeled shoes

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Abdominal may be useful

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Conscious relaxation

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Sleep on firm mattress

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Apply local heat/ice

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Get back rubs

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Do pelvic tilt exercises

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Rest

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Condition will disappear 6-8 weeks after birth

18. Intrapartum – chrioamnionitis • Chrioamnionitis – bacterial infection of the amniotic cavity; occurs in 0.5-10% of pregnancies • Usually diagnosed by maternal fever, maternal and fetal tachycardia, uterine tenderness, and foul odor of amniotic fluid • M/C occurs after ROM/labor has begun • Risk factors o Long labor o Prolonged membrane rupture o Multiple vaginal examinations o Use of internal FHR and contraction monitoring o Young maternal age o Low socioeconomic status o Null parity o Preexisting infections of lower genital tract • Women w/chrioamnionitis are more likely to have dysfunctional labor; may need cesarean • Neonatal risks include pneumonia, bacteremia, and sepsis • An association b/t chrioamnionitis and long-term neurologic development in the newborn, including cerebral palsy, has been reported • To prevent maternal/neonatal complications, treat promptly w/IV broad spectrum ABX o Ampicillin, penicillin, and gentamicin are used most often 19. Intrapartum – food in labor • Ice chips and sips of clear liquids are the only oral intake recommended during labor by the American society of anesthesiologists • Offer fluids and solid foods as ordered by P and desired by laboring women o This provides hydration and calories; enhances positive emotional experience and maternal control • Establish and maintain IV line as ordered o This maintains hydration; provides venous access for medication 20. Intrapartum – hyperventilation • Hyperventilation in pregnancy begins in the 1st trimester and increases 42% by term to meet increased oxygen consumption needs o The enlarging uterus pushes the diaphragm upward, reducing lung volume ! Compensation is necessary to meet increased ventilator demands •

Hyperventilation, sometimes accompanied by respiratory alkalosis, can occur as pain intensifies during labor and more rapid, shallow breathing techniques are used during contractions

21. Intrapartum – meconium stain – decreased FHR • Meconium stained amniotic fluid indicates that the fetus has ed meconium before birth o Major risks associated w/meconium stained amniotic fluid is development of meconium aspiration syndrome (MAS) in the newborn ! MAS causes severe form of aspiration pneumonia that occurs most often in term/post term infants who have ed meconium in utero ! Decreased FHR is a clinical manifestation of meconium stained AF o Emergency management of the newborn w/meconium stained amniotic fluid ! Prior to birth • Assess amniotic fluid • If stained, gather equipment and supplies necessary for resuscitation before birth • Have at least one person capable of performing endotracheal intubation on the baby present at birth ! Immediately after birth • Assess baby’s respiratory efforts, HR and muscle tone • Suction on the baby’s mouth and nose if baby has strong respiratory efforts, good muscle tone, and a HR > 100bpm • Suction below the vocal cords w/ETT to remove any meconium present before any spontaneous respirations have occurred or assisted ventilation has been initiated if baby has depressed respirations, decreased muscle tone, and a HR < 100 bpm 22. Intrapartum – Pregnancy Induced HTN – induction • The higher the BP, the more likely the woman is to be induced •

In women w/severe gestational HTN, immediate birth is indicated (regardless of gestational age) if signs of fetal stress, placental abruption, HELLP syndrome, oliguria, pulmonary edema, eclampsia, or uncontrolled high BP develop

23. Intrapartum – Pitocin – hypersystolic (letanic) contractions • Signs o More than 5 contractions in 10 minutes OR o A series of single contractions lasting > 2 minutes OR o Contractions of normal duration occurring within 1 minute of each other • Interventions w/normal FHR o Reposition or maintain side-lying position o ister IV fluid bolus w/500 ml of LR o If uterine activity has not returned to normal after 10 minutes, decrease oxytocin do by at least half. If still not returned after another 10 minutes, d/c oxytocin until fewer than 5 contractions occur in 10 minutes • Interventions w/abnormal FHR o D/C oxytocin

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Reposition or maintain side-lying position ister IV bolus w/500 ml of LR Consider giving oxygen at 10L/min if above interventions don’t resolve abnormal FHR o If no response, consider 0.25 mg terbutaline subcu according to facility protocol Resumption of oxytocin after resolution of tachysystole o If infusion was d/c for < 20-30 minutes, resume at no more than one half the rate that caused the tachysystole o If infusion has been d/c for more than 30-40 minutes, resume at initial starting dose

24. Intrapartum – placenta previa • In Placenta Previa the placenta is implanted in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces • Risk factors o Hx of cesarean birth o Advanced maternal age o Multiparity o Hx of prior suction curettage o Smoking • Clinical manifestations o Painless bright red vaginal bleeding during the 2nd or 3rd trimester o Most cases diagnosed by ultrasound before significant vaginal bleeding o Abdominal examination usually reveals a soft, relaxed, non-tender uterus w/ normal tone o Presenting part of the fetus usually remains high b/c the placenta occupies the lower uterine segment, thus fundal height is often > than expected for gestational age o B/c of the abnormality, fetal malpresentation (breech or transverse) is common • Complications o Major one is hemorrhage o Development of an abnormal placental attachment o If bleeding cannot be controlled, hysterectomy may be necessary o B/c most women w/placenta previa have cesarean birth, surgery related trauma to structures adjacent to the uterus and anesthesia complications are also possible o Blood transfusion reactions o Anemia o Thrombophlebitis o Infection • Diagnosis

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All women w/vaginal bleeding after 20 weeks should be assumed to have a placenta previa until proven otherwise o Trans abdominal ultrasound to determine placental location Management o Expectant management – observation and bed rest o Active management (if woman is beyond 36 weeks or bleeding is excessive) – immediate cesarean birth is indicated o If ultrasound confirms placenta previa, cesarean birth is indicated in all women

25. Intrapartum – post term induction • Complications associated w/post-term pregnancy o Macrosomia (BW > 4000g) o Enlarging placenta w/increased areas of infarction which may affect its ability to oxygenate the fetus o Olygohydramnios – potential for cord compression and resulting hypoxemia o Meconium stained amniotic fluid, increased chance of meconium aspiration, and low Apgar scores are other potential complications • B/c perinatal morbidity and mortality increase greatly after 42 weeks, most physicians in the U.S. induce labor at 41 weeks 26. Intrapartum – ruptured membranes • SROM – occurs most commonly in the transition phase of the 1st stage of labor • PROM – the spontaneous rupture of the amniotic sac and leakage of amniotic fluid beginning before the onset of labor at any gestational age • Pre-term PROM – rupture occurs before the completion of the 37th week • Most common maternal complication is choriamnionitis • Other less common maternal complications include placental abruptions, sepsis, and death • Fetal complications are r/t intrauterine infection, cord prolapse, umbilical cord compression associated w/oligohydramnios, and placental abruption •

A sterile speculum examination and a Nitrazine (pH) and fern test can confirm that the membranes have ruptured (procedure for test on p437)

27. Intrapartum – stages of labor • 1st stage of labor - onset of regular uterine contractions to full effacement and dilation of cervix o

Latent phase (through 3cm dilation) - progress in effacement w/little increase in descent

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Active phase (4-7cm dilation) - more rapid dilation and increased rate of descent

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Transition phase (8-10cm dilation) - same as active phase

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2nd stage of labor - from the time the cervix is fully effaced and dilated to the birth of the fetus o o

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Latent phase - fetus continues to descend ively d/t uterine contractions Active phase - strong urges to bear down as fetus descends and presses on the stretch 3rd stage of labor - from birth until the placenta is delivered

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4th stage of labor - 1-4 hours after delivery of the placenta

28. Intrapartum – transition • Transition phase - 8-10cm dilation • Marks the shift to the 2nd stage of labor; can last anywhere from a few minutes to hours • Most intense stage of labor; strong contractions coming q2-3 minutes apart and lasting a minute or more • During this phase there is more rapid dilation of the cervix and increased rate of descent • Woman may feel the need to empty her bowel 29. Intrapartum – variable decelerations – action • Variable decelerations – a visually abrupt decrease in FHR below the baseline. Occur at any time during the uterine contraction phase o Significance - occasional variables are no big deal, recurrent variable decelerations on the other hand indicate repetitive disruption in the fetus’s oxygen supply d/t cord compression •

Nursing interventions o Change maternal position (side-lying, knee chest) o Discontinue oxytocin if infusing o ister oxygen at 8-10 L/min by nonrebreather o Notify P o Assist w/vaginal examination to assess for cord prolapse o Assist w/birth if pattern cannot be corrected

30. Newborn – adequate milk supply • Tips for providing adequate milk to baby o Avoid soaps and hard washing of the nipples b/c it can cause extreme dryness/cracking and keep nipples dry b/t feedings o Position baby so that their head, neck, and spine are aligned o Appropriate nursing frequency – adequate supply requires adequate demand o Judge adequate supply on the baby’s weight gain, baby’s poop (should be seedy, mustard colored), and baby’s affect after feeding 31. Newborn – apnea at birth – ventilate

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Implemented if other methods of therapy cannot correct abnormalities in oxygenation Indicated whenever blood gas values reveal the existence of severe hypoxemia or severe hypercapnia (apnea w/bradycardia, ineffective respiratory effort, shock, asphyxia, infection, meconium aspiration syndrome, RDS, or congenital defects that affect ventilation) Dexamethasone may be istered to prevent chronic lung disease in ventilatordependent infants who are unlikely to survive w/out corticosteroids

32. Newborn – asymmetric SGA • Usually results from placental or maternal problems that typically manifest in the late 2nd or the 3rd trimester. When the cause begins relatively late in gestation, organs and tissues are not equally affected, resulting in asymmetric growth restriction • Common causes include o Placental insufficiency resulting from maternal disease o Placental insufficiency caused by multiple gestation o Chronic maternal hypoxemia caused by pulmonary or cardiac disease o Maternal malnutrition • An infant may also have asymmetric growth restriction and be small for gestational age if the mother is a heavy of opioids, cocaine, alcohol, and/or tobacco during pregnancy 33. Newborn – breastfeeding – latch on • In preparation for latch during early feedings the mother should manually express a few drops of colostrum and spread it over the nipple. This lubricates the nipple and entices the baby to open the mouth • Present baby so that their mouth is directly in front of the nipple • Mother should the baby’s neck and shoulders w/her hand and not push on the occiput • The baby’s body is held in correct alignment (ears, shoulders, and hips are in a straight line) during latch • In general, the baby’s mouth should cover the nipple and an areolar radius of about 2-3 cm 34. Newborn – caput succedaneum • Caput succedaneum – a generalized, easily identifiable edematous area of the scalp, most commonly found on the occiput • This edematous swelling, present at birth, extends across suture lines and disappears spontaneously within 3-4 days • Bruising of the scalp is often seen w/caput succedaneum • Causes o W/vertex presentation the sustained pressure against the cervix results in compression of local vessels, slowing venous return. The slowed venous return causes an increase in tissue fluids within the skin of the scalp, and an edematous swelling develops

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Infants born w/vacuum assistance are usually born w/caput in area where the cup was applied

35. Newborn – cephalhematoma – 1st action • Cephalhematoma – a collection of blood b/t a skull bone and its periosteum • 1st action o ??? not sure what the 1st action is! The problem corrects itself! o Can result from pressure during spontaneous birth, low forceps birth and difficult forceps rotation and extraction o A cephalhematoma appears several hours or the day after birth o It’s usually largest on the 2nd or 3rd day, by which time the bleeding stops o Fullness of a cephalhematoma spontaneously resolves in 3-6 weeks o Don’t aspirate b/c of risk of infection o As hematoma resolves, hemolysis of RBCs occurs, and jaundice can result 36. Newborn – cephalhematoma – complication • Complications o Hyperbilirubin →jaundice o Infection o Anemia 37. Newborn – narcotic withdrawal • Nursing care o ive therapy for fluid and electrolyte balance, nutrition, infection control, and respiratory care o Swaddling, holding, reducing stimuli, and feeding as necessary can be helpful in easing withdrawal o If cocaine addicted, position to avoid eye , swaddle infant, use vertical rocking techniques, and us a pacifier to counter poor organizational response to stimuli o

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Neonatal abstinence scoring system – tool for assessing withdrawal symptoms in newborns

Treatment o When indicated, ister 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

38. Newborn – newborn circumcision • Circumcision is a matter of parental choice • Circumcision is not performed immediately after birth b/c of the danger of cold stress and decreased clotting factors, but it’s usually done before discharge

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Feedings are usually withheld up to 2-3 hours before circumcision to prevent vomiting and aspiration o To prepare infant for the procedure, he is positioned in the restraint form, and the penis is cleansed w/soap and water. Infant is draped for warmth and sterile equipment is readied. Most commonly, the Yellen clamp or the plastibell device is used o Four types of anesthesia/analgesia are used – ring block, dorsal penile nerve block, topical anesthetic, and concentrated oral sucrose o Oral acetaminophen may be istered after the procedure q4 hours If bleeding occurs, the nurse applies gentle pressure w/folded sterile gauze Educate parents about care of the circumcised infant o Check for bleeding o Observe for urination o Keep area clean o Check for infection o Provide comfort o Avoid prepackaged wipes b/c they have alcohol o Wash penis gently w/water, if necessary, apply petroleum around the glans after each diaper change o Apply diaper so that it does not press on the circumcised area Encourage parents to change the diaper at least q4 hours

39. Newborn – respiratory distress – oxygen saturation • Assess for cardinal signs of respiratory distress (nasal flaring, grunting, tachypnea, central cyanosis, retractions) • Interventions o Perform gestational age assessment o Observe for signs of respiratory distress o Monitor oxygenation by pulse oximetry o Provide supplemental oxygen judiciously o

Blood gas analysis – RDS would reveal low oxygen and excessive acid

40. Newborn – step reflex neonate • Hold infant vertically, allowing one foot to touch table surface • Infant will simulate walking, alternating flexion and extension of feet • Term infants walk on soles of their feet • Preterm infants walk on their toes • Step reflex is usually present for 3-4 weeks 41. Newborn – T4 TSH newborn screen • Congenital hypothyroidism (low T4, elevated TSH) • Symptoms

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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

42. Postpartum – breast engorgement relief • Use of cold (ice packs, gel packs, cold compresses) after breastfeeding (15-20 min on-45 min off) • Chilled cabbage leaves – washed, chilled in fridge, and placed over breasts • Warmth (shower, warm compress) before breastfeeding • Anti-inflammatory medications - ibuprofen • Breast massage • Pumping •

If not breast feeding encourage snug, bra b/c it limits milk production and decreases discomfort

43. Postpartum – cervical laceration • Cervical injuries occur when the cervix retracts over the advancing fetal head • These lacerations occur at the lateral angles of the external os; most are shallow and bleeding is minimal • Larger lacerations may extend into the lower uterine segment; serious bleeding may occur • Extensive lacerations may follow attempts to enlarge the cervical opening artificially or to deliver the fetus before full dilation is achieved 44. Postpartum – fundal massage – explain boggy • Fundus (either firm or boggy {spongy}) o If firm, measure it – measure the distance from the top of the symphysis pubis to the top of the uterine funds w/centimeter tape measure o If not firm, massage it – place hands appropriately so as not to lose the uterus. With upper hand, firmly apply pressure downward toward vagina and observe for amount and size of expelled clots 45. Postpartum – hemorrhage postpartum • PPH – the loss of more than 500ml of blood after vaginal birth and 1000ml after cesarean • Signs of PPH – use of > 1 perineal pad per hour • Causes o Over distended uterus

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o Previous hx of uterine atony o High parity o Prolonged labor, oxytocin-induced labor o Trauma during labor and birth o Unrepaired lacerations of the birth canal o Ruptured uterus o Inversion of the uterus o Placenta accrete, increta, percreta o Coagulation disorders o Placental abruption, placenta previa Management o 1st step is to evaluate the contractility of the uterus ! If hypotonic, efforts are made to increase contractility and minimize blood loss o Initial management of PPH is firm massage of the fundus o Expression of any clots, elimination of any bladder distention, and continuous IV infusion of 10-40 units of oxytocin in 1000 ml of LR/NS are also primary interventions ! If uterus fails to respond to oxytocin, Ergotrate or Methergine may be given IM o Rapid istration of crystalloid solutions or blood/blood products or both will be needed to restore the woman’s intravascular volume o Oxygen by nonrebreather o Indwelling urinary catheter to monitor urine output o CBC w/platelet count, fibrinogen, PT and PTT

46. Postpartum – IDDM – insulin needs – PP • During the 1st 24 hours, insulin requirements decrease substantially b/c the major source of insulin resistance, the placenta, has been removed • Insulin requirements in breastfeeding women may be one half of pre-pregnancy levels b/c of the carbohydrate used in human milk production o Also, glucose levels are lower in breastfeeding women 47. Postpartum – postpartum hematoma • PP hematoma – localized collection of blood in loose connective skin beneath external gentalia • Causes o Trauma during spontaneous delivery o Trauma during operative vaginal delivery o Inadequate suturing of an episiotomy o Difficult/prolonged 2nd stage of labor • Clinical manifestations o Complaints of pressure and pain

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o Discolored skin that is tight, full feeling and painful to touch o Decrease of absence of lochia flow if vagina is impeded Management o Small hematomas heal on their own o Large hematomas may require evacuation of the blood and ligation of the bleeding vessel Complications o Hypovolemic shock o Anemia, infection o Increased postpartum recovery time o Sepsis o Dyspareunia Nursing interventions/patient education o Inspect perineal for signs of hematoma periodically postpartum o Monitor VS to evaluate for signs of shock o Relieve pain – ice bag, mild analgesia, position for comfort, catheterize if unable to void, teach – balanced diet w/food high in iron

48. Postpartum – postpartum infection • PP infection – presence of fever of 38 ̊ or more on 2 successive days of the 1st 10 postpartum days • Endometriosis is the m/c cause o Other common PP infections include wound infections, mastitis, UTIs, and respiratory tract infections • Risk factors o Women who have concurrent medical or immunosuppressive conditions o Cesarean or operative vaginal birth o Prolonged rupture of membranes o Prolonged labor o Internal maternal or fetal monitoring • Management and care o CBC, venous blood cultures, and uterine tissue cultures o Good maternal perineal hygiene w/ good hand washing o Strict adherence by all health care workers to aseptic techniques during childbirth o Management of endometriosis is broad spectrum ABX and ive care, including hydration, rest, and pain relief o Nursing measures include assess lochia, VS, and changes in woman’s condition, comfort measures (cool compress, warm blankets, perineal care, and sitz baths) o Teaching about side effects of therapy, prevention of spread of infection, s/s of worsening condition, and adherence to treatment plan and need for follow up care

49. Postpartum – postpartum monitor – LGA SVD • SGA – the nurse should monitor blood glucose levels as the priority • LGA – the nurse should assess for hypoglycemia and trauma (palpate clavicles for fracture) 50. Postpartum – postpartum advanced maternal age • More likely to have preexisting conditions – HTN and diabetes • Increased incidence of antepartum hemorrhage, malpresentation, operational vaginal delivery, cesarean delivery, and fetal death • At risk for LBW baby, preterm delivery, placenta previa 51. Postpartum – postpartum WBC • Due to the inflammation, pain, and the stress of birth, neutrophils are increased and are responsible for a marked increase in the white blood cell count during the postpartum period • White blood cell counts may increase to levels as high as 30,000/mm3 o B/c of this normal increase, it is important monitor patients closely for indications of infection 52. Postpartum – PP fatigue – therapeutic communication • Fatigue is common in the postpartum period and involves physiologic as well as psychological components • PPF may be associated w/long labors, cesarean birth, infant care demands, anemia, infection, or thyroid dysfunction, physical discomfort (lack of sleep), • PPF is a risk factor for postpartum depression • Interventions are planned to meet the woman’s individual needs for sleep and rest while in hospital o Back rubs, medication for sleep, side-lying position for breastfeeding mothers 53. Antepartum – tay sachs • Prenatal diagnosis of tay sachs (genetic) via chorionic villus sampling and amniotic fluid testing o Amniocentesis is possible after week 14 – amniotic fluid withdrawn into a syringe o CVS can be performed in the 1st or 2nd trimester – tissue specimen take from the fetal portion of the placenta ! Accomplished transcervically or transabdominally 54. Postpartum – teaching – involution • Involution – the return of the uterus to a non-pregnant state o Begins immediately after birth of the placenta w/UC; extends for 6 weeks after delivery o Teach woman about fundal massage to stimulate UC 55. Mental health/maternity – anxiety/communications/antepartum – emergency delivery • Women who experience emergency child birth are more likely to have high anxiety

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The nurse should remain w/the woman and let her express her fears o Explanations to reduce her fear can be effective o Avoid belittling their fears; don’t tell them not to worry Interventions o Assess level of anxiety o Remain w/patient as much as possible o Elicit patient’s 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 istration – 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 istration – math – ml/hr 4. Med istration – math 5. Med istration/newborn/legal/ethical – immunize NB • Rubella/varicella o Informed consent for rubella and varicella vaccination in the PP period includes information about possible side effects and the risk of teratogenic effects. 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 effects o correct dosage and confirm lot number and woman’s identity before injection w/another RN • HB o Parental consent must be obtained before istration 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

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Fewer than 3 fetal movements within 1 hour warrants further evaluation by a NST or CST, BPP, or a combination of these Fetal movements that cease entirely for 12 hours (fetal alarm signal) o This sign points to a severely disturbed fetus and indicates impending intrauterine fetal death o Such a development is indication for immediate delivery of the fetus, provided it is viable

7. Antepartum – false labor – confirm • False labor o Irregular and unpredictable contractions ! Often stop w/walking or position change ! Can be felt in the back or abdomen above the navel ! Can often be stopped through the use of comfort measures o Cervix may be soft but w/no significant change in effacement or dilation or evidence of bloody show o Fetus presenting part is usually not engaged in the pelvis 8. Antepartum – fetal position • Fetal position is the relationship of a reference point on the presenting part (occiput, sacrum, mentum [chin], or sinciput [deflexed vertex]) • Position is denoted by a 3 part abbreviation o 1st letter – denotes the location of the presenting part in the right (R) or left (L) side of the mother’s pelvis o 2nd letter stands for the specific presenting part of the fetus, O – occiput, S – sacrum, M – mentum, and Sc – scapula o 3rd letter stands for location of the presenting part in relation to the anterior (A), posterior (P), or transverse (T) portion of the maternal pelvis ! Example – ROA – occiput is the presenting part and is located in the right anterior quadrant of the maternal pelvis 9. Antepartum – last trimester – UTI • In the 3rd trimester, UTIs are more serious b/c of the potential for developing a kidney infection o The bladder loses tone during pregnancy. This leads to difficulty emptying the bladder which makes the bladder more prone to reflux (urine flow back up the ureters toward the kidney) o The growing uterus puts extra pressure on the urinary tract. This may block urine drainage from the bladder, leading to back flow of urine up the ureters toward the kidney 10. Antepartum – mag sulfate toxicity • Mag sulfate is the drug of choice in the prevention and treatment of seizure activity caused by severe preeclampsia or eclampsia

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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

11. Antepartum – pregnancy changes 12. Antepartum – pregnancy – positive sign • Positive signs of pregnancy – those signs only attributable to the presence of the fetus o Hearing fetal heart tones o Visualization of the fetus o Palpating fetal movements 13. Antepartum – Rh isoimmunization risk • Rh incompatibility (isoimmunization) occurs when an Rh-negative mother has an Rhpositive fetus who inherits the dominant Rh-positive gene from the father • Genetic risk factor o If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive o If the father is heterozygous for the Rh factor, there is a 50% chance that each infant born of the union will be Rh positive • Usually women become sensitized in their 1st pregnancy w/Rh positive fetus but do not produce enough antibodies to cause lysis of fetal blood cells o During subsequent pregnancies however, antibodies form in response to repeated w/the antigen from the fetal blood, and lysis of fetal RBCs results ! Severe Rh incompatibility results in marked fetal hemolytic anemia b/c the fetal erythrocytes are destroyed by maternal Rh positive antibodies •

Multiple gestation, placental abruption, placenta previa, manual removal of the placenta, and cesarean birth increase the risk of isoimmunization

14. Antepartum – STDs pregnancy • Chlamydia o Maternal effects – PROM, preterm labor, PP endometritis o Fetal effects – LBW o Treatment ! ABX ! Ok during pregnancy • Gonorrhea o Maternal effects – miscarriage, preterm labor, PROM, amniotic infection syndrome, choriamnionitis, PP endometritis, PP sepsis o Fetal effects – preterm birth, IUGR o Treatment ! ABX • Herpes simplex virus o Maternal effects – intrauterine infection (rare) o Fetal effects – congenial infection (rare) o Treatment ! Acyclovir (or some version thereof) • HPV o Maternal effects – dystocia (difficult birth) from large lesion, excessive bleeding from lesions after birth trauma o Fetal effects – none known o Treatment ! Pregnant and lactating women – cryotherapy ! Non pregnant women – prodofilox (topical) • Syphilis o Maternal effects – miscarriage, preterm labor o Fetal effects – IUGR, preterm birth, still birth, congenital infection o

Treatment !

Penicillin

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If allergic to penicillin, Tetracycline or Doxycycline

15. Antepartum – Supine hypotension • Physiology – induced by pressure of gravid uterus on ascending vena cava when woman is supine; reduces uteroplacental and renal perfusion • S/S – pallor, dizziness, faintness, breathlessness, tachycardia, nausea, clammy skin, sweating • Nursing intervention – position woman in side-lying position until her s/s subside and vital signs stabilize WNL 16. Antepartum – tocolyctic treatment – preterm labor (p787-789)

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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 istration, low incidence of maternal and fetal side effects; use is increasing

17. Antepartum – TPAL • TPAL – system of summarizing patients obstetric hx •

T- term births, P - preterm births, A - abortions, L - living children

18. Intrapartum – abdominal trauma • Blunt abdominal trauma – m/c result of motor vehicle crash but may also result from battering or falls o All pregnant victims should be carefully evaluated form s/s of placental abruption after even minor blunt abdominal trauma ! s/s of placental abruption include uterine tenderness/pain, uterine irritability, uterine contractions, vaginal bleeding, leaking of amniotic fluid, or change in FHR characteristics • Penetrating abdominal trauma – m/c result of bullet wounds, then stab wounds o Fetus is more vulnerable to serious injury than is the mom b/c the enlarged uterus protects other maternal organs 19. Intrapartum – anesthesia • Anesthesia – complete pain relief and motor block o Local perineal infiltration anesthesia may be used when an episiotomy is to be performed or when lacerations must be sutured after birth in a woman who does not have regional anesthesia ! Epinephrine is usually added to the solution to localize and intensify the effect and to prevent excessive bleeding o Spinal anesthesia contains either a local anesthetic alone or in combination w/ an opioid agonist; injected into the subarachnoid space. ! Use of this technique is for both elective and emergent cesarean births ! Low spinal anesthesia may be used for vaginal birth , but is not suitable for labor ! Interventions and care prior to and during epidural istration ! Prior to the block ! Assist PHP/A w/education and obtaining consent ! Assess VS, hydration status, labor progress and FHR and pattern ! Start IV line and infuse a bolus (Ringers/NS) if ordered

Obtain lab results (Hct/Hgb) Assess pain using pain scale Assist woman to void During initiation of the block ! Assist woman to assume/maintain proper position ! Verbally guide woman through the procedure ! Assist A w/documenting VS, time/dose of meds ! VS (especially BP) and FHR ! Have oxygen/suction ready ! Monitor for signs of local anesthetic toxicity as test dose is istered ! ! !

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20. Intrapartum – AROM – equipment • Amnihook or other sharp instrument is inserted through the vagina and cervix o P inserts it alongside the fingers and then hooks and tears the membranes 21. Intrapartum – atropine – preop- CS (found nothing in the book about this) • Atropine has been used to reduce gastric secretions before a cesarean section 22. Intrapartum – bladder • Adequate bladder care during labor can reduce the incidence of bladder distention thus reducing the risk for PPH o Nursing interventions ! Encourage women to void q2hr ! If bladder is palpable and patient cannot void, catheterize ! Women w/epidural or spinal analgesia should have a Foley 23. Intrapartum – delivery – parking lot • Highest priority intervention is to put the infant to the breast; this will help contract the uterus and prevent PPH 24. Intrapartum – epidural – BP • After epidural is initiated, the woman should be positioned on her side so the uterus does not compress the ascending vena cava and descending aorta, which can impair venous return and reduce CO and BP o Alternate the woman’s position from side to side every hour • Oxygen should be available if hypotension occurs despite maintenance of hydration w/IV fluids and displacement of uterus to the side • Ephedrine or phenylephrine (vasopressor used to increase maternal BP) and increased IV fluid infusion may be needed 25. Intrapartum – fetal tachycardia • Definition – FHR 160/bpm lasting > 10 minutes • Possible causes o Early sign of fetal hypoxemia o Fetal cardiac arrhythmias

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o Maternal fever o Maternal or fetal infection o Parasympatholytic drugs (atropine) o β – sympathomimetic drugs (terbutaline) o Maternal hyperthyroidism o Fetal anemia o Drugs (caffeine, 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

26. Intrapartum – impending delivery • Signs of labor o Effacement o Dilation o Mucus plug is ed o Bloody show o Surge of energy o SROM o Weight loss 27. Intrapartum – Placenta Previa s/s • Painless bright red vaginal bleeding; initially a small amount and stops as clots form • VS may be normal b/c pregnant women can lose up to 40% of blood volume w/out showing signs of shock • FHR is normal • Abdominal examination usually reveals soft, relaxed, non-tender uterus w/normal tone • Presenting part of fetus – high, not engaged b/c placenta occupies the lower uterine segment, thus fundal height is often greater than expected for gestational age • Fetal malpresentation (breech, transverse, oblique) is common 28. Intrapartum – variable deceleration – action • Nursing interventions o Change maternal position o Discontinue oxytocin if infusing o ister oxygen at 8-10L/min by nonrebreather o Notify MD/midwife o Assist w/vaginal or speculum examination to assess for cord prolapse o Assist w/amnioinfusion if ordered o Assist w/birth if pattern cannot be corrected

29. Newborn – Apgar scoring • Evaluations are made at 1 and 5 minutes after birth • Scores of 0-3 indicate severe distress, 4-6 indicate moderate difficulty, 7-10 indicate minimal/no difficulty HR Absent (0) Slow <100 (1) >100 (2) Respiratory effort Absent (0) Slow, weak cry (1) Good cry (2) Muscle tone Flaccid (0) Some flexion (1) Well flexed (2) Reflex irritability No response (0) Grimace (1) Cry (2) Color Blue, pale (0) Body pink/ext blue (1) Completely pink (2) 30. Newborn – circumcision care • Wash hands before touching • Check for bleeding o If bleeding occurs, apply gentle pressure • Observe for urination o Infant should have 2-6 wet diapers in a 24 hour period the 1st day, then at least 6-8 24 hours to 3-4 days • Keep area clean o Change diaper at least q4hr o Wash penis gently w/warm water to remove urine and feces; apply petroleum jelly to glans w/each diaper change o Don’t wash penis w/soap until circumcision is healed (5-6 days) o Apply diaper loosely Cleanse genitals daily and after voiding or defecating • Check for infection o Glans penis is dark red after circumcision, and then becomes covered w/yellow exudate in 24 hrs, which is normal and lasts 2-3 days. Do not remove it o Redness, swelling, discharge, aor odor indicates infection • Provide comfort o Handle the area gently o Provide extra holding, feeding, and opportunities for nonnutritive sucking for a day or tow 31. Newborn – gavage feed –residual • In gavage feeding, breast milk or formula is given to the infant through a NG tube or OG tube o Can be done either intermittently or continuously ! Volume of the continuous feedings is recorded hourly, and the residual gastric aspirate is measured q2-4 hr • Aspirates of < one hour volume can be refed to the infant ! For intermittent feedings, residuals of < 50% of the previous feeding can be refed to the infant to prevent loss of electrolytes

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Feeding is usually stopped if the residual is > 50% of the feeding or if residuals are increasing

32. Newborn – heat loss – radiation • Radiation – loss of heat from the body surface to a cooler solid surface that is close to, but not in direct o The nurse should keep the newborn and examining tables away from windows and air conditioners 33. Newborn – hematoma – bilirubin • Trauma during birth – vacuum assisted birth, forceps ! A cephalhematoma can result • As the hematoma resolves, hemolysis of RBCs occurs, levels of bilirubin in the blood rise and jaundice results !

No treatment is normally required

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Phototherapy for babies with significant jaundice

34. Newborn – newborn respiration • Once respirations are established, breaths are shallow and irregular, ranging from 30-60 breaths/minute, with pauses lasting < 20 seconds o Apneic periods > 20 seconds are indicative of a pathologic process and should be further evaluated • Newborns are nose breathers • Newborns are abdominal breathers • Signs of respiratory distress o Nasal flaring o Intercostal/subcostal retractions o Grunting w/respirations o Tachypnea o Changes in infants color 35. Newborn – newborn nursing care • Apgar scoring @ 1 and 5 minutes after birth • Physical assessment • Neurologic assessment • Gestational age assessment • Airway maintenance • Maintaining adequate oxygen supply • Maintaining body temperature • Eye/vitamin k prophylaxis • Umbilical cord care • Promoting parent-infant attachment 36. Newborn – phototherapy – home

• • •

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

37. Postpartum – attachment • P 507-8 38. Postpartum – breast assessment • 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 39. Postpartum – breast engorgement – treatment • Instruct mother to feed every 2 hours; softening at least 1 breast and pumping the other (to soften it) • Ice packs/gel packs, cold compresses after BF (15-20 minutes on, 45 minutes off) • Chilled cabbage leaves – reduce swelling • Warm compresses, warm showers before BF • NSAIDS • Breast massage • Pumping • If bottle feeding, suggest a snug bra b/c it limits milk production and reduces discomfort 40. Postpartum – home delivery – Rh negative • Mom has 72 hours to get the Rhogam shot if baby is + • Midwife can give the shot • Baby’s cord blood is used to determine Rh status 41. Postpartum – post epidural headache • Spinal headache is much more likely to occur when the dura is accidentally punctured during istration of the epidural • • • •

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

42. Postpartum – postpartum assess • In addition to VS, physical assessment of the PP woman includes BUBBLE-HE

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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

43. Postpartum – postpartum rubella immunization • Rubella vaccine o Women who have not had rubella or who are serologically not immune, a subcu injection of rubella vaccine is recommended in PP to prevent possibility of contracting rubella in future pregnancies o B/c virus is shed in urine and other body fluids, vaccine should not be given if mother or other household are immunocompromised o BF mother can be vaccinated o Requires informed consent; including information about possible s/e and risk of teratogenic effects o Women must practice contraception to prevent pregnancy for 1 month after being vaccinated o M/c side effects are fever, lymphadenopathy, and arthralgia 44. Postpartum – spinal headache – blood patch • Leakage of CSF from the site of puncture of the dura mater is thought to be the major causative factor in postdural puncture headache (PDPH), aka “spinal headache” • Treatment w/blood patch is considered if headache is severe or debilitating or does not resolve after conservative management • •

Epidural blood patch – the woman’s 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

45. Antepartum – diabetes • Specific assessments to assess the effects of the diabetes, specifically retinopathy, nephropathy, peripheral and autonomic neuropathy, peripheral vascular, and cardiac involvement • In addition to baseline laboratory tests, renal function may be assessed w/a 24 hour urine collection for total protein excretion and creatinine clearance • Urinalysis and culture to assess for the presence of a UTI (more common in diabetics) • Glycosylated hemoglobin A1c – provides a measure of glycemic control over the last 4-6 weeks o Hgb A1c > 6 indicate elevated glucose levels • Fasting glucose levels may be assessed during antepartum visits • Euglycemia is the goal of treatment o Glucose levels in the range of 65-90 mg/dl before meals o Glucose levels in the range of 130-140 mg/dl after meals • Woman should wear a medical identification bracelet • Prenatal visits more often; 1st/2nd trimester – q 1-2 weeks, 3rd trimester – once/twice each week 46. Intrapartum – herpes

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Maternal infection w/HSV-2 can have adverse effects 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

47. Newborn – heel-stick - best method • Warming the heel before the sample is taken is often helpful (heat 5-10 minutes helps dilate vessels) o Cloth soaked w/warm water and wrapped loosely around foot provides warming • Nurse cleanses area w/appropriate skin antiseptic, restrains the infant’s foot w/free hand, and then punctures the site (automatic puncture device causes less pain and requires fewer punctures) • Heel stick - outer aspect of heel and should penetrate no deeper than 2.4 mm • After specimen is collected, pressure should be applied w/dry gauze; site is then covered w/bandage 48. Newborn – hip dysplasia – Ortolani’s maneuver • Hip integrity is assessed using the Barlow test and the Ortolani maneuver o For the Barlow test, the hip is flexed to 90 ̊ and adducted followed by gentle downward pushing of the femoral head, if hip can be dislocated, the femoral head moves out of the acetabulum and examiner feels a “clunk” o The hip is then checked to determine if the femoral head can be returned to the acetabulum using the Ortolani test; as the hip is abducted and upward leverage is applied, a dislocated hip will return to the acetabulum with a clunk

• 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 o

Abdominal pain (premature labor, abruptio placenta, or ectopic pregnancy) Changes in fetal activity (decreased fetal movement may indicate fetal distress) Persistent vomiting (hyperemesis gravidarum) Severe headaches (pregnancy-induced hypertension) Elevated temperature (infection) Dysuria (urinary tract infection) Blurred vision (pregnancy-induced hypertension) Edema of face and hands (pregnancy-induced hypertension) Epigastric pain (pregnancy-induced hypertension) Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, Increased thirst and urination, and headache (hyperglycemia) Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, and lightheadedness (hypoglycemia) Signs of preterm labor

51. Postpartum – cultural – blood transfusion 52. Postpartum – discharge teaching • Self-management topics o Perineal care o Breast care o Nutrition o Rest/sleep/exercise o Family planning o Sexual intercourse/contraception o Medications • S/S of potential complications to report o Chills or fever greater than 38° C (100.4° F) for 2 or more days o Change in vaginal discharge with increased amount, large clots, change to a previous o lochia color such as bright red bleeding, and a foul odor o Normal lochia flow pattern shows ! Bright red vaginal drainage for 2 to 3 days. ! Blood-tinged serous vaginal drainage from days 4 to 10. ! White vaginal discharge from day 11 to 6 weeks. o Episiotomy, laceration, or incision pain, that does not resolve with analgesics, foul smelling drainage, redness, and/or edema o Pain/tenderness in the abdominal or pelvic areas that does not resolve with analgesics o Breast(s) with localized areas of pain and tenderness with redness and swelling and/or nipples with cracks or fissures o Calves with localized pain and tenderness, redness, and swelling. A lower extremity with either areas of redness and warmth or coolness and paleness

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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

53. Abuse/newborn – cocaine exposure • Cocaine crosses the placenta and is found in breast milk • Cocaine is a recognized cause of placental abruption • Neonatal effects o Prematurity o SGA o Placental or cerebral infarctions o Hyperactivity o Difficult to console o Increased risk for SIDS o Hypersensitivity to noise and external stimuli o Reduction in verbal reasoning 54. Mental health/maternity – depress/grief/intrapartum – still birth • There is an early period of acute distress and shock followed by a period of intense grief that includes emotional, cognitive, behavioral, and physical responses • Parents reach the phase of reorganization when they return to their usual level of functioning in society • Parental grief can extend for months to years • Phase of acute distress o Shock o Numbness o Intense crying o Depression • Phase of intense grief o Loneliness o Guilt o Anger, resentment, bitterness, irritability o Fear/anxiety o Disorganization difficulties w/cognitive processing o Sadness/depression o Physical symptoms

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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

55. Mental health/maternity – depress/grief/postpartum – PP depression – assess • Be an active listener and demonstrate a caring attitude b/c women may not volunteer unsolicited information about their depression • Observe for signs of depression • Ask appropriate questions to determine moods, appetite, sleep, energy, and fatigue levels, and ability to concentrate • Use a screening tool to assess whether the depressive symptoms have progressed from PP blues to PP depression • If depression is identified, ask if the mother has thought about hurting herself or the baby