EXAM 2 STUDY GUIDE

Iron deficiency anemia occurs in newborns because

most clients do not have adequate iron stores to meet the 1000 mg requirement of pregnancy via diet alone

iron def anemia labs

• hgb level less than 11g/dL int he first & third semesters

• less than 10.5 g/dL in the second trimester

Iron deficiency anemia maternal and fetal effects

• tachycardia

• pallor

• fatigue

• lethargy

• headache

• inflamed lips

Iron deficiency anemia interventions

• iron supplement

  • ferrous uslfate 325mg

• encourage iron rich diet

  • liver

  • red meat

  • dark green leafy vegetables

• take iron with vitmain C, avoid milk

What is an episiotomy

A surgical incision of the perineum made just before birth to enlarge the vaginal opening

Episiotomy indications

• May be indicated for rapid resolution of shoulder dystocia

• Vacuum or forcep assisted birth

• Occiput posterior position

• Breech delivery

• Macrosomic fetus

Episiotomy risks

• Infection

• Prolonged perineal pain

• Midline episiotomies increase the risk of extending into a third degree tear — or fourth degree tear — greater blood loss

  • Into anal sphincter

  • Through renal sphincter

What is newborn hypoglycemia

• Plasma glucose concentration less than 45 mg/dL in the first 72 hours of life

S/S of newborn hypoglycemia

• Jitteriness

• Lethargy

• Cyanosis

• Apnea

• Seizures

• High pitched or weak cry

• Hypothermia

• Poor feeding

newborn hypoglycemia risk factors

• Prematurity

  • Poor glycogen stores

• Postmaturity

  • Depleted glycogen stores

• IDM (infant of diabetic mother)

  • Most common cause

• IUGR

• Cold stress

• Maternal diabetes

newborn hypoglycemia treatment

• Feed newborn IMMEDIAETLY with breast milk or formula if glucose is 40-45 mg/dL or less

  • breastfeeding

  • forumla feeding

• Administration of a rapid-acting source of glucose such as dextrose gel

• In severe cases

  • IV glucose may be needed

• Close monitoring of glucose

  • ALWAYS recheck glucose

• Avoid glucose water as it can cause a rapid rise in glucose followed by increased insulin production

Postpartum adaptations include

• uterus

  • involution

  • subinvolution

Postpartum adaptations: uterus involution

• The process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle

• the uterus returns to its nonpregnant size through contraction, catabolism, and regeneration of the epithelium

• fundus descends roughly 1cm per day and should no longer be palpable abdominally by day 14

• Vaginal deliveries have heavier bleeding than cesarean deliveries

• Not uncommon for women to experience a sudden, but brief, increase in bleeding 7-14 days after delivery when sloughing of eschar over the placental site occurs

Postpartum adaptations: subinvolution

• the failure to return to normal

• can cause PPH

Postpartum adaptations: Lochia

vaginal discahrge transitions through three stages

• lochia ruba

• lochia serosa

• lochia alba

Postpartum adaptations: Lochia ruba

• Bright red color

• Last 1-3 days

• This is blood from the placental site

Postpartum adaptations: Lochia serosa

• Pinkish brown color

• Lasts 4-10 days

• Blood and wound exudate from the placenta

• Also includes cervical mucosa

Postpartum adaptations: Lochia alba

• • Whitish yellow color

  • Lasts 10-14 days

  • Can last up to 6 weeks

  • Mainly contains WBCs & trophoblastic tissue debris

Postpartum adaptations: Lochia amount

• Scant

  • Less than 1 inch stain on pad

• Light

  • Less than 4 inch stain on pad

• Moderate

  • Less than 6 inch stain on pad

• Heavy

  • Saturated peripad in 1 hr

• Excessive

  • Saturated peripad in 15 minutes

Newborn heat loss types

• convection

• radiation

• evaporation

• conduction

Newborn heat loss types: convection

• Flow of heart from the body surface to cooler ambient air

  • Fan

  • AC

• Ambient temperature in newborn care areas should range between 22^oC  and 26^oC (72 to 78F).

• Humidity should be between 30% and 60%

• Newborns in open bassinets are wrapped to protect them from the cold

• Caps may be worn to decrease heart loss from the infant's head.

Newborn heat loss types: convection and how to combat

• Preterm infants in incubators with warm air

• Keep infant away from drafts

Newborn heat loss types: radiation

• Loss of heat from body's surface to a cooler solid surface NOT in direct contact but proximity

Newborn heat loss types: radiation & how to combat

• Prevention

  • Bassinets and examining tables are placed away from outside windows and care is taken to avoid direct air drafts.

• How to combat

  • Double wall incubator

  • Keep away from exterior walls and windows

  • Radiant warmer

Newborn heat loss types: evaporation

• Loss of heat that occurs when liquid is turned into vapor

• Newborns, heat loss evaporation occurs as a result of moisture vaporization from the skin

  • Wet towel

  • Spit up

• This heat loss is intensified by failing to completely dry the newborn after birth or with bathing. 

• Evaporative heat loss as a component of insensible water loss is the most significant cause of heat loss in the first few days of life

Newborn heat loss types: conduction

• Loss of heat from the body surface to cooler surfaces in direct contact.

• During initial assessment the newborn is placed on a prewarmed bed under radiant warmer to minimize heat loss.

• Scales used for weighing the newborn should have a protective cover to minimize conductive heat loss.

APGAR assessment includes

• Heart rate

• respirations

• muscle tone

• reflex response

APGAR: heart rate score

• 0

  • Absent

• 1

  • Below 100 BPM

• 2

  • 100 BPM or higher

APGAR: respirations

• 0

  • No spontaneous respirations

• 1

  • Slow respirations or weak cry

• 2

  • spontaneous respirations with strong, lust cry

APGAR: muscle tone

• 0

  • Limp, flaccid

• 1

  • Minimal flexion of extremities

  • Sluggish movement

• 2

  • Flexed body posture

  • Spontaneous and vigorous movement

APGAR: reflex response

• 0

  • No response to suction or gentle slap on soles of feet

• 1

  • Minimal response (grimace) to suction or gentle slap on sole of feet

• 2

  • Responds promptly to suction or gently slap to sole with cry or active movements

APGAR: color

• 0

  • Pallor

  • Pale

  • Cyanotic

• 1

  • Bluish hands and feet only (acrocyanosis)

• 2

  • Pink (light skinned)

  • Pink mucous membranes

Interventions for APGAR <7

• 0-2

  • Infant needs immediate resuscitation

• 3-6

  • Gently stimulate by rubbing infant’s back while administering oxygen

  • Determine whether the client received narcotics, which may have depressed the infant's respirations.

PPH

• Cumulative blood loss >/= 1000mL or bleeding accompanied by signs of hypovolemia within 24 hours of birth

• the four T’s

• A full bladder can also cause PPH because it shifts the uterus up and off to the side, making the uterus unable to contract

PPH: the four T’s

• tone

• tissue

• trauma

• thrombin

PPH: the four T’s tone

PPH: the four T’s trauma

• cervical lacerations

• hematoma

• uterine inversion

• uterine rupture

PPH: the four T’s trauma cervical lacteration

• Common during forcep delivery

• Moms who push too early before they are fully dilated

PPH: the four T’s trauma cervical hematoma

• Associated with

  • Episiotomy

  • Instrumental birth

  • nulliparity

PPH: the four T’s trauma cervical inversion

• Top of the uterus collapses into the inner cavity due to excessive fundal pressure or pulling on the umbilical cord when the placenta is still firmly attached

• Must be immediately replaced manually by physician

PPH: the four T’s trauma cervical rupture

• More common in women with previous c-section incisions or those who have undergone any procedures resulting in disruption of the uterine wall

PPH: the four T’s thrombin

• Coagulopathy

  • Preexisting or acquired

early vs late PPH

• Blood loss within the first 24 hours following birth

• Main cause is uterine atony

  • failure of uterus to contract

early vs late PPH

• Blood loss occurring after 24 hours to 12 weeks following birth

• Common causes include

  • Obstetric lacerations

  • Uterine inversion

  • Subinvolution

  • Rupture of uterus

vaginal delivery, postpartum abnromal findings/interventions include

• uterine atony

• distended bladder

• lacerations

• hematomas

vaginal delivery, postpartum abnromal findings/interventions include: uterine atony

• a soft, boggy fundus

• intervention

  • massage the fundus and push downward to expel clots

  • admininster oxytocin

vaginal delivery, postpartum abnormal findings/interventions include: distended bladder

• fundus is above the umbilicus and misplaced from midline

• intervention

  • assist the client to urinate or catheterize

vaginal delivery, postpartum abnormal findings/interventions include: lacerations

• bright red bleeding occurs despite a firmly contracted midline fundus

• intervention

  • notif MD to repair

vaginal delivery, postpartum abnormal findings/interventions include: hematomas

• deep severe unrelenting pelvic/rectal pain, feeling of pressure, or visible bulging, discolored vulvar mess

• intervention

  • apply cold packs to slow bleeding

  • notify MD

  • NPO

Fundal assessment

• provide privacy, explain the procedure, have the PT supine with knees flexed

• ask client to empty bladder before assessment

• place the nondominant hand just above the symphysis pubic to support and anchor the lower uterine segment

• use flat fingers of the dominant hand to palpate the fundus starting at the umbilicus

• assess for consistency and location to umbilicus

  • firm vs boggy

Newborn medications

• Vitamin K 0.5-1.0 mL IM

  • Given because newborns cannot synthesize vitamin K in the intestines due to it being sterile

• Erythromycin ointment 0.5% one ribbon to each lower eyelid

  • Given to prevent 

    • Ophthalmia

    • Neonatorum

    • Conjuncitivitis

  • All which are most often caused by gonorrhoeae

• Possibly Hep B 0.5mL

  • ONLY with a consent

Breastfeeding: benefits

• Less GI infections

• Less EAR infections

• Less RESPIRATORY infections

• Convenient

• Free

• Closer bonding between mother and infant

• Decreases maternal risk for future maternal health cancers 

  • ovarian/breast

• Increased antibody development by infant

• Why NOT

  • More risk fo HIV transmission

  • Galactosemia

    • Body's inability to convert galactose to glucose

Breastfeeding: signs of effective breastfeeding for mother

• Onset of copious milk production by day 3 or 4

• Firm tugging sensation on nipple as infant sucks with NO pain

• Uterine contractions and increased vaginal bleeding while feeding (first week or less)

• Feels relaxed and drowsy while feeding

• Increased thirst

• Breast softens or feel lighter while feeding

• With milk ejection (let down), can feel warm rush or tingling in breasts, leaking of milk from opposites breast

Breastfeeding: signs of effective breastfeeding for infant

• Latches without difficulty

• Has bursts of 15-20 sucks/swallows at a time

• Audible swallowing is present

• Easily releases breast at end of feeding

• Infant appears content after feeding

• Has at least three substantive bowel movements and 6-8 wet diapers every 24h after day 4

hormones associated with breastfeeding

• prolactin

  • initiates maintains milk production, and its level rise in response to infant duckling

• oxytocin

  • causes milk ejection aka let down reflex, releasing milk from the ducts

• estrogen and progesterone

  • high during pregnancy → inhibits prolactin action

  • after delivery of placenta

    • levels drop drastically allowing prolactin to stimulate milk production

hormones associated with breastfeeding: colostrum

transient tachypnea of the newborn

• Mild respiratory distress pulmonary liquid removed slowly or incompletely; resolution by 72 hours of age

transient tachypnea of the newborn: risk factors

• C section birth without labor

  • dt no chest compression to squeeze fluid out

• macrosomia

• maternal asthma

• maternal diabetes

transient tachypnea of the newborn: nursing assessment

• Maternal sedation or birth by c-section

• Tachypnea

  • Respiratory rates between 100-140

  • onset within few hours of birth

• Expiratory grunting

• Retractions

• Labored breathing

• Nasal flaring

• Mild cyanosis 

  • usually resolves with supplemental oxygen

• Barrel shaped chest

• Slight decreased breath sounds

transient tachypnea of the newborn: chest xray

• Mild symmetric lung hyperaeration

• Prominent perihilar interstitial marks and streaks

transient tachypnea of the newborn: nursing managment

• Oxygenation

• Supportive care

• IV fluids or gavage feedings

• supplemental oxygen

• Neutral thermal environment

cold stress

• When infants are stressed by cold

  • Oxygen consumption increase

  • Pulmonary and peripheral vasoconstriction occur

  • Thus decreasing oxygen uptake by the lungs and oxygen to the tissues

  • Anaerobic glycolysis increases and there is a decrease in PO2 and pH, leading to metabolic acidosis

cold stress s/s

• Pale in color

• Cold hands and feet

cold stress in newborns

• Elevated oxygen demand

• Diminished surfactant production

• Deplete glucose levels

• Metabolic acidosis

• Elevated fatty acids in blood

• Systemic and pulmonary vasoconstriction

  • Hyperthermia

  • hypothermia

cold stress & themogenesis

• when infants drop in temperature, nonshivering thermogensis (metabolism of brown fat) increases metabolic rate

• newborns CANNOT shiver effectivly

  • they rely on nonshivering thermogenesis through BAT metabolism

• BAT metabolism burns oxygen and glucose rapidly to generate heat

Neonatal abstinence syndrome

• disorder where infants exposed to drugs into utero demonstrate signs of drug withdrawal

Neonatal abstinence syndrome s/s

• Irritability (scratches at face)

• High pitched cry

• Hyperreflexia

• Increase suck

• Hyperemesis

• Diarrhea

• Poor feeding coordination

• Sever; seizures

• Difficult to console

• Diaphoresis

• Frequent yarning/sneezing

• Nasal stuffiness

• Poor sleeping patterns

• Excoriation

  • Scratching face

  • Severe diaper rash from watery stools

Neonatal abstinence syndrome interventions

• keep stimuli low

• swaddle baby snuggly in a flexed position

• frequent using high calorie formulas to offset energy expended during hyperactivity

• skin to skin contact

• breastfeeding encouraged unless mother uses illict drugs

• Support feeding

• Support rest periods

• Assess and intervene for diaper dermatitis

• Support containment

• Medications

  • Morphine

  • Methadone

  • Clonidine

Neonatal abstinence syndrome assessment tool

• Scoring

  • Finnegan scale

  • Lipsitz tool

  • eat/sleep/console q2-4h

• Collect a urine or meconium sample to see if baby is positive

• Work with social work if CPS is involved

Neonatal abstinence syndrome common substanced

• Marijuana

• Opioids

• SSRIs

• Buprenorphine

• Methadone

• Methamphetamine

Mastitis