Maternity and Newborn Nursing Review

Clinical Logistics and Administrative Updates

• Midterm Dates:

  • Next week is designated for midterms.
  • There will be no scheduled class sessions.
  • There is no clinical rotation next week, with the exception of students required to submit a clinical paper on Monday.

• Resumption of Class:

  • Classes resume in Week 9 on campus.
  • The schedule for the hospital clinical rotation is set for 10:00 AM.

• Mandatory Clinical Documentation:

  • Students must complete the following forms:
    • Release of Responsibility.
    • Confidentiality and Nondisclosure agreement.
    • Good Health Attestation.
  • Required personal data includes:
    • Date of Birth.
    • MCH Employee Status: Explicit "Yes" or "No."
    • Student ID: Defined by the hospital as the last five digits of the student's Social Security Number.

Contraception and Reproductive Health

• Intrauterine Device (IUD) Complications:

  • Common problems associated with IUDs include abnormal spotting, bleeding, and infection.
  • The presence of the IUD (a foreign body) in the uterine orifice predisposes the patient to infection.
  • Copper IUDs are specifically associated with heavier menstrual periods and frequent spotting.

• Dysmenorrhea Treatment:

  • The first-line treatment for dysmenorrhea is Naproxen (Anaprox or Motrin/Ibuprofen).
  • Mechanism of Action: Naproxen is a Non-Steroidal Anti-Inflammatory Drug (NSAID) that prevents prostaglandin synthesis by inhibiting the conversion of COX-1 and COX-2.

• Secondary Amenorrhea:

  • Definition: The cessation of regular menstrual periods in women of reproductive age.
  • The most common cause of secondary amenorrhea is pregnancy.

• Uterine Fibroids (Leiomyomas):

  • Uterine fibroids are estrogen-dependent; they grow under the influence of estrogen during childbearing years and typically shrink after menopause.
  • Treatment: Medications like GnRH agonists (e.g., Lupron) are used to stop ovulation and the production of estrogen to shrink the fibroids.

• Breast Mass Assessment:

  • Benign Breast Masses (Fibrocystic Breast Disease): Often characterized as bilateral, frequently painful masses with regular margins. They are mobile (not fixed) and do not cause nipple retraction.
  • Malignant Breast Masses: Typically characterized as unilateral, hard, painless, irregularly shaped, poorly delineated, immobile (fixed to the chest), and may be associated with skin dimpling and bloody nipple discharge.
  • Risk Factors for Breast Cancer: Increased exposure to estrogen (e.g., menopause after age 51, early menarche before age 11). Menarche at age 13 is considered normal and is not a risk factor.

Pharmacology and Dosage Calculations

• Magnesium Sulfate Infusion Calculation:

  • Order: $1\,g/hr$
  • Stock (Available): $4\,g$ of Magnesium Sulfate in $250\,mL$ of $D_5W$
  • Formula: $\frac{\text{Desire}}{\text{Have}} \times \text{Quantity}$
  • Calculation: $\frac{1\,g}{4\,g} \times 250\,mL = 62.5\,mL/hr$
  • Rounding: To the nearest whole number, the flow rate is $63\,mL/hr$.

• Magnesium Sulfate Toxicity:

  • A primary sign of magnesium toxicity is a respiratory rate below $12\,bpm$ (e.g., $10\,bpm$).
  • Therapeutic Range: The therapeutic serum level for Magnesium Sulfate is $4 \text{ to } 7\,mEq/L$.
  • Note: A serum level of $2\,mEq/L$ is below the therapeutic range. Proteinuria of $3+$ is a sign of preeclampsia, not toxicity.

• Rho(D) Immune Globulin (RhoGAM):

  • Critical intervention for Rh-negative clients who experience pregnancy loss (spontaneous abortion, ectopic pregnancy).
  • RhoGAM must be administered within $72\,hours$ to prevent the formation of maternal antibodies against an Rh-positive fetus.

Maternal and Fetal Complications

• Preeclampsia Assessment (Clonus):

  • To assess for clonus, the nurse should dorsiflex the woman's foot. When the foot is released, jerky, rhythmic movements as it returns to a normal position indicate a positive result.

• Fetal Heart Rate (FHR) Monitoring:

  • Variable Decelerations: Characterized by a V-shape in the tracing (e.g., dropping from a baseline of $140\,bpm$ to $100\,bpm$ for $15\,seconds$). These are caused by cord compression. The priority action is to change the maternal position from side to side.
  • Late Decelerations: Caused by decreased uteroplacental blood flow/insufficiency.
  • Early Decelerations: Caused by fetal head compression.

• Internal Fetal Monitoring Criteria:

  • Cervical dilatation must be at least $2\,cm$.
  • Amniotic membranes must be ruptured.
  • The presenting part must be low enough for electrode placement.
  • A skilled practitioner must be available to insert the electrode.

• Spontaneous Abortion and Ectopic Pregnancy:

  • In the event of a miscarriage, blood type and Rh factor must be tested. If the mother is Rh-negative, RhoGAM is required regardless of the fetal blood type (which is usually unknown).

Labor, Delivery, and Postpartum Care

• Fetal Position:

  • The least favorable position for vaginal delivery is Occiput Posterior (OP).
  • OP positioning often leads to severe back pain and a prolonged, difficult labor due to the wider diameter of the fetal head.

• Obstetric Lacerations:

  • Third-degree Laceration: Extends through the skin and muscle into the anal sphincter muscle.
  • Fourth-degree Laceration: Extends through the anal sphincter and into the rectal mucosa.

• Postpartum Hemorrhage (PPH) Risk Factors:

  • Chorioamnionitis (infection prevents effective uterine contraction).
  • Labor augmentation (chronic Pitocin exposure can saturate receptors, leading to uterine atony).
  • Placenta previa.
  • Uterine inversion.

• Postpartum Assessment Timing:

  • Following delivery, assessments typically occur every $15\,minutes$ for the first hour. If an assessment is completed at 14:30, the next is due at 14:45.

• Normal Postpartum Findings vs. Critical Signs:

  • Temperature: A temperature of $100.3^{\circ}F$ within $4\,hours$ of delivery is often due to dehydration. The nurse should encourage fluids.
  • Bowel Movements: It is common for nulliparous clients not to have a bowel movement by the first day postpartum due to slowed digestion during labor. The nurse should document the finding and encourage ambulation and fiber rather than immediately administering laxatives.
  • Lochia Progression: Lochia Alba (white/yellowish discharge) is considered normal approximately $11\,days$ postpartum.
  • Afterpains: Menstrual-like cramps during breastfeeding are caused by the release of oxytocin (not prolactin). Provide a mild analgesic.
  • Hematocrit: An acute decrease in hematocrit is abnormal and suggests significant blood loss/hemorrhage.

• Maternal Role Development (Ruben's Phases):

  • Letting Go Phase: Characterized by moving forward as a family unit and re-establishing roles.

• Mastectomy Post-Operative Care:

  • Elevate the affected arm on a pillow to promote lymphatic drainage and prevent lymphedema.

Newborn Assessment and Development

• Fetal Development Landmarks (Chronological Order):

  1. Blastocyst development is complete.
  2. The four chambers of the heart are formed.
  3. Vernix caseosa is present on the skin.
  4. Testes descend into the scrotal sac (typically occurs after $36\,weeks$).

• APGAR Scoring Example:

  • Heart Rate $132\,bpm$ (>100): 2 points.
  • Respiratory Effort (Lusty cry): 2 points.
  • Muscle Tone (Active movement): 2 points.
  • Reflex Irritability (Grimaces/coughs to bulb syringe): 2 points.
  • Color (Pink body, blue extremities - Acrocyanosis): 1 point.
  • Total APGAR Score: 9.

• Classification of Preterm Infants:

  • Extremely Preterm: $24 \text{ to } 28\,weeks$ gestation.
  • Very Preterm: Between $28 \text{ to } 32\,weeks$.

• Newborn Clinical Findings:

  • Cephalohematoma: Firm swelling of the scalp that does not cross suture lines. Caused by birth trauma (e.g., operative vaginal delivery). May take weeks to resolve.
  • Surfactant Deficiency: Causes the alveoli to collapse with each expiration, leading to respiratory distress.
  • Foramen Ovale Closure: Triggered by increased pressure in the left atrium after birth.
  • Hip Dysplasia Assessment (Ortolani's Maneuver): Flexing hips and knees to $90^{\circ}$, grasping thighs, and abducting the hips $180^{\circ}$ to check for clicks or "clunks."
  • Ballard Score: Utilized to assess physical and neuromuscular maturity. Physical parameters include plantar creases (more in term babies), skin texture (thin/transparent in preemies, leathery in post-term), and genitalia.
  • Jaundice: Jaundice occurring within the first $24\,hours$ of life is always pathologic (e.g., at $12\,hours$ old).

• Newborn Transition Risks:

  • All newborns are at risk for Cold Stress, which can metabolically lead to Hypoglycemia.

• Neonatal Herpes:

  • Transmission risk is highest if the mother has a primary (initial) herpes infection during pregnancy.
  • Cesarean delivery is recommended if active lesions are present during labor.

Parenting and Breastfeeding

• Breastfeeding Recommendations:

  • The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first $6\,months$.

• Breastmilk Immunology:

  • The primary antibody found in breastmilk that provides immunologic advantages is IgA.

• Vitamin K Administration:

  • The newborn's gut is sterile at birth. Vitamin K is not produced by the body until after the first feeding introduces bacteria to the gut.

• Mastitis Prevention:

  • Instruct the mother to frequently change nursing positions and ensure complete breast emptying to prevent stasis and infection.

• Partner's Role Development:

  • Reality Stage: Occurs within the first three weeks when the partner wants to be involved but feels unprepared or overwhelmed by the requirements of infant care.

Questions & Discussion

• Question: What can be delegated to unlicensed assistive personnel (techs/CNA) for a one-hour-old newborn?

  • Response: The tech can perform the blood glucose assessment via heel stick. The RN must perform the initial bath, all medical assessments, and medication administration.

• Question: What is the appropriate goal for an 8-week pregnant client with a family history of cystic fibrosis?

  • Response: The priority is genetic counseling to determine if the parents are carriers. If neither is a carrier, no further testing (like chorionic villi sampling) is required.

• Question: Which STI can cause preterm birth?

  • Response: Trichomoniasis. It is also associated with premature rupture of membranes (PROM). Note that HIV does not cause neonatal sepsis, and Candida is not transmitted in utero or via breast milk.

• Question: What is the "S" in the SAVE model for domestic violence?

  • Response: Screening. The nurse asks: "Within the last year, have you been physically hurt by someone?"

• Question: Which symptom group of PTSD is defined by nightmares and flashbacks?

  • Response: Intrusion.

• Question: What is a sign of hypovolemic shock in a PPH patient?

  • Response: Urine output below $30\,mL/hr$ (e.g., $25\,mL/hr$).