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Nursing 160
Nursing of Women and Newborns
Class Outlines
Winter 1999
160 Nursing of Women and Newborns
Topics Page
Course Overview 3
Computer Orientation 4
Maternity Care Overview 5
Conception, Prenatal Development, and Healthy Pregnancy 11
Antepartal Nursing Assessment (Inserted pages)
Nutrition for Childbearing 18
Fetal Monitoring & Fetal Monitoring Worksheet (Inserted pages)
Intrapartal Needs and Care (Inserted pages)
Postpartum Physiological Adaptations 23
Postpartum Psychosocial Adaptations 38
Other Postpartum Complications 41
Normal Newborn: Adaptation, Assessment and Care 47
Normal Newborn: Assessment and Care 56
Indicators for Infant Screening for Perinatal Substance Abuse 70
Infant Feeding 71
The High Risk Newborn 81
Complications of Pregnancy (Inserted pages)
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N160 Nursing of Women & Newborns
I. Course Overview: (What are we doing today and for the next 16 weeks?)
Goal: To get to know each other and the course expectations.
A. Welcome: Index Card Assignment
B. Introductions: Faculty and students
C. Tour of the syllabus: (underlined pages mean they are on the web)
D. Class calendar: What we will be covering:
Healthy first and high risk later of the following:
Maternal-newborn overview
Reproductive, conception & prenatal development review
Labor and delivery
Women's health
E. N160 resources
N160 bulletin board (across from S416 office)
Post current issues, articles, cartoons and inspirational thoughts
I will E-mail them to you
Sign-up sheets for outside hospital experiences
Faculty open office hours, E-mail, Student Ambassadors, Dine & Discuss
Each other - study groups & class & clinical discussion lists
F. Teaching/learning philosophy: Active learning, encourage participation and
evaluation of your own learning
Encourage you to ask questions before, during, or after class.
Encourage feedback and open communication.
G. Faculty/student expectations
H. Review what we are doing tomorrow:
Begin assigned readings & assignments due
I. Questions/comments/concerns
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II. Computer Orientation: N160 Internet address: http://www.missouri.edu/~nurshein
Goal: Subscribe to class & clinical discussion lists & post information requested
Access N160 web site, see pre & post class surveys & student feedback forms.
Learn research strategies & tools to search databases & evaluate web sites.
A. Showme Basics: Youll need your showme account & pin numbers
How to access showme: Your user ID is c followed by your student #
Example: c12345Your e-mail address is userID@showme.missouri.edu
Example: c12345@showme.missouri.edu
Your password is your birthday (month and date) and University 4 digit PIN #
(used for registration). It is recommended you change this password.
Example: May 15 and PIN # 1234 = 05151234
Add your name to your e-mail so we know who you are: Go to Pine main
menu. Type S to change pine setup. Select C to change your configuration.
Type C to change the value of this field & enter your name. Press Return to
accept these changes & press E to exit the configuration setup & return to
main menu.
B. Discussion Lists Basics
How to subscribe to lists: To: listproc@lists.missouri.edu and under message
type: subscribe N160-L <first and last name> (Class discussion list)
subscribe N160<clinical group letter>-l <first and last name>
Example: subscribe N160-L Anne Heine (Class discussion list)
subscribe N160A-L Anne Heine (Clinical discussion list)
Tip: make sure nothing in subject or signature only this message
when subscribing
Be sure to save the message you receive back from the listproc after you
successfully subscribe to these lists. This contains valuable information to
remind you how to subscribe, compose, un-subscribe etc... and will be a
good reference guide. You might want to print off a copy to have as
How to compose a message to your list: To: N160-L@lists.missouri.edu
or your clinical group list name N160B-L ...: To: N160A-L@lists.missouri.edu
C. Internet Basics
How to search, cut, paste & print, go to, bookmarks . . .
Web evaluation resources:
Critical thinking on the World Wide Web resources:
D. Information Access and Technology Services Help Desk phone #: 882-5000
Web site: http://www.missouri.edu/cc/index.html
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I. Maternity Care Overview
Purpose: To develop an appreciation of where we've been, where we are going
and the challenges we are facing today.
A. Past, Present and Future
1. Birth settings
2. Providers
3. Mortality rates
a. Birth rate: # live births/1000 people
b. Maternal: # of deaths/100,000 live births
c. Neonatal: # of deaths/1000 live births who die < 28 days of life.
d. Perinatal: # of fetal & neonatal deaths/1000 live births
e. Infant: # of deaths/1000 live births before reach 1yo.
f. Ethnic differences exist:
g. Mortality rates in U.S.A.
4. Family changes
5. Federal response
a. Title V Social Security Act - (1935) & Medicaid
b. Women, Infants and Children Program (WIC)
c. Folic acid fortification to all foods (Jan. 98)
d. Federal & State Regulations on length of stay
6. Consumer demands
a. Self-care movement
b. Reed/Lamaze/Brazelton:
c. Family-centered care: Rooming-in
d. Labor-Delivery-Recovery Rooms (LDRPs)
B. Nurse's role in maternity care
1. Certified nurse midwives
2. Nurse practitioners
3. Clinical nurse specialists
4. Childbirth educators
5. Others: Staff nurses, lactation consultants, entrepreneurs
Nurses are challenged to create cost-effective care through innovative practices:
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C. Cultural perspectives in childbearing
1. Assess for and understand
a. Culture: A set of goals, beliefs, attitudes passed down from one generation to
b. Aculturalization: Modification of cultural beliefs in favor of dominate culture.
2. Avoid
a. Stereotypes
b. Ethnocentrism
3. Ascribe to develop: Culturally sensitive care:
Knowledge & Understanding
Know: possible differences in beliefs & practices
Understand: postpartum routines or rituals
Ask: about prefered foods & fluids
Encourage extended family support
Grandmother is often the primary helper
Speak slowly and clearly if language barrier exists
Modify communication to match that of the culture
Avoid slang and speak in simple terms
Ask for verification of information given
Be attentive to cues indicating misunderstanding
Weber, S.E. (1996). Cultural aspects of pain in childbearing women. Journal of Obstetric,
Gynecological, and Neonatal Nursing, 25 (1), 67-72.
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II. Ethical, social and legal issues related to reproductive and newborn health:
A. Current ethical dilemmas and application to practice
A. Ethical issues
B. What is an ethical dilemma?
3. Basis for ethical decision making
ANA Code of Ethics Pregnant Patient Bill of Rights
Respect for human dignity
Protect confidentiality
Safeguard patient
Accountable and responsible for own actions
Maintains competence
Exercises decision-making skills
Contributes to nursing knowledge
Improve standards of nursing
Insures environment of high quality care
Maintain integrity of nursing profession
Collaborates to meet health needs of public
Access to health care and information about
Informed of all risks to self and fetus and/or
any drugs, procedures, tests, etc. . .
Involved in decision making
Informed of who is providing care
Right to make choices in her care and care of
her infant
Receive culturally sensitive care
Receive ongoing education and support for
pregnancy, breastfeeding, childbirth and
postpartum periods.
B. Relevant social issues and application to practice
1. Social issues
a. Poverty
b. Homelessness
c. Access to care
d. Uninsured
e. Domestic violence
f. Illiteracy
g. Adolescent pregnancy
2. Redesigning health care system priorities
a. Improve access
b. Control costs
c. Improve quality
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C. Relevant legal issues and application to practice
1. Legal issues
a. Malpractice
b. Nurse's role with informed consent
c. Documentation
d. Client advocacy/confidentiality
2. Application to practice
III. Tools Needed in Maternal Newborn Nursing Practice
A. Critical thinking
Examples of Thinking Styles
Thinks out loud
Draws energy from being with people
Thinks inside
Draws energy from being quiet
Perceives the world discretely through
the five senses
Looks for facts
Perceives the world overall
Looks for meaning
Uses objective data
Seeks just decisions
Uses subjective data
Seeks fair decisions
Orders the environment
Likes to plan
Keeps things flexible and open
Likes to be spontaneous
[From Myers-Briggs Type Indicator (Myers, 1987). From Schoessler, M., Conedera, F., Bell, L., et. al., (1993).
Use of the Myers-Briggs type indicator to develop a continuing education department. Journal of Nursing Staff
Development, 9(1), 9.]
B. Knowledge Base
C. Critical Pathways
D. Standards of Care
E. Communication Skills
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F. Teaching Skills
Amy is a 16 yo single G1 P1 pt. who had a cesarean delivery 4 hours ago, was on Mg 504 to
prevent seizures, q 1E VS's, and very sleepy. She is also on MSO4 PCA for pain. Amy is
mentally challenged and had an estimated 4th grade education level. Her infant was in NICU
on a ventilator due to the emergent delivery at 25 weeks for pregnancy induced hypertension.
What factors influence Amys learning ability?
What factors influence the teaching/learning process in maternity care?
G. Nursing Process Skills
The Nursing Profession as a Tool for Critical Thinking
C Assessment: Continuous, deliberate subjective & objective data collection designed to
provide the information required to:
C Predict, detect, prevent, control or eliminate health problems.
C Identify ways of helping people obtain optimum wellness and independence.
C Diagnosis: The process of analyzing data, putting related information together, drawing
conclusions, and identifying:
C Actual and potential health problems.
C Underlying causes of the health problems.
C Resources and strengths.
C Health states that are satisfactory, but could be improved.
C Planning: Determination of specific & prioritized goals (desired outcomes) and
interventions. The interventions are designed to:
C Achieve the desired outcomes in a timely fashion.
C Detect and prevent new health problems.
C Promote optimum wellness and independence.
C Implementation: Putting the plan into action by:
C Assessing readiness to act.
C Acting, then reassessing to determine initial responses.
C Making immediate changes as needed.
C Keeping records to monitor progress.
C Working with the patient & family to achieve desired outcomes
C Evaluation: Determining whether the expected outcomes have been met by comparing the
patient's current assessment data with the outcomes recorded during Planning; modifying or
terminating the plan as appropriate; planning for ongoing continuous assessment and
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I. Reproductive Review: on your own (but ask if you need help).
Do you know what I asked my OB teacher in clinical? I bet you cant top my question!!!
My kids get this in grade school and high school and I know many of you have had this in
anatomy class so here are some questions to focus your study.
1. What characteristics make the female reproductive tract so wonderfully designed for
How about those uterine walls? How do they help with conception, delivery and
What about those female hormones & their effect on reproduction?
How can that big baby fit out of that small hole down there?
Check out that pelvis! Which one really matters in deciding if the baby can fit through and if
you could choose the best one for childbirth, which one would you want?
2. Review the reproductive cycle.
3. So how will I know when my twins (Kate & Kurt) are going through puberty? What are the
tell tale signs and when should I expect them? By the way, are they fraternal or dizygotic
Theoretically, how many times can a women conceive in her lifetime?
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Conception, Prenatal Development and Healthy Pregnancy
Key Points: The first 8 weeks is the most critical time in fetal development because the
All women should be assessed for genetic risks and informed of tests
Nurse should implement care to promote a positive fetal outcome through
assessment, teaching and support.
I. Stages of fetal development
A. Pre-embryonic:
1. Fertilization (single or multifetal)
a. Occurs
b. Egg fertile ____ hrs. sperm ____hrs. but most fertile 1
____ hrs.
c. Sex is determined and blueprint for G&D established
d. Twinning
*Dizygotic twinning (fraternal) autosomal recessive

*Monozygotic twinning (identical)
e. Implantation is completed in _______ after fertilization. *Sometimes
have "_________________________________."
2. Development of fetal membranes
a. Amnion - surrounds the fetus and it's cells produce amniotic fluid
*Polyhydramnios >________ cc's and associated with CNS or GI tract
*Oligohydramnios <______ cc's and associated with poor fetal lung
development and malformations from compression of fetal parts.
b. Chorion - surrounds amnion and blends with placenta
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3. Development of decidua
a. It is the uterine endometrium
4. Development of the placenta and its function
a. Temporary organ
b. Maternal/fetal blood
- Maternal portion - (Dirty Duncan)
- Fetal portion - (Shinny Shultz)
- Functions
hCG (Human chorionic gonadotropin) is secreted 8-10 days after
implantation occurs and is present in maternal serum and detectable in
maternal urine
hPL (human placental lactogen)

B. Embryonic stage: Most vulnerable time.

1. C-V system begins to function
2. Fetal circulation established
3. Germ layers develop structures
- Ectoderm -
- Mesoderm -
- Endoderm -
C. Fetal Stages (What's developing when?) See handout.
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Label the following structures on Figure 42 and, using arrows, trace the normal pathway of fetal
Umbilical vein
Foramen ovale
Ductus venosus
Ductus arteriosus
Inferior vena cava
Umbilical arteries
Figure 4-2 Fetal circulation (From Spence, A. P., & Mason, E. B.: Human Anatomy and
Physiology. 3
ed. Menlo Park, CA: Benjamin/Cummings Pub. Co., 1987, p. 862.)
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Sinclair School of Nursing
N160 Nursing of Women and Newborns
Stages of Fetal Development
Preembryonic Embryonic Stage Fetal Stage
Weeks Gestation: 1 2 3 4 5 6 7 8 9 12 16 20 24 28 32 36 38
Major Developmental Events
Fertilization occurs
Beginning development of:
1. Fetal membranes
2. Decidua
3. Placenta
(3) C.V. System is functional before first missed
(4) Heart begins to beat
GI tract develops along with heart central
nervous system and all other organs
Germ layers developing:
1. Ectoderm (outside)
2. Mesoderm (middle
3. Endoderm (inner)
(10-12) FHT's Dopplable
(12) Kidneys produce urine
(16) Musculoskeletal system has matured
Sex can be seen on ultrasound
(20) Quickening occurs
Vernix and lanugo cover body
(22-23) Age of viability
(24) Eyebrows and eyelashes formed
Activity increases
Skeleton develops rapidly
(28) Opens eyes
Begins sub-q fat deposits
Surfactant forms in lungs
(32) Sub-Q fat being laid down
(36) L/S ratio > 2:1 > indicates fetal lung maturity
PG present
Lanugo begins to disappear
(38) Receives antibodies from mother
Lanugo and vernix decreasing
Spontaneous Abortions
usually due to
Ectopic pregnancy can occur
Most critical time in development
All organ systems being formed
Highly vulnerable to teratogens
Less vulnerable to teratogenic effects
however noxious agents may interrupt
normal functioning and development
especially central nervous system (CNS)
AH:ld 09/10/92
11/21/94; 07/95; 8/97
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II. Factors that influence embryonic and fetal development
Genes and Chromosomes
# Genes: composed of DNA
# Dominant genes: expressed even if heterozygous
# Recessive genes: expressed only if homozygous
# Abnormalities affect fetus in various ways and varying degrees
# Defective genes can be transmitted to offspring
# Teratogen can adversely affect fetal-newborn health according to:
degree of toxicity, amount of exposure, timing of contact and degree of susceptibility
# Karyotype is a photograph of an individuals chromosomes
A. Genetic - Heredity
1. Single gene inheritance:
a. Autosomal dominate trait
(e.g. Blood type, Huntington's disease, Alzheimer's disease)
b. Autosomal recessive trait
(e.g. Tay-Sachs disease, sickle cell, cystic fibrosis)
c. X-linked trait
Turner's syndrome only have single X chromosome.
2. Chromosomal abnormalities
a. Down's syndrome
b. Turner's syndrome
B. Environment
1. Teratogen: any substance, agent, or process that induces the formation of
developmental abnormalities in a fetus. Should avoid exposure to:
Other infections (varicella or group B streptococcus)
Cytomegalovirus infection (CMV)
Herpes genitalis
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2. Mechanical disruptions to fetal development
Fibrous amniotic bands
C. Multifactorial
1. Genetic predisposition + Environmental factors cause defect
2. Risk depends on history of genetic defects in family.
a. cleft lip and palate
b. neural tube defects
c. gastroschises, pyloric stenosis and congenital heart disease
III. Nursing care:
A. Preconceptual counseling
Think ahead: Tips for Couples
# Visit your health care provider early
# Learn about your family history
# Stop smoking, drinking, & taking drugs
# Avoid exposure to toxic substances & chemicals
# Reduce stress
Think ahead: Tips for Women of Childbearing Age
# Consume 0.4 mg. Folic acid every day
# Achieve ideal weight before pregnancy
# Eat a balanced diet
# Exercise regularly
# Manage existing medical conditions
# Find out if your immune to rubella
# Avoid eating undercooked meat or handling cat litter
B. Prenatal history screening
C. Prenatal testing
# Chorionic villus sampling (CVS)
# Karyotyping done on blood or amniotic fluid
# Maternal Serum Alpha-fetaloprotein (MSAFP)
Triple marker test
# Amniocentesis
D. Counseling and support if genetic referral necessary
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Group Activities
Post test
1. Genes are composed of
1. alleles
2. DNA
3. autosomes
4. deoxyribose
2. The twenty-third chromosome pair is the
________________ chromosome.
1. autosome
2. karyotype
3. allele
4. sex
3. When the autosome pairs are arranged in
order from the largest pair to the smallest
for study, this is called a
1. photomicrograph
2. pedigree
3. karyotype
4. genogram
4. A gene that requires two identical copies of
the gene for the trait to be expressed is
1. recessive
2. dominant
3. a mutation
4. heterozygous
5. A woman who has an autosomal dominant
disorder has a ____ chance of transmitting
the disorder to her children.
1. 25%
2. 50%
3. 75%
4. 100%
6. Males are more often affected with
Xlinked recessive disorders because
1. the father is the carrier
2. the Y chromosome is also abnormal
3. males have only one X chromosome
4. there is an extra X chromosome
7. The genetic sex of the fetus is determined
at the
1. end of the first six weeks of prenatal
2. end of the first trimester
3. time of conception
4. age of viability
8. Multifactorial birth defects are usually
a. isolated defects
2. not detected at birth
3. part of a syndrome
4. very rare
9. One way that a woman can prevent fetal
exposure to teratogens is to
1. limit intake of alcohol to one drink
per day
2. avoid radiologic procedures during
the last trimester
3. receive rubella immunization prior to
4. use only drugs from pregnancy
category X
10. process of genetic counseling
A. focuses on one individual in the
B. helps people understand a disorder
and the risk of its occurrence in their
C. determines the course of action
which the family should take
D. usually takes only one session to
determine the origin of the defect
Copyright 1994 by W. B. Saunders Company. All rights reserved.
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N160 Nursing of Women and Newborns
Nutrition for Childbearing
1. Explain the importance of adequate nutrition and weight gain during pregnancy.
2. Describe common factors that influence a woman's nutritional status and choices.
3. Describe common nutritional risk factors and explain how they affect nutritional
requirements during pregnancy.
4. Compare the nutritional needs of a postpartum woman who is breastfeeding with one who is
5. Apply the nursing process to nutrition during pregnancy, the postpartum period and
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Nutrition for Childbearing
I. Weight gain during pregnancy
A. Recommendations for total weight gain in pregnancy:
1. Normal weight:
2. Underweight:
3. Overweight:
4. Twin pregnancies:
B. Recommended pattern of weight gain for normal weight women:
1. First trimester:
2. Second trimester:
3. Third trimester:
C. Recommended caloric needs:
II. Nutritional requirements during pregnancy
A. Recommended dietary allowances (RDA)
1. Protein
2. Calcium
3. Iron
4. Vitamin C
5. Folic acid
List dietary sources rich in folates? Hint: Found in similar foods high in iron
B. Supplementation
1. Iron:
a. Increases absorbtion
b. Decreases absorption
c. Dietary sources of iron:
d. Common side effects:
2. Calcium:
a. Best source of calcium
b. Decreases calcium absorption
c. List other dietary sources of calcium
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3. Prenatal vitamin (PNV) use
a. Folic acid benifits
b. Flintstone vitamins or other prenatal vitamins
c. Vitamin supplementation hazards
C. Fluid recommendations in pregnancy
D. Recommended servings during pregnancy
1. Bread group: ____________ servings
2. Vegetable group: _________ servings
3. Fruit group: _____________ servings
4. Milk group: _____________ servings
5. Meat group: _____________ servings
III. Nutrition after birth
A. Nutrition for the lactating woman
1. Calories needed
2. Alcohol and caffeine use
B. Nutrition for the non-lactating woman
1. Protein & Vitamin C
2. Vitamin supplementation
3. No dieting
4. Iron supplementation (if anemic)
IV. Nursing care to promote nutrition
A. Assess:
1. How do you assess a patients current nutritional status and needs?
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2. What factors could cause the pregnant or postpartum patient to be at risk for
nutritional deficiencies and what would you do if a patient presented with these
B. Nurses role regarding nutrition in pregnancy:
C. Evaluating & reassessing nutritional status:
Rev. 11/95, 9/98
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Group Activities
I. Case Study
Mrs. Lopez is a gravida 3, para 2. It has been 15 weeks since her last menstrual period.
She has gained 15 pounds with this pregnancy and her hemoglobin level is 10.8 gm/dl.
1. What should the prenatal nurse identify as the priority in this situation?
2. How can the nurse identify Mrs. Lopez's nutritional problems?
3. What nutritional problems does Mrs. Lopez have?
4. What foods should Mrs. Lopez include in her diet to correct her nutritional problems?
Copyright 1994 by W. B. Saunders Company. All rights reserved.
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N160 Nursing of Women and Newborns
Postpartum: Physiological & Psychological Adaptations
1. Explain the physiological changes that occur during the postpartum period.
2. Identify nursing assessments that are necessary during the postpartum period.
3. Describe the nurses responsibility for providing care and instruction that protect the health of the new
4. Recount nursing interventions for the most common nursing diagnoses during the postpartum period.
5. Describe the nurse's responsibility for clients who choose early discharge from the birth facility.
6. Compare cesarean birth and vaginal birth in terms of nursing assessments and care.
7. Explain the process of bonding and attachment.
8. Describe the progressive phases of maternal adaptation to childbirth and how these impact nursing
9. Discuss postpartum blues in terms of cause, manifestations, and interventions.
10. Describe the process of family adaptation (father, siblings) to the birth of a baby.
11. Identify and discuss factors that affect family adjustment.
12. Discuss cultural influences on family adaptation.
13. Identify interventions to promote maternal/family adaptation.
14. Describe postpartum hemorrhage in terms of predisposing factors, causes, clinical signs, and
therapeutic management.
15. Identify complications of postpartum hemorrhage.
16. Explain major causes, clinical signs, and therapeutic management of subinvolution.
17. Describe three major thromboembolic disorders in terms of predisposing factors, causes, clinical
signs, and therapeutic management.
18. Discuss puerperal infection in terms of location, predisposing factors, causes, and therapeutic
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Postpartum Physiological Adaptations
Key Point: Understand normal postpartum physiological changes to plan &
implement care & teach patients self-care.
Fourth stage of labor:
I nvolution:
I. Physiological changes:
A. Reproductive system: Involution
1. Uterus: Heals by exfoliation
a. Decent of fundus: Normal process
b. Afterpains:
c. Lochia: Outer endometrial layer
Type Color Time Description Amount
1. Rubra 1. Scant < 1-2"
2. Serosa 2. Light < 4"
3. Alba 3. Moderate < 6"
4. Heavy saturated pad in 1hr.
Factors increase lochia flow:
d. Cervix - takes approx.2 wks. to heal after del.
e. Vagina - takes approx. 4-6 wks. to heal
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f. Perineum - stretched. Episiotomy/ lacerations
Degree Extension
1. 1st degree to the muscle of perineal body
2. 2nd degree through the perineal body muscle
3. 3rd degree through the anal sphincter
4. 4th degree into the anterior rectal wall (OUCH!)
B. Cardiovascular system
1. Blood volume
a. Estimated blood loss (EBL)
b. Diuresis:
c. Diaphoresis:
2. Coagulation: risk of thrombus formation due to blood clotting factors.
3. Blood values
WBC's to protect against infection (nl. 5-10,000) to 20-30,000 .
4. Vital signs
Temperature - monitor for dehydration & infection
Blood pressure - monitor for:
Pregnancy Induced Hypertension (PIH)
Orthostatic hypotension
Bardycardia common:
Respiration normal & breath sounds clear
C. Gastrointestinal system
1. Constipation:
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D. Urinary system
1. risk of over distention postpartum
2. Hazards of a full bladder postpartum
3. Assessment for a full bladder
E. Musculoskeletal system
1. Fatigue, aches, pains common after childbirth
2. Assess for & treat diastasis recti
F. Integumentary system
1. Skin changes disappear
G. Endocrine system: estrogen and progesterone & prolactin after delivery
1. Ovulation:
a. Non-nursing:
b. Lactating:
Influence on ovulation:
Birth control recommendations
2. Lactation:
a. Stimulation of milk production: Prolactin
-breast engorgement:
-sore nipples:
b. Treatment for bottle-feeding mothers:
3. Weight loss after childbirth
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II. Application of the nursing process
A. Assessment
1. Initial assessment
a. Gather important information
b. Assess immediately upon arrival

c. Make judgements, anticipate problems and prioritize care
PP Complications High Risk Factors for PP Complications
Blood Clots
Postpartum Hemorrhage:
Definition: Blood loss > 500 cc's following vaginal delivery
> 1000 cc's following C-delivery
Types and Causes of postpartum hemorrhage:
Early: within the first 24 hrs after delivery. The causes are:
Late: after the first 24 hours to 4-6 weeks PP
Know the normal lochia progression:
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Assessment Atony Laceration Hematoma Subinvolution
Fundus * *
Lochia 0
Treat the cause!
Medications: Oxytocin
Full bladder:
Retained placenta:
Treat complications:
Hypovolemic shock:
Watch for S&Sxs
Give IV fluids/volume expanders
Give O2 @ 6 liters/min.
Assess blood loss and monitor urine output
Monitor VS's closely
No Trendelenburg
Provide support
Explain exhaustion:
Teach self-care:
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2. Focus assessment following delivery
a. VS's (air and prevent hazards)
Factors that can effect VSs:
* Anemia:
* C-delivery:
* MSO4 epidural:
* Patient controlled analgesia (PCA):
b. "BUBBLE-HE" (promote normalcy and prevent hazards)
* Breasts: Soft & non-tender first 2-3 days
* Uterus: Firmness and location
* Bowel: Bowel sluggish
* Bladder: Check distention & S&Sxs UTIs
* Lochia: Observe while massaging fundus
* Episiotomy (REEDA)
* Homan's sign: Prone to blood clots
* Emotional status: Bonding, support, rest/sleep,
c. Nutritional needs (food and fluids)
* Intake prior to, during and following delivery:
* IV therapy status: Insure proper infusion
d. Elimination needs
* Last void - output adequacy
* Resumption of usual bowel status: Many afraid of 1st BM.
e. Rest and sleep needs (activity and rest)
* Length of labor
* Treatments for common sources of discomfort
gas pains
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* Cultural differences related to activity/rest postpartum
f. Emotional needs (solitude and social interaction)
* Bonding opportunities
* Social support during labor and delivery
* Time to rest (organize care)
B. Planning (Nursing diagnosis and mutual goals to achieve)
1. Verbalize, understand and demonstrate self-care
2. Understand and report any deviations from normal
3. Utilize resources and referrals as needed
C. Implementation
1. Teaching self-care measures and what to expect
a. Normal involutional changes to expect & when to notify provider
b. Breast care:
Bottle feeding
c. Bowel care: Increase fruits, veg., fiber, fluids, exercise.
d. Bladder care: Void q 2 hrs, increase fluids to 2000 cc's/day
e. Perineal care: Good peri-care
f. Exercise, activity and hygiene: Fatigue #1 complaint PP
Abd. strengthening exercises
Exercise after bleeding stops
Kegels exercise good to tone
Continue to use peri-bottle and good peri-care till bleeding stops
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g. Resumption of sexual activity:
h. Contraception: Previous experience with methods, what will work best for
couple, motivation, use, knowledge, and skills, & method of feeding a
i. Nutrition: No dieting. Eat healthy foods, Vit. C and protein healing.
j. Medications: Review how to take, side effects, why important
Recommendations if breastfeeding
k. Time for self: Important to help cope with emotional demands of parenthood.
l. Signs and symptoms to report:


Foul smelling vaginal


Pain: Breast
Head (Emotional)

Incisional separation
m. Follow-up (Medications and appointments)
If Mom Rh negative & indirect Coombs negative
Baby Rh positive & direct Coombs negative
Draw type and screen on mom
Give to mom within 72 hrs.after delivery
Klienhauer-Betke test done if large maternal/fetal exchange
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Rubella: If non-immune
Obtain verbal consent
Check allergies
Teach side effects
May need another Rubella if RhoGAM given at the same time
Follow-up appointments:
2. Exploring resources available:
a. Support system and coping resources:
Who is there to help?
Are roles delineated to stress?
Coping skills for adapting to parenthood
Realistic perceptions, stress management, equilibrium.
b. Referrals: Social service, public health, stress or help lines
Parents as Teachers:
Parent Stress Help line
Parentlink: 1-800-552-8522
Parents of Twins Club
Parents Experiencing Perinatal Loss (PEPL)
LaLeche League
III. Early discharge: Advantages & disadvantages
A. Criteria: Mother and baby without complications
B. Nursing care: Insure understanding of S-C & when and who to call if problems
1. Follow-up care calls: 24 hrs. after discharge by nurse esp. for 1st time moms
2. Follow-up home visits: If discharged before 12-24 hrs.
Critical paths: are expected care at expected times with expected outcomes.
Case management: handle all needed referrals and looks at total needs of
mother, family unit from beginning to end of contact.
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IV. Nursing care following cesarean birth: Assessment, Plan & Intervention
Assessment Care
1. Air:
Risk factors
General anesthesia
Epidural narcotics
Assess breath sounds
Encourage not to smoke!
Check resp. rate q 1 hr. x 24 hrs. if narcotic epidural.
2. Food & fluids
Assess bowel sounds
Assess abd. distention
Assess when passing flatus
Assess diet toleration
Monitor IV's & I&O
Encourage ambulation/leg exercises
Progress diet as ordered/tolerated
Avoid drinking out of straws, carbonated beverages.
Record amt. eaten.
3. Elimination
Assess foley, bleeding Monitor I&O
4. Activity & rest
Assess discomfort & fatigue
Assess PCA
Measure pain on scale of 1-
10, record, intervene &
Encourage PRN's for pain
Notify if SE's puritis, or vomiting.
Encourage gradual ambulation with assist
Give oral hygiene, back, foot rubs, clean linens, peri/foley care,
teach splint incision, teach huffing technique.
5. Prevention of hazards
Monitor for hemorrhage,
infection, & injury
Monitor IV, PCA precautions
Position baby to prevent hazards (falling).
Encourage ambulation with assist till stable
6. Solitude & social
Assess bonding & family
Organize care
Assist with bonding.
Provide comfort (football hold, use pillows).
Assist with balancing time with baby, family, to rest.
7. Normalcy
Assess adaptation to
changes, exercise/sex...
Normal to have disappointment about C/S.
Allow to ventilate feelings.
Provide reassurance & support.
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Group Activities
Case Study
Nita is a 27-year-old white female,
gravida iii, para iii, who delivered twin boys
4 hours ago. Twin A weighed 6 pounds and
Twin B weighed 5 pounds 6 ounces. Nita is
being admitted to the postpartum unit
following an uneventful recovery. On the
initial assessment, you collect the following
data: pulse 60, respiration 20, blood
pressure 110/70, fundus slightly soft and
located to the right of the umbilicus, lochia
moderate, episiotomy intact with slight
1. What is your interpretation of these
2. What is your first intervention?
3. What are Nita's immediate teaching
Nita is going to breastfeed her twins.
She successfully breastfed her other two
children. She tells you, "I want to
breastfeed, but when I do, I really have a lot
of cramping."
4. What is the best response for the nurse
to make?
5. What are the factors involved in the
cramping that Nita is experiencing?
6. How can the nurse intervene to correct
this problem?
Copyright 1994 by W. B. Saunders Company. All rights reserved.
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Nita tells you that she has been
constipated during the last few months of her
7. How should you assess Nita for this
8. What interventions may help correct or
prevent constipation?
As you routinely check Nita's vital
signs, you note a pulse rate of 52.
9. Does this indicate a problem in Nita's
involutional process?
10. Explain the physiology behind the
bardycardia you have observed.
Nita is two days postpartum. Her
fundus is firm at -1.
11. Since the fundus is expected to
descend one fingerbreadth per day,
why is Nita's fundus not at -2?
12. On the third day postpartum, what
changes should be expected in the
lochial flow?
As you assess Nita's episiotomy, you
note a slight redness along the suture line,
close approximation of the edges of the
episiotomy, and no edema or drainage.
13. Would you consider that the
episiotomy is healing normally?
14. What data support this conclusion?
15. What does the slight redness along the
episiotomy indicate?
Copyright 1994 by W. B. Saunders Company. All rights reserved.
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Nursing Care During the Postpartum Period
1. True/False: Circle T if true of F if false for each of the following statements. Correct
the false statements.
T F 1. If a postpartum woman receives both Rh immune globulin and a rubella
vaccine, the effectiveness of the rubella vaccine may be reduced.
T F 2. Severe hypotension is a major side effect following administration of
methergine or ergotrate maleate.
T F 3. The most dangerous potential complication of the fourth stage of labor is
T F 4. Ice packs are most effective in reducing perineal edema formation during the
first 2 hours following birth.
T F 5. Rubella vaccine should not be given to a woman who is breastfeeding.
T F 6. In order to receive RhoGAM, a postpartum woman should be Rh negative,
antibody (Coombs) negative, and have given birth to an Rh positive infant.
2. Matching: Match the description in Column I with the appropriate drug from Column II
Column I Column II
___ 1. IV infusion of 10 to 40 U after birth to A. Methylergonovine (Methergine)
stimulate phasic uterine contractions.
B. Oxytocin (Pitocin, Syntocinon)
___ 2. Witch hazel pads soothing to
episiotomies and hemorrhoids. C. Carboprost (Prostin/M15)
___ 3. Administered intramuscularly to Rh D. RhoGAM
negative women to suppress the
formation of Rh positive antibodies. E. Tucks
___ 4. Oral administration of 0.2 mg every
6 hours during the postpartum period to
stimulate rapid, sustained contraction of
the uterus.
___ 5. IM injection of 250 g to effect rapid
sustained contractions of the uterus within
minutes. It can also be injected directly
into the myometrium.
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3. Critical Thinking Exercises:
1. When caring for a woman during the fourth stage of labor, the nurse notes an excessive
rubra flow.
A. State the criteria the nurse should have used to evaluate the flow as rubra and
B. Identify the nurses priority action in response to the assessment finding.
C. Describe the nurses legal responsibility in this clinical situation.
2. Anita is a postpartum woman awaiting discharge. Since her rubella titre indicates that
she is not immune, a rubella vaccination has been ordered before discharge. State what
you would tell Anita regarding this vaccination.
3. The physician has written the following order for a postpartum woman. Administer
RhoGAM (Rh immune globulin) if indicated. Describe the actions the nurse should
take in fulfilling this order.
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Postpartum Psychosocial Adaptations
I. Process of parental-role taking:
Develops over time
Requires change in family structure, function and roles
Need anticipatory guidance and support.
A. Acquaintance - getting to know. "Fall in love"
B. Bonding - unidirectional
- initial attachment, parent to child,
- sensitive period is quiet alert state after birth.
- gaze, awake, suck reflex @ peak.
C. Attachment - bidirectional
- Maternal touch progresses from finger tip to palm to enfolding.
- Verbal high pitched voice.
II. What factors affect adaptation to parenthood?
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III. Developmental self-care requisite
A. Adaptation to parenthood (progression of maturational process)
(normative vs major crisis)
B. Acceptance of outcome through effective coping mechanisms
(situational prevention of deleterious effects)
Able to mobilize coping mechanisms to cope with outcome.
What are some ways people cope with crisis or changes?

Teach family to use internal capabilities and external resources to: Express their
feelings, develop effective coping, and reach resolution of the crisis.
IV. Nurses role in promote transition to parenthood
A. Encourage early and frequent parent-infant contact
B. Assess/facilitate bonding behaviors
1. Maternal behaviors
a. Rubin's phases:
* Taking-in:
* Taking-hold:
* Letting-go:
b. Understand the normal bonding progression & watch for deviations
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2. Paternal behaviors: Usually parallels maternal adjustment
Factors that influence adaptation
3. Sibling behaviors: Factors that influence adaptation
Recommendations to facilitate successful adjustment
C. Involve family in infant care
D. Provide anticipatory guidance
1. Realistic expectations: What is the "end of the rope" syndrome?
2. Set priorities: Let housework go. Have simple meals.
3. Keep lines of communication open: Talk with partner about feelings

4. Reorganize roles and responsibilities: Talk to each other and negotiate roles
5. Use support and resources:
6. Support sibling adaptation:.
7. Provide resource phone #'s and information
* Parentlink phone #: 1-800-552-8522
* Parents as teachers #: See local school system in phone book
* WIC, Medicaid, La Leche league, Parents of twins club, Parents experiencing
perinatal loss (PEPL)...
E. Identify families in need of follow-up:
1. Adolescent, single parent, little support
2. Social situation or financial problems
3. Inadequate bonding behaviors
4. Inability to meet infant's needs
5. Postpartum depression
6. History of current drug abuse or child abuse or neglect
E. Implement referrals as needed
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Causes Wound Endometritis Urinary tract
-manual removal
of placenta
-prolonged L&D
-freq. SVE's
-freq. caths.
-freq. SVE's
-birth trauma
-prolonged 2nd
Signs & symptoms *fever (low grade)
sudden onset
*localized pain
*fever (saw-tooth)
*large boggy tender
*foul smelling
*dark brown or
profuse lochia
*fever (low grade)
*lower back pain
Treatment Oral antibiotics
Removal of stitches
Sitz bath
IV antibiotics
Urine C&S
Fluids (3000cc/d)
Vitamin C
Sulfa drugs
Self-care measures:
1. Importance of monitoring S&Sx's of infection.
2. fluids
3. Monitoring lochia and uterine changes and reporting deviations from nl.
4. Proper peri-care with frequent hand washing
5. Good nutrition vitamin C and protein
6. Taking antibiotics, oxytocics, analgesics as prescribed
7. Proper positioning to promote drainage of lochia by ambulation, Semi-fowler's
8. Balance activity/rest and solitude/social interactions to meet rest needs
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Causes Mastitis (Breast infection)
Usually 1st time breastfeeding moms and usually only affects 1 breast
-Plugged duct
-Cracked nipples
-Unclean hands
-Fatigue & stress
Signs &
*Heat - fever
*Erythemic - red, hot, hard area on breast
*Ache - flu-like sx's
*Tender - localized pain
Treatment Heat to area
Empty breast frequently
Time to rest & Tylenol prn
Proper breast/nipple care & positioning
Good handwashing
Freq. feeding & position changes
Increase fluids
Get help at home
Complete antibiotics
If not better after 12-24 hrs call HC provider
Is stop nursing, may lead to abscess
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Thromboembolic Disease Differences
Causes Superficial
3-4th day pp
Deep Vein
takes 4-6 wks.to resolve
complication of DVT
Signs &
-pain with walking
-may palpate enlarged
hardened vein
-sudden severe leg pain
-stiffness of affected
-pain on ambulation
-paleness ("milk leg")
-increase temp. &
-chills & malaise
-+ Homen's sign
- periferal pulses
-chest pain
-increase resp. rate
-increase pulse
-rales & friction rub
-air hungar sx's.
Treatment Activity restriction
-leg elevation
Apply moist heat
After 5-7 days BR &
sx's disappear
gradually ambulate,
avid venous stasis, and
wear support hose
No anticoagulants
needed usually
Activity restriction
-leg elevation
Apply moist heat
Anticoagulants to
make PTT 1 1/2 - 2x's
Antibiotics to prevent or
control infection
Elastic support after acute
inflammation subsides
No ASA or Tylenol while
on anticoagulant
Have Protamine Sulfate
Raise head of bed
Support, calm, stay with
Notify Dr. STAT!
Give O2
Do chest X-ray
Keep warm
Give pain meds.
To Intensive Care
Required immediate
Heparin treatment for
Embolectomy if no time to
allow clot to dissolve
Self-Care Teach: Prevent
venous stasis
Do not message
affected extremity
Postpone dental apts.

Use soft toothbrush
Teach: Prevent venous
Do not message affected

Teach: Prevent venous
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Diagnosis Blues Depression Psychosis
Incidence 75-80% 3-30% .1% (1/1000)
Signs &
-transitory blues
-mood swings
-general fatigue
-loss of appetite
-low self-esteem
with or
manic episodes
Treatment Anticipatory
Reassurance &
Reassurance &
Support group referral
Suicide precautions
Key Points to Postpartum Complications:
1. Recognize predisposing risk factors.
2. Identify signs and symptoms of postpartum complications early.
3. Describe/teach preventative self-care measures.
4. Treat causes of these complications early.
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Student Activities To test your familiarity with the information complete the
following activities.
Clinical simulations 1. When evaluating Felice Fouillard two days after cesarean
delivery, the nurse measures a temperature over 100.4EF
on two occasions. The next morning, Ms. Fouillard has a
temperature of 100.8EF, pulse rate of 102 beats/minute,
respiratory rate of 24 beats/minute, and blood pressure of
110/68 mg Hg. Ms. Fouillard complains of chills and a
headache. Her fundus is tender on palpation; her lochia
has increased in flow and taken on a slightly foul odor.
The nurse should suspect what condition is the cause of
Ms. Fouillard's signs and symptoms? Explain your answer.
2. Reviewing Ms. Fouillard's antepartal and intrapartal
records, the nurse notes that during pregnancy she was
treated for anemia and gained only 15 lbs because of her
poor dietary intake. Her amniotic sac ruptured at least 36-
hours before her admission to the labor and delivery area.
Her laboraugmented with oxytocin to expedite
deliverylasted 18-hours. Internal fetal monitoring was
used and numerous vaginal examinations were performed
because of her slow labor progress. Eventually, cesarean
delivery was performed because of the apparent fetal
position and lack of cervical dilation. Explain why the
review of Ms. Fouillard's medical records strengthens the
nurse's initial suspicion about the cause of her signs and
symptoms. Identify the antepartal and intrapartal risk
factors on which the nurse would base this suspicion.
3. After notifying the physician of Ms. Fouillard's clinical
findings, the nurse should expect the physician to order
which laboratory studies?
4. The nurse should implement which measures for Ms.
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5. Madeleine Johnson, a 41-year-old gravida 4, para 4004
client, delivered a neonate yesterday morning. Despite her
anemia and obesity, she had an uneventful labor and
delivery. However, on arising this morning, she complains
of pain and stiffness in her right calf, directly over the site
of a previous episode of phlebitis. Palpating a blood vessel
in the calf where the pain is centered, the nurse finds the
vessel hard, cordlike, sensitive to pressure, erythematous,
and warm. Ms. Johnson also has a low-grade fever. The
physician arrives to evaluate Ms. Johnson further and
diagnoses superficial thrombophlebitis. Identify five
factors in Ms. Johnson's history that increased her risk for
this condition.
6. Which potentially life-threatening disorder might have
developed had Ms. Johnson's condition gone undetected?
To prevent this disorder, the nurse should implement which
7. Three weeks after delivery, Janis Nathan, a breast-feeding
client, visits the physician's office to seek treatment for a
cracked nipple and a warm, sore, reddened area in her left
breast. Her temperature measures 99.6EF. After
diagnosing mastitis, the physician prescribes a full course
of antibiotics and bed rest. Describe the topics the nurse
should include when teaching Ms. Nathan about her
8. Eight hours after her precipitous labor and delivery of a 9-
pound son, Iris Greer, a primiparous client, calls the nurse
to her room to report heavy vaginal bleeding. The nurse
assesses profuse, bright red vaginal Bleeding, a thready
pulse of 112 beats/minute, and a blood pressure of 90/50
mm Hg. Noting that Ms. Greer appears diaphoretic and
pale and cannot sit up, the nurse suspects delayed
postpartal hemorrhage. However, because her fundus is
firm, well contracted, and located at the midline, the nurse
rules out uterine atony as a possible cause. List other
possible causes of postpartal hemorrhage that the nurse
should consider.
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N160 Nursing of Women and Newborns
Normal Newborn: Adaptation, Assessment and Care
1. Explain the physiological changes that occur in the cardiovascular and respiratory systems
during transition from fetal to neonatal life.
2. Describe thermoregulation in the newborn.
3. Identify newborn reflexes and sensory ability.
4. Describe common variations of the musculoskeletal system.
5. Compare gastrointestinal functioning in the newborn and adult.
6. Explain the causes, effects and treatment of hypoglycemia, physiological and pathological
7. Describe kidney functioning in the newborn.
8. Discuss the potential benefits, risks, and methods of circumcision.
9. Explain the functioning of the newborn's immune system.
10. Describe the periods of reactivity and the six behavior states of the newborn.
11. Describe the assessments that the nurse makes during the initial and ongoing care of the
12. Explain the nurse's responsibility in cardiorespiratory and thermoregulatory assessment and
13. Describe nursing assessments and interventions regarding feeding and urine and stool
14. Explain the information new parents need about infant care in preparation for discharge.
15. Describe methods of protecting newborns from infection and kidnaping.
16. Explain the purpose, procedure and tools used in gestational age assessment.
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Normal Newborn: Adaptation to Extrauterine Life
Key Points
* Major physiological and behavioral adaptations occur during first 28 days.
* The changes made during the first 24 hours are critical to survival.
* Nurses need to understand normal adaptation and recognize deviations!
I. Initiation of respirations
A. Surfactant development:
1. Begins production approx. 24-26 wks.
2. Lecithin/sphingomyelin (L/S) ratio of 2:1 indicates:
Fetus has reached approximately 35-36 wks.
Less susceptible to respiratory distress syndrome (RDS)
3. Phosphatidylglycerol (PG) is a major phospholipid of surfactant:
Present when fetus is approx. 36 wks. gestation
Less susceptible to (RDS).
B. Initiation of respiration:
1. Chemical:
2. Sensory:
3. Thermal:
4. Mechanical:
II. Cardiovascular adaptation
A. Transition from fetal to neonatal circulation
1. Changes after birth:
a. foramen ovale:
Takes several months to close permanently
b. ductus arteriosus:
Permanent closure: 3-4 wks. Prematurity, asphyxia, hypoxia may result in
Patent Ductus Arteriosus (PDA).
c. ductus venosus:
Fibrosis of DV occurs by end of 1st wk.
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B. Normal vital signs: Know these!
1. Heart rate:
2. Respiratory rate:
3. Blood pressure:
4. Temperature:
III. Thermoregulation adaptation: Narrow thermal neutral zone.
A. Differences between newborn and adult heat regulation
1. surface area:
2. evaporative heat loss:
3. ability to shiver and generate heat.
4. Non-shivering thermogenesis (NST)
a. Primary method of heat production in newborn:
stimulate brown fat to metabolism and produce heat.
Uses oxygen and glucose to produce heat
b. Brown adipose tissue (BAT):
located in chest, spine, and perineal areas
c. Effects of heat/cold stress on the newborn:
Depletes brown fat
O2 and glucose used. Don't sweat well when hot
Makes RDS worst and Hyaline Membrane Disease (HMD)
Can lead to kernicterus
B. Heat-loss mechanisms:
1. Convection:
2. Radiation:
3. Evaporation:
4. Conduction:
IV. Hematologic adaptation
A. Factors affecting Hematocrit results?
1. Cord clamping
2. Central vs heal sampling
B. Blood values
1. Hematocrit: 41-63%
2. Hemoglobin:
Fetal hemoglobin: Composes 90-95% of NB hemoglobin (carries O2 easier)
Shorter life span.
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3. Blood sugar:40-93 mg/dL
4. Leukocytes: Leukocytosis normal.
5. Iron stores:
V. Renal adaptations
A. Voiding: Usually 1st by 12-24 hrs. after birth.
No void by 48 hrs. report to provider
6-10/day pale straw color first 2 days

B. Inability to concentrate urine:
Urate crystals give rise to pink colored urine.
Minimal range of chemical balance and safety.
C. Limited ability to excrete drugs:
VI. Gastrointestinal adaptations
A. Bowel sounds: Heard 1 hr. after birth.
B. Vitamin K, AquaMEPHYTON: 0.1 mg. IM or 0.2 mg. po
Given prophylactically to newborns
What is need to synthesize Vit. K that the newborn doesnt have at birth?
Where do you give an I M injection in the newborn?

C. Normal stomach capacity:
D. Why is regurgitation normal in the newborn?
E. Normal stools:
1. Meconium: Black, green, viscous, tarry stool
2. Transitional: thin slimly brown to green passed 3rd-6th day.
3. Breast: loose golden yellow non-offensive.
4. Bottle: soft, pale yellow - odor and irritation to skin.
VII. Hepatic system:
A. Blood glucose maintenance:
1. Brain requires large amt. of glucose.
2. risk of blood sugar: stress - asphyxia and cold stress
3. Signs and symptoms of hypoglycemia:
a. jitteriness,
b. poor muscle tone,
c. resp. distress, RR, apnea, cyanosis
d. poor suck,
e. CNS sx's, high pitched cry, lethargy, seizures, coma
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B. Conjugation of bilirubin:
1. Types of jaundice
a. Physiologic:
b. Pathologic:
c. Breast milk jaundice:
2. Factors that the risk of jaundice:
a. Trauma
b. Delayed feeding
c. Physiological destruction of RBCs
d. Pathologic destruction of RBCs
3. Bilirubin excretion:
C. Iron storage:
D. Metabolism of durgs:
VIII. Immunological adaptation
A. Increased risk of infections:
B. Passive immunity & breastfeeding help protect newborn
XI. Integumentary system: Know these!
A. Normal newborn findings
1. Acrocyanosis: Vasomotor instability
2. Caput succedaneum: Local edema of scalp due to sustained pressure on
presenting part that appears at birth.
Crosses the suture line and resolves few days after birth.
3. Cephalhematoma: appears 1-2 days after delivery.
Can be underlying skull fx's, intercrainal bleed.
Blood between skull and periosteum.
Does not cross suture line and resolves 6 wks. after birth.
Can result in jaundice.
4. Milia: obstructed sebaceous cysts
5. Mongolian spot: Darker pigmentation on non white infants fades over months
to years
6. Vernix caseosa: Cheesy protective coating. Effective skin barrier to bacteria.
7. Erythema toxicum: Benign maculopapular rash with an erythematous base and a
pale yellow papule. Resolves in 2-3 days.
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X. Reproductive system
A. Female
1. Hymenal tag: Small piece of tissue from vaginal opening disappears in a few wks.
2. Pseudomenstruation: Small amt. of vaginal bleeding due to maternal hormones.
3. Smegma: White mucous vaginal discharge normal in newborn.
B. Male
1. Testes descended: to scrotal sac @ 36 wks.
2. Rugae: with gest. age.
3. Urethral position
a. epispadias:
b. hypospadias:
XI. Behavioral adaptation
A. Periods of reactivity: Changes during early hrs. after birth.
1. First period of reactivity:
2. Period of sleep/inactivity:
3. Second period of reactivity:

B. Reflexes: Assessing CNS intactness and any limitations in movement
Look for equal response bilaterally
C. Sleep/wake states
1. _______________: Quiet sleep, reg. resp., not easily disturbed with stimuli.
2. _______________: Moves extremities at times, REM present, irregular.
respiration, startle to noise.
3. _______________: Between sleep and awake. Open or closed eyes. Startle
and move extremities slowly, May go back to sleep or awake with stimulation.
4. _______________: Bright, interested, minimal body movements, focus on
objects and people. Great bonding time.
5. _______________: Restless, resp. faster and irregular, aware of feelings of
discomfort, less able to focus on stimuli.
6. _____________: Continuous and lusty, eyes closed, irregular respirations
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D. Sensory behavior
1. Vision: Can see 7-8 inches away.
Will track and follow human eyes.
< 5 days old like black and white patterns.
Darken room and hold upright helps open NBs eyes.
2. Hearing: Can hear immediately after birth. At 1 min. can turn to sound.
3. Smell: Can smell and turn to breast milk.
4. Touch: Lips very sensitive. Infant message very effective in relaxing baby.
5. Taste: Likes sweet taste.
E. Factors influencing newborn's behavior
1. Gestational age: CNS maturity will affect observed behavior
2. Medication: Effects of maternal analgesia/anesthesia on NB behavior can depress
3. Stimuli: Maternal anxiety baby senses can HR and RR, NICU stimuli
4. Time: Recuperate after L&D or time since last feeding.
5. Culture: Differences can be noted.
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N160 Nursing of Women and Newborns
Assessment of the Newborn
Group Activities
1. Neonatal nurses are responsible for the assessment of a newborn's physiologic integrity. As part of
this responsibility the nurse must be aware of the significance of data that are collected. Label
each of the following assessment findings, if present in a 12-hour-old full-term male neonate, as
"N" (reflective of normal adaptation to extrauterine life) or "P" (reflective of potential problems
with adaptation to extrauterine life).
Assessment findings: Evaluation:
a. Crackles on auscultation of the lungs. _________
b. Respirations: 36, irregular, shallow. _________
c. Episodic apnea lasting five to ten seconds. _________
d. Slight bluish discoloration of feet. _________
e. Jaundice on face and chest. _________
f. Regurgitation after 8:00 a.m. feeding. _________
g. Nasal flaring and slight sternal retraction. _________
h. Head 34 cm and chest 36 cm. _________
I. Apical rate: 126 with sinus arrhythmia. _________
j. Overlapping of parietal bones. _________
k. Hematocrit 36% and hemoglobin 12 g. _________
l. Liver palpated 1 cm below right costal margin. _________
m. Spine straight with dimple at base. _________
n. Slightly depressed anterior fontanelle. _________
o. Adhesion of prepuce -- unable to fully retract. _________
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2. Respiration, circulation, and heat regulation are the three factors most crucial to the newborn's
extrauterine existence. Describe the interrelationship of these survival factors.
Respiration Circulation Thermogenesis
Fill in the blanks:
1. Variations in state of consciousness of newborn infants are called the __________-__________
wake cycles. There are __________ sleep states and __________ wake states. The optimum state of
arousal is the __________ __________ state, in which the infant can be observed smiling,
vocalizing, and moving in synchrony.
I dentify and prioritize the problems in each situation. Explain what influenced these problems and list
specific nursing interventions for each.
1. Baby Jane is a term female infant who was transferred to WBN two hours ago immediately following
a deliver. During transfer report you were told that Mom weighed 250 pounds and that the labor was
lengthy with a forceps delivery. Upon presenting to the nursery, the baby Jane was somewhat
lethargic but cried with stimulation. Apgars at birth were 5/9. Acrocyanosis was present with
notable molding. Lungs were scattered rales.
Weight: 9 lbs 0 oz. Length: 19 inches T: 36.0 R: 58 P: 160
1 hour D-stick was 32 HCT 50
2. Baby Clark is a term 12-hour male infant who was delivered vaginally to a 25-year-old G3 P3 A0.
Delivery was without complications. Over the last 12-hours, the baby has become slightly lethargic
and is a poor eater. His skin appears to be yellow in color. Baby's blood type is AB+ and mother's
is O+. Baby's blood work also indicated a positive Coombs.
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Normal Newborn: Assessment and Care
Goals of nursing care:
1. Implement measures to prevent problems, identify problems early and treat
2. Keep infant safe
3. Teach parents how to provide care.
The ABCs of Newborn Care after Delivery:
I. Early assessments and care
A. Establish and maintain an airway (air):
1. Meconium stained fluid: Is it below cords?
2. C-delivery: What are the risks to the newborn?
3. Gestational age <35 wks.: Is surfactant sufficient?
B. Use universal precautions (hazards)
C. Prevent hypothermia (hazards)
D. APGAR score (normalcy): To assess initial transition
Criteria & Scoring 0 1 2
Heart rate
0 <100 >100
Resp. rate
0 slow, irr. good cry
Muscle tone
limp some flexion active motion
0 grimace cough
pale/blue acrocyanosis all pink
<4 = Severely
4-7 =
7-10=Healthy 1 min. =
5 min. =
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E. Perform brief "bird's eye" assessment: Assess normalcy
F. Promote maternal-infant-family bonding (solitude/social):
G. Promote food and fluids: Breastfeed if ready, willing, and able.
H. Assess excrements (elimination):
I. Assess activity/rest status: Unstable VS's first 30 mins.
J. Properly ID mother/baby/partner pair (hazards):
II. Assessment and care of newborn upon admission to NBN
A. Prevent hazards:
1. Prevent neonatal kidnapping or switching babies
2. Obtain report:
3. Implement universal precautions:
4. Prevent hypothermia:
B. Assess normalcy (perform congenital anomaly appraisal):
1. VS's: Check q 15 mins. x 4 or till stable and q 1 hr. x 4 then q 8 hrs.
2. Obtain measurements:
a. weight: 2500-4000 gms. SGA < 2500 gms. LGA > 4000 gms.
b. length: 48-53 cms. (19-21")
c. head circumference: 33-35 cms. (13-14")
d. chest circumference: 30-33 cms. (12-13")
d. abdominal circumference: 30-33 cms. (12-13")
3. Auscultate heart, lung and bowel sounds:
4. Assess respiratory status: Without distress, grunting, retractions.
Reg/irregular rate with apnea <15 secs. & no color change or heart rate es.
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5. Assess general appearance and gestational age:
General appearance:
- skin color: Normal vs abnormal.
Cyanosis with crying or exertion
- posture: well flexed vs extended
- maturity: preterm, term, postterm.
- activity: spontaneous and bilaterally equal
- over-all well-being: no distress

Assess gestational age
A. Tools
1. Dubowitz
2. Ballard: A shortened form of the Dubowitz.
B. Characteristics assessed
1. Physical characteristics
2. Neuromuscular characteristics
C. Purpose:
D. Obtain and interpret the results:
1. Small for gestational age (SGA):< 10 % on growth chart
2. Average for gestational age (AGA):10-90% on growth chart.
3. Large for gestational age (LGA):>90% on growth chart.
4. Factors that influence gestational age score
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6. Perform head to toe assessment
a. Assess head: Palpate and observe for tramua, rashes, . . .
fontanelles: Palpate with head elevated.
crying (bulging normal). Quiet with bulging (meningitis, hydrocephalus)
sutures: Wide (hydrocephalic) Fused (craniostenosis)
molding: Overlapping sutures
caput succedaneum: Edema over presenting part. Crosses suture line and
disappears approx. 24 hrs. after birth.
cephalhematoma: Appears 24-48 hrs. after birth and disappears approx.
3-6 wks. Firmer to touch, does not cross suture line, blood between bone
and periosteum. Increased risk of jaundice.
b. Assess eyes
check red-reflex. Prophylactic eye ointment (Erythromycin) given soon
after birth to prevent ophthalmic neonatorum, which is caused by
gonorrhea & conjunctival chlamydia.
check alignment: Upper pinna should be in line with upper pinna.
note discharge: Purulent (infection) or tearing (plugged lacrimal duct)
measure distance between: Should be < 3cms. apart. Wide spaced
(associated with Down's syndrome).
Until 6 months, pseudo strabismus present
PERRL: If not (CNS disorder).
Should be able to focus and follow during quiet alert state.
c. Assess ears
alignment with eyes: Upper pinna in line with outer canthus.
skin tags: or periauricular sinuses associated with kidney or other
chromosomal abnormalities or can be normal variation.
patency: after mucus cleared after birth can respond to sound and will
startle to sudden noise.
d. Assess nose:
patent/give Vitamin K: Pass NG tube or occlude one nares at a time
Bilateral occlusion, pink with crying. Unilateral, at risk for air blockage.
Choanal atresia, a bony membranous obstruction.
Aspirate stomach contents before giving Vit. K.
> 20ccs (possible GI obstruction).
Check color. Bright green (possible GI obstruction.)
malformation or drainage: CNS anomalies. Tracheal-esophageal (TE)
fistula, infection, snuffles (congenital syphilis), frequent sneezing (drug
withdrawal). Normal for newborn to sneeze.
Short and upturned nose (fetal alcohol syndrome or TE fistula).
nasal flaring early sign of respiratory distress and should be
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e. Assess mouth
lips, gums, hard and soft palates: Check for cleft lip and palate.
Epstein's pearls normal (white pearls occlusive cysts on gum line.)
White patches (candida albicans/thrush). Protruding tongue (Downs)
rooting, sucking, swallowing, gagging reflex:
Heavy drooling or constant bubbling of oral mucous (may indicate TE fistula)
Esophageal atresia will get projectile vomiting because no passageway to
f. Assess neck and clavicles
movement: Bilateral and equal and should turn easily side to side.
Congenital torticollis (deviation from midline).
Webbing present or short neck (Turner's syndrome)
masses/intact: Check for breaks and crepitus which can occur especially with
difficult deliveries of LGA babies.
g. Assess chest
U respiratory effort: Without retractions of sternum and/or intercostal
muscles, no grunting, nasal flaring, rhonchi.
point of maximal impulse: PMI 4th ICS ,LSB.
If deviated may have enlarged heart or transposition.
breast: Used in gestational age assessment. Witches milk and breast
engorgement normal due to maternal estrogens and usually resolves 2-3 days.
h. Assess abdomen
U 3 vessel cord/intact:
< 3 associated with cardiac/GU anomalies.
kidneys palpable: Easiest to feel right after delivery posteriorly.
drainage, discharge, bleeding from cord:
Clamp removed after dry
Cord care TID with alcohol X 7-10 days falls off and without discharge.
femoral pulses: Equal and strong bilat. Coarctation of aorta will have
difference in strength. Easiest to feel by flexing legs at groin.
distention/depression: Abdomen normally protuberant.
Concave (diaphragmatic hernia),
convex (distended). Check for abdominal mass.
i. Assess genitals
females: Hymenal tag, pseudomenstruation, mucus discharge present due to
maternal estrogens and normal. Will resolve few days.
males: Urinary meatus midline.
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j. Assess anus
patency: With NG tube. No meconium (? lower bowel obstruction.)
note stool: Usually 24 hrs. after birth.
k. Assess extremities
muscle tone: Strong normally. Weak (? prematurity, CNS injury,
neuromuscular disorder).
symmetrical movement: Brachial plexus injury from difficult delivery (Erb's
# digits: Extra or missing digits?
Simian crease: Associated with Down's syndrome.
tremors: ? Hypoglycemia, CNS injury, neuromuscular disorder, drug
withdrawal if blood sugar normal.
gluteal folds and Ortolani's maneuver: Done to detect congenital hip
dysplasia: an incomplete development of the acetabulum. Allows head of
femur to slip out of acetabulum and become dislocated.
Ortolani's maneuver: Check for jerk, clunk, click.
Allis's sign: knee on affected side higher when flexed with feet on
acrocyanosis: Normal due to poor/sluggish peripheral profusion and will
resolve in few days.
l. Assess back
straight spine: easily flexed.
pilonidal dimple: associated with spinal bifida. Fold of skin at
sacrococcygeal area. Check for sinus tract. May need to X-ray.
m. Assess reflexes bilaterally:
rooting, sucking, swallowing
grasping, palmer, planter
Moro, tonic neck
stepping, coughing and sneezing
n. Assess blood values
blood glucose:
If < 40 do pre and post prandial blood sugars X 3 or till stable (> 40 %).
C. Promote food and fluids
1. Test feed: to assess swallow and patency to stomach if bottle feeding.
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2. Assist/teach dependent care agent/s:
a. Teach how to handle choking infant
b. Teach how to use bulb syringe and to have nearby
3. Monitor toleration and adequacy:
a. Breastfeeding: every 1-3 hrs but not longer than 5 hrs. if possible.
Attend to sleep/wake cycle. Approx. 10 mins. each breast.
b. Bottle feeding: every 3-5 hrs. but not longer than 5 hrs. if possible.
Should take approx. 15-30 cc's formula. Attend to sleep/wake cycle.
D. Promote bonding (solitude and social interaction)
E. Promote balance between activity/rest
1. Monitor sleep/wake cycles:
2. Teach ways to intervene:
F. Evaluate elimination
1. Voiding:
2. Stooling:
III. Assessment of behavioral capabilities
A. Brazelton Neonatal Behavioral Assessment Scale:
1. Habituation: Response to repeated stimuli 12" away.
2. Orientation: To inanimate and animated visual and auditory assessment stimuli.
Ability to fix and follow objects, focus on face, turn to sound/voices.
3. Motor maturity: Overall assessment of body tone as the infant responds to all stimuli.
4. Variation: Frequency of alert states, state changes, color changes, activity, and peaks
of excitement are assessed throughout exam.
5. Self-consoling behavior: Assessment of how often, how quickly, and how
effectively newborns can use their resources to quiet and console themselves when
upset or distressed. Putting the hand to mouth, sucking on a fist or the tongue are
6. Social behavior: Encompasses the infant's need for and response to being held. Is
the infant cuddly, unresponsive, or irritable?
B. Value of the Brazelton assessment?
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V. Circumcision: The surgical removal of the foreskin of the penis.
Key Point: Current recommendations by AAP is that circumcision has potential medical
benefits and advantages as well as disadvantages and risks. It also states that
it is a generally safe procedure when performed by experienced practitioners on
stable, healthy infants. The decision lies with informed parents.
A. Advantages/disadvantages:
1. To prevent phimosis - stenosis of the preputial ring that results in the inability to
reveal the glans by retracting the foreskin.
2. Prevention of penile cancer
3. Decrease cervical cancer in female
4. Decrease incidence of UTI's in circumcised males.
5. Decrease incidence of STDs in circumcised males.
B. Contraindications: Should be delayed in:
1. sick, unstable, or preterm infants
2. if a family Hx of bleeding disorder is known
3. hypospadias or epispadias
C. Risks: .2-.6% rate of complications with bleeding and local infection most common
1. Hemorrhage
2. Infection
3. Mutilation (too much or too little removed)
D. Types
1. Gomco: Use a cone that is eased between the foreskin and the glans. After foreskin
removed, the clamp and cone are removed and the glans is left exposed.
2. Plastibell: Or plastic bell is placed over the glans with suture tied around the skin
covered rim of the bell. The pressure of the bell acts to prevent hemorrhage and
infection and after 1 wk, the bell falls off.
E. Pain Medication: Controversy about pain medication prior to this procedure.
1. topical cream Emla (Lidocaine 30% cream) 30-60 mins. prior to procedure,
2. sucking on pacifier coated with sugar water during procedure
3. dorsal penile nerve block using 1% Lidocaine without epinephrine
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F. Nursing responsibilities:
III. Preparation for discharge: What should you teach parents about NB care?
A. Maintenance of airway
1. Bulb syringe:
2. Positioning:
a. To promote gastric emptying
b. To prevent Sudden Infant Death Syndrome (SIDS)?
Campaign by American Academy of Pediatrics:
"Putting the infants Back to sleep".
B. Promotion of food and fluids:
C. Monitor elimination: To assess adequacy of feeds
D. Prevent hazards
1. Car safety:
2. Cord and circumcision care: Should know and demonstrate proper care.
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3. Immunizations: Teach limited resistance to infection and need to restrict visitors for
at least 2 wks. and anyone with infections.
4. Other
a. Teach to monitor skin for jaundice and how to assess with blanching.
b. Teach how to take temp.
c. Teach to never prop bottle
d. Prevent hypothermia
e. Importance of proper hand washing
5. Follow-up care:
a. Approx. 2 wks. return to HCP for weight check, problems/concerns
b. Teach parents to call HCP anytime they think something is wrong with NB
6. Signs and symptoms to report: The ABCs of infant dis-ease
a. Apnea > 15 secs.
b. Behavior change change (lethargy, irritable)
c. Color change (jaundice, cyanotic)
d. Diarrhea x 2
e. Emesis x 2 or refusal of feeding
f. Foul smelling discharge form umbilicus or bleeding
g. Grunting or difficulty breathing
h. Hyperthermia or hypothermia
i. Inadequate voiding
j. Jitteriness
7. Avoidance of second-hand smoke
E. Promote solitude/social interaction
1. Teach infant abilities and characteristics (Brazelton)
a. Encourage rooming-in to learn infant care/behavior
b. Inform of habituation and self-consoling mechanisms baby has and NB senses
F. Promote balance between activity and rest: Sleep/wake cycles and how to intervene
G. Promote normalcy
1. Bathing: After temp. stable sponge bath sufficient until cord falls off and healed
2. Handling and swaddling: Support head
3. Dressing: Needs one layer more than you
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H. Promote and support developmental self-care
1. Growth and development needs:
a. Erickson's trust vs mistrust
b. Recommend Parents as Teachers and other resources for support and education
2. Discuss measures to promote sibling/family adaptations:
a. Provide anticipatory guidance about what to expect (regression...)
b. Encourage time for sibling
c. Recognize siblings feelings and needs for attention.
d. Encourage verbalization of feelings
e. Encourage and support sibling visitation
IV. Newborn screening tests: To detect inborn errors of metabolism
(Hereditary disorders transmitted by mutant gene).
Most transmitted by autosomal recessive gene
State required tests to screen all newborns.
If not detected & treated, leads to mental retardation due to build-up of toxic metabolites
A. Phenylketonuria: Incidence: 1:12,000
1. Can't metabolize amino acids phenylalanine which is in protein foods such as milk.
2. Done on day of discharge after milk ingestion but preliminary results may be accurate
even if fed poorly.
3. Done 24 hrs. after 1st protein feed but preferably 72 hrs.
4. Some states recommend repeating test 10-14 days to make sure catch problems.
B. Hypothyroidism: Incidence: 1:4,000
1. Thyroxine needed for G&D is not sufficient
C. Galactosemia:
1. Absence of enzyme needed to convert milk sugar galactose to glucose.
2. Rx. is to eliminate milk from diet.
D. Sickle cell and others done if indicated.
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Answer the following questions:
A newborn lab results are the following: Hct, 68%, heelstick glucose <45%, and a bilirubin of 15 mg/dl.
What are the significance of these and what nursing interventions would you do?
While working in the nursery, you notice a baby, 5 hrs. old, has turned blue. He has a large amount
of frothy mucus in his mouth. What immediate nursing interventions would you perform?
How would you respond to the following questions?
Why are there tiny white spots across the bridge of her nose and on her chin?
Why does his head look funny? The bones of his head cross over each other and look so narrow on
the sides?
Are her feet clubbed? They turn in?
Why are my babys hands and feet so blue and cold?
When I changed my babys diaper, there was blood on it.
Why are my sons breasts so swollen. Will the swelling go down?
What other questions have you been asked and how have you responded to them?
AH:ld Rev. 5/97, 10/98, 12/98
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N160 Nursing of Women and Newborns
Newborn Adaptations and Care
Group Activities
1. Apgar scoring evaluation practice
(indicate the score for the following
Apgar scoring evaluation practice:
a. Appearance - acrocyanosis
b. Pulse - above 100
c. Grimace - cry response
d. Activity - vigorous movement
e. Respirations - good cry
TOTAL SCORE _________
a. appearance - acrocyanosis
b. pulse - below 100
c. grimace - frown
d. activity - minimal
e. respirations - slow and irregular
TOTAL SCORE _________
a. appearance - pale
b. pulse - below 100
c. grimace - no response
d. activity - flaccid
e. respirations - slow irregular
TOTAL SCORE _________
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True or False: Check the answer; correct the false statements.
1. According to the principles of universal True
precautions, the nurse should wear False
gloves, gown, and mask when assessing
a full-term newborn during the
immediate postbirth period.
2. For the first 12-hours after birth, a True
newborn's temperature should be taken False
3. CPR guidelines for infants recommend True
cycles of five compresses and one False
ventilation (a 5:1 ratio), with the five
compressions completed at a rate of < 3
4. After a feeding, infants should be True
placed on their left-side to facilitate False
gastric emptying into the small
5. The recommended site for intramuscular True
injections in the newborn is the vastus False
lateralis muscle.
6. A major preventive measure for True
hyperbilirubinemia is early feeding False
of the newborn.
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Indicators for Infant Screening for Perinatal Substance Abuse
These guidelines have been developed for identification of those infants known to be at substantial
risk for exposure to drugs of abuse in utero. Identification of these infants will allow for more
appropriate medical care. Infants will have meconium drug of abuse analysis for the following
1) Parental history of previous or gestational illicit drug use.
2) Behavioral characteristics of illicit drug use by parents during prenatal care or during labor
(i.e., appearance of intoxication, confusion, inappropriate words or actions).
3) History of pregnancy denial, domestic violence, or previous child abuse or neglect.
4) Late or no prenatal care.
5) Out of hospital birth.
6) Failure to bond (i.e., reluctance to hold, feed, rough handling).
7) Neonatal malformations of injuries consistent with drug effects (i.e., features consistent with
Fetal Alcohol Syndrome, necrotizing enterocolitis or intracranial hemorrhage in the near term
or term infant, unexplained growth retardation or microcephaly).
8) Symptoms of neonatal abstinence syndrome (i.e., agitation, persistent unexplained tachypnea,
diarrhea, vomiting, excessive sneezing, excessive sedation).AH:ld
Psychosocial Risk Appraisal for Pregnant Women
Put an X in any box that applies. Please review all criteria as any patient with one of these conditions
could benefit from a Social Service referral.
( ) 1. History of drug/alcohol abuse.
( ) 2. History of child abuse/neglect.
( ) 3. History of physical abuse.
( ) 4. Rape victim.
Is pregnancy the result of a rape? ( )
( ) 5. History of psychiatric illness.
( ) 6. History of incarceration.
( ) 7. Considering relinquishment.
( ) 8. Serious medical complications.
( ) 9. Fetal complications with probable NICU admission.
( ) 10. Fetal demise.
( ) 11. Adjustment to pregnancy.
Referrals should be made to the appropriate social worker.
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N160 Nursing of Women and Newborns
Infant Feeding
1. Identify nutritional and fluid needs of the infant.
2. Compare the composition of breast milk with that of formula.
3. Explain important factors that influence choice of infant feeding.
4. Explain the physiology of lactation.
5. Identify nursing management of initial and continued breastfeeding.
6. Describe nursing assessments and interventions for common problems in breastfeeding.
7. Describe nursing assessments and interventions in formula feeding.
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Infant Feeding
I. Normal infant requirements
A. Normal growth patterns
1. Normal weight loss
2. Regains birth weight
3. Doubles birth weight
4. Triples birth weight
B. Calories
1. Full term needs
2. Breast milk and formula
C. Fluids
1. Breastfed
2. Bottlefed
D. Supplements
1. Breastfed
2. Bottlefed
E. Solids
1. Start ~ 4-6 months when extrusion reflex disappears and enzymes function.
2. Avoid cow's milk until 6-12 months because hard on digestive tract.
3. Use whole milk 1
2 years & avoid skim milk. Need fat for brain development
4. Avoid certain foods that could cause:
a. Airway obstruction: nuts, popcorn, hotdogs
b. Food allergies: egg whites, orange juice
c. Botulism: honey
II. Breast milk and formula composition
A. Breast milk
1. Colostrum
a. Secreted first 1-4 days after delivery then changes to transitional milk
b. Composition: High in protein, WBC's, antibodies (IgA)
Lower in calories and fat
c. Advantages: Fewer infections, incidence of allergies, laxative affect.
2. Mature milk: Changes from transitional to mature 2 weeks after delivery
a. Foremilk: a milk volume, low in protein & fat, thin blue white color
b. Hindmilk: b milk volume, fat content, thick creamy white color
B. Formulas: Many on the market.
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III. Consideration in choosing a feeding method
A.. Breastfeeding
1. Advantages Disadvantages
2. Common myths
a. Size of breasts
b. Insufficient milk concerns
3. Self-care agency
a. Knowledge
b. Motivation
c. Skills
d. Support
B. Formula feeding
C. Combination feeding
1. Start after 4-6 weeks if possible
2. Explain options:
1. Exclusive breastmilk (pumping when not with baby and saving milk)
2. Breastfeed when possible and supplement with formula when away.
When with baby exclusively breastfeed.
3. Breastfeed before and after work/school and continue this schedule.
D. Nurses role in promoting successful infant feeding
E. Baby Friendly Hospital Initiative
F. Cultural considerations related to infant feeding
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IV. Normal breastfeeding
A. Preparation for breastfeeding
1. Prenatal assessment
a. knowledge
b. nipple condition
* Hoffman's exercises:
* breast cups:
* nipple rolling when graspable:
2. Prenatal preparation
a. Controversy on whether it nipple tenderness or success.
b. Recommendations:
B. Hormonal changes
Key point: Important to understand A&P of breastfeeding to prevent and treat
common problems, questions and concerns!
1. Milk production: Prolactin (anterior pituitary)
2. Milk ejection: Oxytocin (posterior pituitary)
Need nipple stimulation and proper positioning
qNeed right intensity, duration, & frequency to cause adequate milk
production and let-down/milk-ejection.
C. Supply and demand
1. Normal infant growth spurts
2. Need to teach about growth spurts & what to do
D. Application of the nursing process
1. Assessment
a. Condition of breasts and nipples
b. Mom's self-care agency
c. Infant feeding behaviors
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2. Diagnosis, plan and implement care
a. Assist with first feed
Encourage breastfeeding immediately after birth (if able)
b. teach feeding techniques
* proper positioning:
Baby directly facing nipple with ear, shoulder &
abdomen in line. Hands: not in the way of proper latch on
* promote comfort during feeding to facilitate milk ejection
Pillows, privacy, analgesics, fluids, calm/relaxing environment
* teach proper latch-on techniques "START"
Support breast with hand cupped
Tickle baby's lips: lips very sensitive to touch
Areola - most in infant's mouth
Rest - relax, room-in
Time - nurse 5-10 mins. each side
Alternate breasts starting on each feed.
Burp between breasts.
* suckling pattern:
nutritive slow rhythmic sucking
non-nutritive: rapid, short sucks without swallowing
* removal from breast: with little finger in corner of mouth
* frequency of feedings: q 1E - 3E not > 5E usually
c. Teach ways to prevent problems
* proper positioning! cradle hold, football hold, lying down
* teach good breast and nipple care
d. Encourage rooming-in and skin to skin contact
e. Teach signs of adequate feeding
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f. Provide supportive-educative resources
* prenatal classes
* LaLeche League:
* written materials:
* lactation consultant:
g. Teach techniques to promote infant weight gain: "FAT"
* Frequent feedings
demand feedings (8-10 x/24E)
duration should be 5-10 minutes of swallowing at each breast
* Avoid supplemental water, formula or nipple shields
* Treat yourself
Take prenatal vitamin (PNV) every day
Eat ~500 calories more/day
Ask for help and support
Try to drink 8-10 glasses water and/or juice/day
h. Discuss contraceptive options
3. Evaluation:
a. Nutritional history from parents
b. Weight gain
c. Growth chart percentiles
d. Physical examination
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V. Common breastfeeding concerns
A. Infant problems (Teach to be attentive to infant's sleep-wake state.)
1. Sleepy infant (very common first few days, especially first 24 hours)
a. Teach how to wake the baby
* change diaper
* undress/loosen blankets
* talk to and hold upright
* apply cool cloth to forehead
* hold infant's hand
* stimulate sucking on finger and transfer to breast
* stroke under chin, on soles of feet
* express milk into infant's mouth
b. Provide reassurance and support
2. Fussy baby: Teach how to calm the baby
a. Feed before baby gets too hungry
b. Use football hold
c. Comfort before putting to breast
d. Stimulate flow of milk before putting to breast
e. Use calming techniques: quiet environment, soothing voice, skin to skin contact,
swaddling, continuous rooming-in
3. Nipple confusion: Has been theorized but no research to support
a. Different suck patterns with breast/bottle feeding
b. Don't know who will develop
4. Infant complications: Essential to inform that breastfeeding is possible!
a. preterm or sick infant (suck/swallow matures _______ weeks gestation)
* begin massaging breasts/nipples and pumping when able
* encourage early nuzzling of infant at breast
* use fresh breast milk first
* discuss normal fluctuations
* encourage mom to use the easiest method of expressing possible despite
cost. Some insurance companies cover cost.
* pump after feeding if nursed < 10 minutes
* use nipple stimulation before pumping or nursing to flow/production
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B. Maternal concerns
1. Expressing breast milk: All breast feeding women should learn this skill.
a. Methods
* hand: cheapest, most convenient, cleanest
* manually-operated pumps
* battery-operated pumps
* electric: most expensive but requires least maternal energy
b. Tips for success
* stimulate let-down before expressing: nipple stimulation, warm water
message: nipple rolling before pumping for 2-3 mins.
relaxation techniques
* relax and be confident (decrease emphasis on amount removed)
c. Praise and encourage all efforts
d. Provide community referrals for support
e. Teach how to store and use breast milk:
* Store in plastic containers labeled with date/time
* Fresh: Use within 6 hrs.
* Refrigerated: Use within 5 days
* Frozen: Keeps 2 weeks in refrigerator/freezer unit.
Keeps 6 months or longer in deep-freeze (0 degrees F or <)
* Thawing: Under warm water
Mix well and do not refreeze.
Can layer cold milk over frozen but not warm milk.
2. Engorgement:
a. Prevent with demand feedings
b. Avoid skipping feedings
3. Sore nipples
a. Teach prevention
* proper positioning, good breast and nipple care
* breaking suction correctly and if ineffective suck
b. Promote let-down
* warm water, relaxation techniques, gentle massage
* analgesics, comfort measures
c. Topical measures
* ice on nipples in wash cloth
* warm tea bags, warm water soaks
* rotate positions, nurse least sore side first
* nurse more often for shorter sessions
4. Flat or inverted nipples
a. Wear breast cups
b. Ice on nipple before feeding
c. Pump breasts after feeding
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5. Plugged ducts
a. Heat to area
b. Gentle message
c. Position to empty area
6. Mastitis: Breast infection - can continue to breastfeed
a. Teach signs and symptoms: "HEAT"
* Hot: fever
* Erythemic area: red, hot area
* Ache: flu-like aches/pains
* Tender: area
b. Teach treatment: "HEAT"
* Heat: warm, moist packs best or bathtub
* Empty: try to rotate positions and empty area
* Antibiotics for 10 days: will feel better after 24-48 hours.
* Time to rest: fluids and protein: have someone help.
7. Weaning
a. Do gradually: eliminate one feed every 2-3 days.
b. Omit least favorite feed first: normally middle of day feeds.
c. Substitute love/attention: playing, letting dad hold and feed.
VI. Formula feeding: Application of nursing process
A. Assess
1. Mother's knowledge and experience with feeding
2. Infant feeding behaviors: teach to attend to sleep/wake behaviors
B. Diagnosis, plan, and implement care
1. Teach types of formula available & formula preparation
a. ready-to-feed
b. concentrated
c. powder
2. Teach feeding techniques
a. positioning: Keep nipple full with milk during feeding & baby upright
b. burping
c. frequency
d. amount: .5-1 oz. (15-30 ccs) but increases to 2-3 oz./feed by 3
3. Teach precautions:
No propping bottle
No bottle at night
Dont force feed to finish bottle
Throw away left over feeding
No microwaving to heat milk
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N160 Nursing of Women and Newborns
I nfant Feeding
Group Activities
Margaret is breastfeeding for the first time. She seems awkward in handling her baby and states that the baby
is not feeding well. The baby cries frequently while Margaret is attempting to feed her.
1. What is the first nursing action to take in this situation.
The infant responds to your interventions..
2. What should the nurse do now to assist Margaret with breastfeeding?
The infant latches onto the breast and is sucking vigorously. Margaret begins to relax. She states, "I
thought this would be so easy but it isn't."
3. How should the nurse respond to this comment?
Margaret asks, "How can I prevent any more problems with breastfeeding? I'm worried that my breasts
will get engorged or that my nipples will crack."
4. How can Margaret prevent these problems from occurring?
Margaret has successfully completed breastfeeding her infant at this feeding. She asks, "She seemed
to suck a lot, but how do I know that she is getting enough to eat?"
5. What signs or behaviors should Margaret look for that will indicate adequate nutritional intake?
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I. Care of high risk newborns: Overview
A. Incidence
B. Etiology
1. premature labor and delivery (PTL)
2. premature spontaneous rupture of membranes (PSROM)
3. pre-eclampsia
4. Rh incompatibilities
5. infection
6. genetic disorders
C. Characteristics specific to preterm infants: less body fat and development
1. physical signs
2. neurological signs: decreased muscle tone and reflexes
a. posture
b. flexion
3. Overview of common problems: all systems are premature
a. Air: Respiratory distress syndrome (RDS)
b. Food and fluids:
* necrotizing enterocolitis
* immature suck/swallow reflex
c. Prevention of hazards:
* thermoregulation difficulties
d. Normalcy:
* immature development systems
* immature liver
- jaundice
e. Health deviations:
* Cardiac problems
- Patent ductus arteriosus (PDA)
* Potential for intraventricular hemorrhage (IVH)
* Potential for retinopathy of prematurity (ROP) neonatal blindness
due to too much oxygen use
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II. Common health deviations of high risk newborns: Air
A. Respiratory distress syndrome (RDS):
Most at risk for developing are premature infants and infants of diabetic mothers
who have slower surfactant development.
Infants who are stressed in utero (due to PTL, drugs...) develop surfactant sooner
than non-stressed infants and therefore have less RDS problems.
1. Pathophysiology of RDS
a. absence of alveoli and progressive atelectasis
b. pulmonary vascular resistance
c. reverse to fetal circulation R-L shunting
d. hypoxemia and hypercapnia
e. pulmonary vasoconstriction enhanced by a Ph
f. pulmonary vascular resistance
g. prolonged hypoxemia
h. atelectasis
i. ability to produce surfactant
2. Clinical presentation of RDS
a. grunting
b. retractions
c. nasal flaring
d. O2 requirements
e. peripheral vasoconstriction
f. flaccid
g. poor quality breath sounds
h. tachypnea
i. oliguria
3. Treatment
a. Airway management/support
* Ventilatory assistance
- Continuous positive airway pressure (CPAP)
- conventional ventilator
- high frequency jet ventilator
* O2 supplementation
* prevent alveolar atelectasis, hypoxia and hypercarbia
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* surfactant replacement
* monitor oxygen saturation
- arterial blood gases (ABG's)
- transcutaneous monitor
- pulse oximeter
* monitor cardiorespiratory status (monitors)
b. Complications of ventilation
* barotruma
* air leaks
* oxygen toxicity
* subglotic stenosis
* pulmonary infections
* cerebral hemorrhage
* retinopathy of prematurity (ROP)
B. Hyalin membrane disease (HMD)
1. Damage to alveoli due to progressive RDS inhibits gas exchange and leads to a
diminished lung compliance. This causes scaring, hardening and long-term disease.
C. Transient tachypnea of the newborn (TTN): delayed absorption of fetal lung fluid
1. Clinical presentation
a. respiratory rate
b. mild cyanosis
c. retractions
d. grunting
e. barrel shaped chest
2. Etiology
a. predisposing factors
* prematurity
* C-delivery
* breech delivery
3. Treatment
a. Oxygen
b. monitors
c. NPO
D. Pneumonia
1. Pathophysiology
a. primary or as part of generalized sepsis
b. may be acquired in utero (PROM > 24E, excessive OB manipulation, UTI,
maternal fever)
c. during labor (beta strep, other bacteria passing into oropharynx)
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d. postnatally
e. droplets of personnel
f. parents
g. other infected infants
h. viral respiratory syncytial virus (RSV)
i. candida albicans (most common fungus)
j. invasive devices
2. Clinical presentation
a. nonspecific
b. temperature instability
c. lethargy
d. poor peripheral perfusion
e. apnea
f. tachycardia
g. cyanosis
h. grunting
i. retractions
j. nasal flaring
3. Treatment
a. antibiotic therapy
* ampicillin, gentamicin, cefotaxime
b. O2 therapy
III. Nursing care for RDS and other respiratory conditions
A. Air
1. Positioning: Prone position
2. Suctioning: Mouth first then nose
a. Be cautious of vaso-vagal stimulation with deep suctioning
3. Assessment and evaluation
a. monitors
b. lab values
c. physical assessment
IV. Problems/Assessment of the GI system: Food and fluids
A. Gut motility problem due to potential hypoxic insult
1. All infants NPO upon admission to NICU first few days
2. Day 5: initiate enteral/parenteral feeds and assess infant capabilities
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B. Necrotizing Enterocolitis: Caused by hypoxic gut insult
1. Signs and symptoms
a. Abdominal distention
b. Inability to tolerate feedings - gastric aspirate > 25% of feeding
c. Vomiting
2. Treatment
e. Replace aspirate if >25% of feeding
b. Notify doctor of S&Sxs observed & feeding intolerance
c. Hold feedings - NPO
C. Assessment/nursing care
1. IV/central lines patency
2. Lab values
3. Fluid/nutrition administration
4. Assess readiness for feeding: feeding capabilities
a. Oral: Respiratory rate < 60/min.
b. Feeing toleration
Oral: assess suck/swallow reflex
- Complete feeding in < 25-30 mins.
* Tips for success
* Encourage parents to feed
Tube placement
Feeding at room temperature
Check placement
Check residual/aspirates
Position on right side after feedings to promote gastric emptying
Encourage sucking during feeding
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V. Prevention of hazards
A. Temperature regulation essential: narrow thermal neutral zone
1. decreased ability to respond to cold stress
2. exacerbates RDS
3. causes hypoglycemia
4. results in failure to gain weight
5. can cause shunting of blood/hypoxia
B. Implement measures to prevent cold stress
1. Maintain temperature at 36.3-37.2 axillary temperature
2. Will apnea, growth
C. Implement universal precautions
1. Utilize good handwashing
2. Maintain suctioning
3. Maintain a clean bedside
4. Maintain IV access
5. Always be looking for S and Sx's of sepsis
VI. Premature infant development: Promote normalcy
A. Stages of development:
1. 25-32 weeks (physiologic stage)
a. stress shown by physical changes
b. implement minimal stimulation interventions
2. 32-35 weeks (coming out stage)
a. some control over physiological system
b. engagement cues
3. 35 weeks and over (interactive stage)
a. ready to interact more
b. teach parents how to attend to cues (quiet-alert state)
B. Nursing care to promote development and balance between activity/rest
1. Attend to overstimulation cues
a. heart rate, color changes
b. yawning, sneezing,
c. hypertension, finger splays, grimace, gaze aversion
2. Avoid overstimulation
a. Be attentive to signs and symptoms
b. Touch times
c. Provide boundaries around babyKeep flexed
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3. Solitude and social interaction
a. Encourage parent/family bonding, involvement, and to touch the infant
to make the experience real.
b. 24 hr. visitation
c. Ronald McDonald house
d. Toll free phone #
e. Frequent and early contact
f. Facilitate successful interaction
g. Provide information and support
h. Like black and white shapes when interactive
i. Teach parents appropriate interaction methods
j. Educate about engagement cues and overstimulation cues
4. Developmental SCR: Normalcy
a. Catch up with growth and development
b. Provide information and support
VII. Other health deviations in the newborn
A. Hyperbilirubinemia/Jaundice
1. Definition: a yellowing of the skin that develops because of the presence of indirect
(unconjugated) bilirubin in the blood.
2. Kernicterus: is the deposition of unconjugated bilirubin in the basal ganglia
of the brain and results in neurologic damage.
3. Signs and symptoms:
4. Abnormal bilirubin levels:
a. term
b. preterm
5. Etiology
1. RBC breakdown
a. Rh incompatibility
* Rh- mon and Rh+ fetus/baby
* D antigen is most prevalent
* antigens can be detected as early at 38 days gestation
* transplacental hemorrhage occurs in 50-70% of all pregnancies
* 1st born usually not affected
b. Trauma
* cephalhematoma
* pulmonary or intracerebral hemorrhages
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c. ABO incompatibility
* mom type O blood and baby AB
* so mom has anti A and anti B antibodies
* can occur in 1st pregnancy
* 15-20% of infants are ABO incompatible but only 3% become
2. Interferences with bilirubin conjugation
a. breast milk jaundice
b. drugs
c. hypothyroidism
d. acidosis and hypoxia
e. maternal viral infections
f. neonatal bacterial or viral infections
3. Symptoms:
a. jaundice within 24 hrs.
b. rapid and high rise in bilirubin
c. positive direct or indirect Coombs
d. hepatosplenomegaly
e. petechiae
f. hypoglycemia
g. hydrops fetalis
h. erythroblastosis fetalis
4. Lab findings
a. Direct Coombs
b. Indirect Coombs
c. Blood types
d. Hct/glucose
e. Platelets
a. Phototherapy: helps breakdown bilirubin through skin so it can be
excreted through the urine and stool.
* side effects of phototherapy
* dermal rash
* lethargy
* possible eye damage
* in insensible water loss
* thrombocytopenia
* bronze baby
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* Nursing care for infant receiving phototherapy:
* protect neonate's eyes
* provide maximal exposure to phototherapy
* turn every 2 hours
* monitor skin integrity
* monitor hydration by checking specific gravity q 4 hrs.
* note bilirubin levels (draw q 12 hrs.)
* monitor Hct. for anemia
* support parents
b. Exchange transfusion
* to correct severe anemia
* remove antibody coated RBC's in hemolytic disease
* remove excessive unconjugated bilirubin
* use Rh- blood
* Nursing care
* type and screen
* maintain IV line/infusion
* record events
* observe infant during/after procedure
5. History suggesting non-physiologic jaundice
B. Sepsis
1. Incidence:
a. Preterm births: 1:250 live births
b. Term births: 1:1000 live births
2. Signs and symptoms: ALARM
a. Acidosis
b. Lethargy, poor feeding
c. Abdominal distention
d. Respiratory distress ( RR, grunting, apnea)
e. Major system distress ( BP, blood sugar, temp. instability)
3. Physical assessment:
a. skin color
b. capillary refill
c. BP
d. activity level
e. muscle tone
f. respiratory effort (apnea)
g. temperature
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4. Physical signs of underperfusion
a. urine output
b. delayed capillary refill
c. acrocyanosis
d. lethargy
C. Infant of a diabetic mother (IDM)
1. Clinical presentation and assessment
a. Large baby (LGA)
b. may have birth injury
c. RDS
d. polycythemia - ruddy red
e. jaundice
2. Assessment and intervention
a. Monitor Hct.& D-stix
b. X-rays
c. Check for Erb's palsy
d. Promote early feeding or IV glucose
e. Watch closely for S and Sx's of hypoglycemia
D. Prenatal Drug Exposure
1. Identification of intrauterine drug exposure "WITHDRAWAL"
a. Wakeful
b. Irritable
c. Tremors
d. High-pitched cry
e. Difficult to console
f. Restless, rhinorrhea
g. Apneic attacks
h. Weight loss
i. Alkalosis (respiratory)
j. Lacrimation
2. Nursing care for drug exposed infant
a. Prevent distractions/stimulation
b. Enhance retention of feedings
c. Activity/rest: Minimize stimulation, calm approach, swaddle
E. Congenital defects
1. See book for examples of common ones for interest/information
2. Congenital Heart Defects
a. Common signs of CHD
* Color: cyanosis or pallor
* Heart murmurs: HR and RR
* Difficulty feeding
3. Provide support and information