Postpartum and Newborn (MC test 2)

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What is the postpartum period

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  • 6 week time frame between birth of the baby and return of the organs to pre-pregnancy state

Immediate = first 24 h

Early = first week

Late= 2-6 week

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Involution

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  • process of the uterus returning to a pre pregnant state
  • begins after expulsion of placenta
  • uterus reduces in size and weight rapidly
  • caused by sudden decrease in estrogen and progesterone
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What is the postpartum period

  • 6 week time frame between birth of the baby and return of the organs to pre-pregnancy state

Immediate = first 24 h

Early = first week

Late= 2-6 week

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Involution

  • process of the uterus returning to a pre pregnant state
  • begins after expulsion of placenta
  • uterus reduces in size and weight rapidly
  • caused by sudden decrease in estrogen and progesterone
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What factors SLOW involution

  • prolonged labor
  • incomplete expulsion of placenta
  • anesthesia
  • previous labors
  • full bladder
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What can INCREASE involution

  • uncomplicated birth
  • early ambulation
  • breastfeeing
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What method is used to asses uterine involution

Fundal height measurement

  • descent of uterus usually 1 cm per day
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Before preforming fundal massage, what do you instruct the women to do?

Empty her bladder

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How to preform fundal massage

  • cup one hand above the symphisis pubis to support the lower uterine segment

  • With the other hand palpate the top of fundus, if not firm, lightly massage

  • indicated if the uterus is boggy, causing increased bleeding

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Sub-involution

  • failure of the uterus to go back to pre pregnancy state
  • usually caused by retained placental fragments
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Afterpains

  • uterine contractions occurring first 2-3 days post birth
  • caused by hormone oxytocin to contract uterus and stop bleeding
  • breastfeeding can cause worsening afterpains due to the increase of oxytocin during this time
  • NSAIDS are most effective
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Lochia

  • postpartum vaginal discharge
  • contains blood from placental site, uterine tissue, mucus
  • fleshy odor
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Different types of lochia

Lochia rubia = bright red (1-3 days postpartum)

Lochia serosa= pink to brown (4-10 days)

Lochia Alba = yellowish (10 days to 6 weeks)

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Assessment of lochia/bleeding

  • fundus firmness (not firm = excessive bleeding possible)
  • weighing pads (1mL of blood = 1 gram)
  • Lochia increases briefly during ambulation (normal)
  • excessive bleeding can indicate retained placenta, sub involution or infection
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REEDA scale

Assessment of episiotomy site

  • Redness
  • edema
  • eccymosis (bruising)
  • discharge
  • approximation
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Nursing care for pain of perineum

  • cold sitz baths
  • warm and cold application
  • pads with witch hazel
  • medications
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During the first few days what hormone regarding muscles decreases?

Relaxin

  • ligaments and cartridge of the pelvis begin to return to pre pregnancy state
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What should the nurse do to asses for a beginning DVT?

  • passive dorsiflexion of women's feet that causes pain is a POSITIVE HOMANS sign.
  • May be an early sign of venus thrombosis.
  • Also watch for redness, swelling and warmth of calf
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How much blood loss is normal during birth?

Vaginal = 200-500 mL

C-section 1,000 mL

  • more than that is considered a hemorrhage
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How is fluid built up during pregnancy eliminated?

  • increased urinary output (may be as much as 3000ml/day)
  • heavy sweating (diaphoresis)
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Labs that change after birth

  • temporary rise in Hct and Hgb (returns to normal in 2-4 wks)
  • lekocytosis (incresed WBC) (returns to normal in 10 days
  • GFR increased (returns to normal in 8 weeks or less)
  • Mild protienuria as a result of uterine cell breakdown
  • fibrinogen remains high (returns to normal within 2 weeks)
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Changes to VS after birth

  • temp may be 100.4 or above during first 24 hours, but if it remains high could indiate infection
  • Bradycardia for first 6-8 days postpartum
  • B/P should be the SAME
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Factors that cause urinary retention post partum

  • tissue around the bladder is traumatized

  • anesthetic drugs

  • Bladder had reduced ability to contract

  • Decreased sensation of needing to void

    WATCH FOR URINARY RETENTION

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Complications of urinary retention postpartum

  • bladder distends, pushing the uterus to the side which causes uterus to not be able to contract
  • inability of the uterus to contract can lead to excessive bleeding
  • MAKE SURE TO MONITOR URINARY OUTPUT to prevent
  • urinate q2-3 hours to prevent
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Hormone changes post birth

  • estrogen and progesterone drop right after birth
  • if NOT breastfeeding, estrogen returns in 3 weeks which leads to return of the period in about 3 months
  • ovulation returns in 1 month
  • Prolactin increases in women who are breastfeeding to stimulate milk
  • oxytocin triggers the release of milk (also contractions which is why some feel afterpains while breastfeeding)
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How is weight lost after pregnancy

  • loses 10-13 lbs right away from baby and placenta
  • lochia
  • increased urination and perspiration
  • involution
  • fat stored for feeding is gradually used up as the women breastfeeds
  • normal weight is back by 6mo
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What are some major causes of hemorrhage postpartum

Early Postpartum Hemorrhage:

  • uterine lacerations
  • uterine atony (lack of proper contraction of uterus)

Late Postpartum Hemorrhage:

  • retained placental fragments (causes inability for uterus to contract all the way)
  • decreased involution
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Methods to relive discomfort from breast engorgement

  • supportive bra worn for 72 hours
  • ice packs
  • analgesics (ibuprofen, Tylenol)

Engorgement usually occurs 3-5 days postpartum

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phases of postpartum adaption

Phase 1: Taking in: mother is willing to let others do things for her, hold the baby, ect. Focus is on recovery

Phase 2: Taking hold: Mother becomes interested in caring for infants, increased concern. BEST TIME FOR TEACHING

Phase 3: Letting go: giving up previous lifestyle, accepting the real child (not the ideal)

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Postpartum check acronym

B: breasts and nipples (engorgement, lactation, redness)

U: Uterus (fundal height, location, firmness)

B: Bladder (intake/output frequency, pain)

B: Bowel (BM?)

L: Lochia (amount, color, odor, clots?)

E: Episiotomy (REEDA scale)

-

H: Homans Sign (passive dorsiflextion of foot causing pain)

E: Emotional status

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Is postpartum chill (shaking) normal/common after birth

  • yes, as long as it is not accompanied by a fever
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Cold vs heat on perinium

Cold: for first 24 hours

Heat: after 24h

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Nursing management for application of pain creams to perinial area

  • apply after a sitz bath
  • wait 1-2 minutes before putting on pad
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Sexual intercourse after birth

  • safe after discharge turns white
  • episiotimy is healed (about 3 weeks after birth)
  • use contraceptives!! Breastfeeding is not effective
  • oral contraceptives begin 2-3 weeks after birth for non-lactating, and as soon as lactation is well established in lactating women
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Identifying amount of fluid on perineal pad

Scant= 2 inch stain (10 mL)

Small = 4 inch stain (10-25 mL)

Moderate = 6 inch stain (25-50 mL)

Large = >6 inch stain (50-80 mL)

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Postpartum hemorrhage

Blood loss more than 500 mL for a vaginal birth and 1000 mL for c section

  • greatest risk in the first 24h
  • can be caused by: uterine atony, laceration in early, later hemorrhage may be caused by retained placental fragments or sub-involution
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When is peri pad changed

  • after BM
  • after voiding
  • if soiled
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Physical s/s of hemmorage

  • cold, clammy skin
  • increased HR and RR
  • Pale skin
  • dizziness
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Uterine atony

inability of the myometrium to contract

  • vessels cannot heal
  • occurs in first hours after birth
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Hematoma

  • caused by trauma
  • bulging mass
  • may form in upper portion of vagina, leading to massive hemorrhage
  • S/S = perineal pain (not usually bleeding), edema, uterus may be firm, decreased B/P, inability to void, urge to defecate
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Normal height of fundus post birth

  • after birth, fundus is 2 cm below umbilicus
  • decreases 1 fingerbreadth below the umbilicus
  • after 2 weeks, fundus cannot be seen or felt
  • A fundus that is higher than normal after birth may be because of sub involution
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Anahpylactic syndrome of pregnancy (amniotic fluid embolism)

  • entrance of amniotic fluid into maternal circulation
  • triggers release of cells that cause pulmonary artery hypoxia
  • hypoxia of pulmonary artery causes heart muscle damage and can lead to L sided heart failure
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Mastitis

Infection of the breasts

  • usually cased by entrance of bacteria into from cracks in nipples
  • can be caused by blocked duct/stasis of milk, nipple trauma, poor breastfeeding, inadequate hand-washing in between peri care and breast care
  • S/S = painful reddened area, enlarged glands, fever, chills, malaise

Treated by antibiotics, ice, warm packs, supportive bra

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Diastasis Recti

Separated abdominal muscles

  • strengthening exsersize to fix
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Colostrum

  • yellowish fluid secreted by breasts
  • nutrient rich
  • stimulated peristalsis in baby
  • normal
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Are bowels sluggish after birth?

Yes! Constipation common

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Risk factors for postpartum hemorrhage

  • oxytocin labor induction/augmentation
  • multiple fetuses (twins)
  • preeclampsia
  • operative delivery
  • chorioamnionitis (infected amniotic fluid)
  • hx of past uterine surgery or past hemorrhage
  • prolonged or difficult labor
  • placenta previa
  • aburuptio placente
  • large baby
  • episiotomy
  • traumatic delivery, use of forceps or vacuum
  • thrombocytopenia (low platelets)
  • fetal demise
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Thrombocytopenia S/S

  • nosebleeds
  • ecchymosis
  • petechiae on lower extremities
  • bleeding from gums
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Postpartum (puerperal) infection

Endometritis most common

higher risk for:

  1. c section births
  2. Foley caths
  3. episiotiomy
  4. frequent vaginal exams
  5. retained placenta
  6. chorioamnionitis (infected amniotic fluid)
  7. traumatic birth
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Normal vital signs for the newborn

RR: 30-60/min

  • periods of apnea not greater than 15 seconds = normal

HR: 110-160

  • auscultate all heart sounds (APTM) to look for murmurs

B/P: 60-80/40-50

Weight: 5.5-8.8

Length: 18-22 inches

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Newborn temperature

Only take auxiliary temp

  • approx. same temp of mother at birth, may drop 1- 2 degrees but should return to normal in 8 hrs

HIGH RISK for hyPOthermia

  • cold stress causes oxygen demands increase and acidosis can occur
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Non-shivering thermogenesis

Because newborns cannot shiver to increase body heat, they use non-shivering themogenisis

  • uses the metabolism of brown adipose tissue (brown fat)
  • Brown fat metabolizes and creates warmth

If Infant is exposed to lots of cold stress, brown fat stores are depleted causing impaired thermoregulation

  • drugs such as meperidine (demorol) given during labor can mess with brown fat
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Where is brown fat found and when does it go away?

found on

  • neck
  • axille
  • around kidneys
  • adrenals
  • sternum
  • along abdominal aorta

Dissapears after three months

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Cold stress potential consequences

  • Hypoglycemia (CBG less than 40)
  • Acidosis
  • reopening of fetal circulation
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Skin asessment of the infant

Acrocyanosis (bluish hands and feet) normal for first 6-12 hrs post birth

Pallor/dusky, cyanosis

  • decreased O2, CNS depression, anemia

Harlequin sign

  • half of body is pale, other half is red
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Jaundice

Physiologic Jaundice

  • benign
  • r/t breakdown of RBC and liver immaturity
  • increase in bilirubin
  • usually shows up after 3rd day of life

Pathological Jaundice

  • within the first 24 hours
  • bilirubin more than 12
  • r/t RH or ABO incompatibility
  • shows up BEFORE 3rd day of life
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Hydrocephalus

  • excessive cerebral fluid within brain cavity surrounding brain
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Fontanel abnormabolities

  • bulging when baby is not crying = increased ICP
  • depressed fontanel = dehydration
  • third fontanel can = down syndrome
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Phenalkeytoneuria (PKU)

Newborn cannot metabolize phenylalanine which is in protein, including breast milk

  • levels accumulate in blood
  • causes mental problems
  • Gutherine test to determine
  • goal to maintain levels between 2-10
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Ear/eye height

Top of ear should be level with other canthus of eye

  • low set ears can indicate chromosomal abnormalities
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Newborn tremors

  • newborn tremors are common
  • asses to ensure they are not seizures
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What indicates hip dysplasia

Asymmetric creases on thighs + limited hip abduction

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Newborn reflexes

  • Rooting = searching for nipple
  • Gag: on stimulation of uvula
  • Blinking: stimulate with flashlight
  • Moro’s: allowing head and trunk of newborn to fall
  • Tonic neck: head turns to one side quickly, arm and leg extend on that side (fencing posture )
  • Crawl: placed on abd will make crawling motions
  • Dance/step: stimulates walking (while holding up) dissapears and three weeks
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Newborn car safety

  • rear facing seat until 2
  • safety seat reclines 45 degrees to maintain airway
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How should newborns be placed after feeding

  • on thier right side to prevent aspiration
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Should you wait to bathe an infant after feeding?

Yes, risk of regurgitation due to increased handling

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Preventing SIDS

  • firm crib mattress
  • placed on back during sleep!
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Nutrition during breastfeeding

  • 500 more calories than non pregnant diet
  • Protein 65mg/day
  • 8-10 glasses of non caffeinated liquid per day
  • some foods the mother eats may cause infant gas
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Stages of milk production

Colostrum = first 3-4 days postpartum

  • easier to digest
  • antibodies

Transitional Milk

  • between mature and colostrum
  • 5 days to two weeks

Mature milk

  • looks like skim milk can be bluish
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How long on each breast for feeding

15-20 min

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what position should the newborn be in during feeding

chest to chest (babies chest facing mothers chest)

  • turning the infants head may interfere with swallowing
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Hand position during breastfeeding

Hand in a C position

  • supporting breast from below
  • thumb above the nipple below the areola
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Storing breast milk

  • store in glass or hard plastic
  • do not keep at room temp for over 4 hours
  • DO NOT use plastic with numbers 3,6 or 7 on the bottom
  • can stay in fridge for 5 days
  • fridge freezer for 2 weeks
  • deep freezer for 12 months
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Preterm/premature infant

Born before 38 weeks, regardless of weight

  • late preterm is between 34-36 weeks
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Term infant

Born between 38-42 weeks, regardless of weight

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Low birth weight

Newborn who weighs less than 5.5 lbs or 2500g

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Small for gestational age

Below the 10th percentile for weight

  • prone to hypoglycemia r/t glucagon stores being depleted
  • calorie needs are high
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Large for gestational age

Above the 90th percentile for weight

  • more than 8.8 lbs
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Postterm

Born after 42 weeks

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What can cause fetal growth restriction (leading to SGA)

  • small parents
  • reduced blood flow to uterus (DM,hypertension, kidney disease)
  • smoking + substance abuse
  • malnutrition of mother
  • placental abnormalities
  • multi fetal pregnancy
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Size of newborn if mother has DM

In women with DM who do not have vascular changes

  • high glucose levels cross into placenta, leading to large for gestational age newborn
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Complication of post-term newborns

  • hypoxia due to placenta not giving adequate oxygenation anymore due to it being old
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When is the newborns resp system fully developed?

After 35 weeks

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Nutrition intake is considered sufficient when the preterm newborn gains ___ per day

20-30 grams per day

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kangaroo care

Skin to skin contact

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Retinopothy of prematurity is caused by

Oxygen toxicity

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Most premature infants catch up by__

24 months (2 years) of age

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Physical characteristics of preterm newborn

  • wrinkled skin
  • lanugo covered skin
  • weak cry
  • poor muscle tone
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Physical characteristics of post-term newborn

  • thin with loose skin
  • cracked and dry skin, leathery appearance
  • long fingernails
  • little lanugo
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Blanch test for jaundice

Apply pressure on skin over a bony area (nose, forehead, sternum)

  • yellow tinge in the blanched area indicated jaundice
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S/S of hypoglycemia in newborn

  • lethargy
  • jitteriness
  • poor feeding
  • tachapnea
  • apnea
  • sweating
  • shrill cry
  • low temperature
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Spina Bifida

Imperfect closure of spinal vertibre

  • small opening on spine, may have protrusions
  • Needs surgical correction
  • protect membrane w/ sterile moist dressing to prevent drying
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Infants of DM mothers have

High glucose in the fetus during pregnancy

  • high maternal glucose is cut off when cord is clamped
  • prone to hypoglycemia
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Respiratory distress syndrome

Caused by surfactent (keeps alveoli from collapsing and helps gas exchange) deficiency leading to poor gas exchange

  • respiratory acidosis can occur
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S/S of dehydration in the infant

  • urine output of less than 1mL/kg/hr
  • weight loss
  • dry MM
  • no skin turgor
  • sunken fontanells
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Nursing care for the infant receiving photo-therapy

  • keep eyes and genitalia covered
  • keep baby naked
  • do not apply lotions or creams before
  • remove from photo-therapy q4h and remove mask to check for injury
  • Reposition q2h
  • check aux temp q4h
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is bronze discoloration and maculopapular skin rash during photo-therapy normal?

Yes, this is normal

  • Do however watch for sunken fontanells indicating dehydration