1
Q
What are the 2 causes of bleeding the first trimester of pregnancy?
A
Spontaneous abortion and ectopic pregnancy.
2
Q
What are the signs/symptoms spontaneous abortion?
A
- Vaginal bleeding
- Uterine cramping
- Partial or complete expulsion of products of conception.
3
Q
What are the signs/symptoms of ectopic pregnancy?
A
Abrupt unilateral lower-quadrant abdominal pain with or without vaginal bleeding.
4
Q
What are the cause of bleeding the second trimester of pregnancy?
A
Gestational trophoblastic disease
5
Q
What are the signs/symptoms of gestational trophoblastic disease?
A
- Uterine size increasing abnormally fast
- Abnormally high levels of hCG
- Nausea and increased emesis
- No fetus present on ultrasound
- Scant or profuse dark brown or red vaginal bleeding.
6
Q
What are the 3 causes of bleeding in the third trimester of pregnancy?
A
- Placenta previa
- Placental abruption
- Vasa previa
7
Q
What is a sign/symptom of placenta previa?
A
Painless vaginal bleeding
8
Q
What are the signs/symptoms of placental abruption?
A
- Vaginal bleeding
- Sharp abdominal pain
- Tender rigid uterus.
9
Q
What is vasa previa?
A
When the fetal vessels are implanted into the membranes rather than the placenta.
10
Q
What are 3 other causes of bleeding during pregnancy?
A
- Recurrent premature dilation of the cervix
- Preterm labor
- Hydatidiform mole
11
Q
What are the signs/symptoms of recurrent premature dilation of the cervix?
A
Painless bleeding with cervical dilation leading to fetal expulsion.
12
Q
What are the signs/symptoms of preterm labor?
A
- Bloody discharge
- Uterine contractions becoming regular
- Cervical dilation
- Effacement.
13
Q
What is a hydatidiform mole?
A
A benign proliferative growth of the placental trophoblast.
14
Q
What 2 ways can you calculate a women’s delivery date?
A
- Naegele’s rule
- Measuring the fundal height
15
Q
How is Naegele’s rule calculated?
A
Take the first day of the client’s last menstrual cycle, subtract 3 months, and then add 7 days and 1 year, adjusting for the year as necessary.
16
Q
Where do you measure the fundal height?
A
From the symphysis pubis to the top of the uterine fundus
17
Q
During what weeks of gestation can measuring the fundal height be used?
A
Between 18 and 30 weeks gestation
18
Q
Measuring the fundal height approximates the gestational ages, plus or minus ___ gestational weeks.
A
2
19
Q
What is gravidity?
A
The number of pregnancies.
20
Q
What is nulligravida?
A
A client who has never been pregnant.
21
Q
What is a primigravida?
A
A client in their first pregnancy.
22
Q
What is a multigravida?
A
A client who has had 2 or more pregnancies.
23
Q
What is parity?
A
The number of pregnancies in which the fetus or fetuses reach at least 20 weeks of pregnancy, not the number of fetuses.
Parity is not affected whether the fetus is born stillborn or alive.
24
Q
What is nullipara?
A
No pregnancy beyond the stage of viability.
25
What is primipara?
Has completed 1 pregnancy with a fetus or fetuses who have reached at least 20 weeks of gestation.
26
What is multipara?
Has completed 2 or more pregnancies to 20 weeks of gestation or more.
27
What is viability?
The point in time when an infant has the capacity to survive outside the uterus.
28
What gestational weeks are considered viable?
There are no specific weeks of gestation, however, infants born between 22 and 25 weeks are considered on the threshold of viability.
29
What does the GTPAL acronym stand for?
G - gravidity
T - term
P - premature births
A - abortions/miscarriages
L - living children
30
What gestational weeks are considered premature births?
From viability up until 37 weeks.
31
What gestational weeks are considered early-term?
37 weeks, 0 days through 38 weeks, 6 days.
32
What gestational weeks are considered full-term?
39 weeks, 0 days through 40 weeks, 6 days.
33
What gestational weeks are considered late-term?
41 weeks, 0 days through 41 weeks, 6 days.
34
What gestational weeks are considered post-term?
Greater than or equal to 42 weeks, 0 days.
35
What gestational weeks are considered abortions/miscarriages?
Prior to viability
36
What are the cardiovascular physiological statuses of pregnant clients?
* Heart rate increases, blood volume increases, cardiac output increases.
* BP range should stay the same in the first trimester.
* Sometimes their heart gets a little larger to handle the excess volume.
*Supine hypotension
37
What is supine hypotension?
Pregnant women laying on her back, it puts pressure on the vena cava and reduces blood flow causing hypotension and fetal hypoxia.
38
Supine hypotension can affect the ____ of the patient.
BP
39
What is a nursing intervention for supine hypotension?
Laying the patient on their left side to improve perfusion.
40
What are the respiratory physiological statuses of pregnant clients?
* Respiratory rate will increase because they are trying to get more oxygen.
* Total lung capacity decreases.
41
What is a nursing intervention for respiratory help for pregnant women?
Deep breathing exercises
42
What is the musculoskeletal physiological status of pregnant clients?
Pelvic joints relax in order to allow passage of the baby.
43
What are the gastrointestinal physiological statuses of pregnant clients?
* Nausea and vomiting in the beginning of pregnancy due to hormonal changes.
* Constipation
44
Why can constipation occur in pregnant women?
Because of the supplements they take; they contain high iron.
45
What is the renal physiological status of pregnant clients?
Urinate more frequently.
46
What is the endocrine physiological status of pregnant clients?
placenta becomes endocrine organ for the baby.
The endocrine system is going to maintain the hormonal balances.
47
What are the uterus and breast physiological statuses of pregnant clients?
* Cervical changes: becomes purplish color, cervix becomes softer as you go along.
* Breast increase in size, will be tender. * * Areolas darken.
48
What are the skin changes of pregnant clients?
* Linea nigra
* Striae gravidarum
49
What is linea nigra?
Dark line of pigmentation from the umbilicus extending to the pubic area.
50
What is striae gravidarum?
Stretch marks most notably found on the abdomen and thighs.
51
What are 2 nursing interventions for linea nigra and striae gravidarum?
1. Moisture the abdomen
2. Hyrdation
52
What are 2 nursing interventions for the body systems?
1. Tell the patient what to look for, what is going to change
2. Refer them to counseling if needed.
53
When will measuring the fundal height be inaccurate? Why?
This will be only be inaccurate with molar pregnancy because molar pregnancy is bigger.
54
An ultrasound tells you ____.
What is going on.
It tells you abnormalities, how many fetuses, amniotic fluid, sex of baby, etc.
55
What is a biophysical profile (BPP)
It uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe fetal biophysical responses to stimuli.
56
A biophysical profile (BPP) combines ____ and ____.
It combines FHR monitoring (nonstress test) and fetal ultrasound.
57
What is a nonstress test (NST)?
It’s a noninvasive procedure that monitors response of the FHR to fetal movement.
58
When is a nonstress test (NST) usually performed?
Usually performed during the third trimester.
59
What does a nonstress test (NST) look for?
Accelerations and deaccelerations in fetal movement.
60
How does a nonstress test (NST) work?
The client pushes a button attached to the monitor whenever they feel a fetal movement, which is then noted on the tracing.
61
What is amniocentesis?
The aspiration of amniotic fluid for analysis by inserting a needle transabdominally into a client’s uterus and amniotic sac.
62
What does an amniocentesis look for?
This test looks for genetic materials in the fluid to determine if there is anything wrong with the baby.
63
When can an amniocentesis be performed?
After 14 weeks of gestation.
64
What is maternal serum alpha-fetoprotein (MSAFP)?
It is a screening tool used to detect neural tube defects.
65
Clients who have abnormal findings with maternal serum alpha-fetoprotein should be referred for a ____.
Quad marker screening.
66
What is the quad marker screening?
A blood test that measures 4 substance instead of 3.
67
Why is nutritional care important in pregnancy?
Because maternal nutritional status is a significant health factor that can prevent a variety of health problems for both the mother and baby.
68
What should the nurse talk to their pregnant client about in regards to nutrition?
* Taking prenatal vitamins
* Eating a balanced diet
* Eating calcium rich foods
* Eating fruits and vegetables
* Getting folic acid
69
What does eating fruits and vegetables help with during pregnancy?
It helps prevents constipation and gives the baby essential vitamins.
70
What does folic acid do when taken during pregnancy?
It prevents neural tube defects.
71
What is precipitous labor?
Quick labor, less than 3 hours.
72
Who is more likely to have a precipitous labor?
Could be someone who’s had multiple pregnancies, preterm labor, etc.
73
What is dysfunctional labor?
It's deviation from the normal progress. Such as having a hard time dilating, presenting a part that shouldn’t be presenting (foot coming out first), etc.
74
What are physiological changes that may precede labor?
* Back aches (constant low, dull backache caused by pelvic muscle relaxation)
* Weight loss (1-3.5 lbs)
* Lightening (feeling that the fetus has “dropped”)
* Contractions start
* Increased vaginal discharge or bloody show
* Rupture of the membrane (water breaking)
* Energy burst
* Gastrointestinal changes (less common; include nausea, vomiting, and indigestion)
* Cervical ripening
75
Explain labor contractions
They begin with irregular uterine contractions (Braxton Hicks) that eventually progress in strength and regularity.
76
What are hypertonic contractions?
They are closer than every 2 min, don’t relax. Or they last 2 long (greater than 1.5-2 min).
77
Hypertonic contractions put ____ and can cause ____
Stress on the baby; fetal hypoxia.
78
What are nursing interventions for hypertonic contractions?
* Put mom on oxygen
* If they’re getting oxytocin, stop it
* Lay them on their side
* Increase their IV fluid to increase perfusion to the baby (increases delivery of oxygen to the baby).
* Monitor vital signs
* Monitor fetal heartrate
79
What are the mechanisms of labor?
There are 5 factors that affect and define the labor and birth process.
80
What are the 5 P's of the birth process?
1. Passenger
2. Passageways
3. Powers
4. Position
5. Physiological response
81
What is the passenger in the 5 P's of the birth process?
It consists of the fetus and placenta. The size of the fetal head, fetal presentation, fetal lie, fetal attitude, and fetal position affect the ability of the fetus to navigate the birth canal.
82
Passenger in the birth process consists of 4 components?
1. Presentation
2. Lie
3. Attitude
4. Fetal position or fetopelvic
83
What does presentation mean in regards to the birth process "passenger"?
The part of the fetus that is entering the pelvic inlet first and leads through the birth canal during labor. It can be the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum or feet).
84
What does lie mean in regards to the birth process "passenger"?
The relationship of the maternal spine to the fetal spine (transverse, parallel or longitudinal).
85
What does attitude mean in regards to the birth process "passenger"?
The relationship of fetal body parts to one another.
86
What are the 2 components of attitude in regards to the birth process "passenger"?
1. Fetal flexion
2. Fetal extension
87
What is fetal flexion?
Chin flexed to chest; extremities flexed to torso.
88
What is fetal extension?
Chin extended away from chest, extremities extended.
89
What does fetal position/fetopelvic mean in regards to the birth process "passenger"?
The relationship of the presenting part of the fetus (sacrum, mentum, or occiput) in reference to its directional position as it relates to one of the 4 maternal pelvic quadrants.
90
What is the passageways in the 5 P's of the birth process?
The birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening).
91
What is the powers in the 5 P's of the birth process?
Uterine contractions cause effacement (shortening and thinning of the cervix) during the first stage of labor and dilation of the cervix (enlargement or widening of the cervical opening and canal) that occurs once labor has begun and the fetus is descending.
92
What is the position in the 5 P's of the birth process?
The position of the client. The client should engage in frequent position changes during labor to increase comfort, relieve fatigue, and promote circulation.
93
How does gravity affect the birthing process?
Gravity can aid in the fetal descent in upright, sitting, kneeling, and squatting positions.
94
What is the physiological response in the 5 P's of the birth process?
Maternal stress, tension, and anxiety can produce physiological changes that impair the progress of labor.
95
What does disseminated intravascular coagulation (DIC) mean?
It means your body cannot clot.
96
Bleeding in pregnancy can occur at any time. However bleeding at 20 weeks or more needs to be ____.
Addressed immediately by their healthcare provider.
97
What is RhoGAM?
It prevents the Rh-negative mom from making antibodies during pregnancy that could cause HDFN in future pregnancies.
98
What is rhogam used for in pregnancy?
It stops the body from creating harmful antibodies that could cause severe complications or hemolysis in future Rh-positive pregnancies.
99
In what situations is RhoGAM given?
Before and after birth, and following potential blood-mixing events like miscarriages, abortions, or ectopic pregnancies.
100
Stable ectopic pregnancies are given what medication?
Methotrexate
101
What needs to occur for a ruptured ectopic pregnancy?
They need to either fix the tube or remove it. It is an immediate emergency surgery.
102
Placenta previa occurs before ____.
Placental abruption
103
What are the complications with placenta previa?
1. Fetal stress
2. Maternal hemorrhage
3. Stillbirth
104
Preterm labor can be categorized as:
* Very preterm (less than 32 weeks of gestation).
* Moderately preterm (32 to 34 weeks of gestation).
* Late preterm (34 to 36 weeks of gestation).
105
What are the risk factors for preterm labor?
* Infection
* UTIs are a huge cause of preterm labor.
* HIV, active herpes infection, or intrauterine
* Age
* Multifetal
* Lack of prenatal care
* Previous preterm
* Smoking/substance abuse
* Violence or abuse
* Uterine abnormalities
* Low pregnancy weight
* Advance maternal age
106
What are the expected findings of preterm labor?
* Uterine contractions
* Pressure in the pelvis and menstrual-like cramping
107
What are the physical findings of preterm labor?
Increase, change, odor or blood in vaginal discharge.
108
What are the complications of preterm birth?
* Necrotizing enterocolitis
* Infection
* Hyperbilirubinemia (liver is not ready)
* Anemia
* Hypoglycemia
* Delayed growth and development.
* Respiratory distress syndrome (the babies don’t have the surfactant, lungs aren’t fully developed).
* Eye issues
* Cardiac issues
109
What is necrotizing enterocolitis?
A serious, often fatal GI disease, where the intestinal wall becomes inflamed, dies, and develops perforations
110
What are nursing interventions for preterm birth?
* Ensure hydration (dehydration can cause you to have contractions. Hydration can potentially stop the contractions).
* Encourage rest in side-lying position (on left side. It increases the blood flow. When you lay on the right side, the uterus can press on the inferior vena cava and decrease blood flow).
* Modified best rest (have patient on modified best rest to decrease activity which prevents the risk of thrombosis)
* Talk to them about avoiding sexual intercourse.
* Treat infection if they have one. Give antibiotics that are not teratogenic.
* Give them betamethasone (steroid for fetal lung development).
111
Why can’t you give magnesium sulfate and nifedipine the same time?
Because they are contraindicated.
112
What are the side effects of nifedipine?
113
What is indomethacin? What does it do?
It is an NSAID. It helps suppress uterine contractions.
114
NSAIDs cause ___ so monitor for ____.
Bleeding; hemorrhage
115
Do not give indomethacin for more than ____ hours.
24
116
What is betamethasone used for?
It's used to enhance fetal lung maturity and induce surfactant production.
117
How many doses of betamethasone do you give for preterm labor? How far apart do you give the doses?
2 doses, 24 hours apart.
118
What is a prolapsed cord?
When you can see the cord protruded through the cervix
119
What are nursing interventions for a prolapsed cord?
* Call for help, put on sterile glove, and push cord back into uterus using a sterile-gloved hand. Do not leave the client.
* Notify the provider.
* Apply a warm, sterile, saline-soaked towels to keep cord moist if you cannot push the cord back in to prevent the cord from drying out. Because if the cord dries out, maternal blood can’t circulate to the baby and the baby will die.
* Apply oxygen: Nonrebreather mask.
* Initiate IV access, and administer IV fluid bolus.
* Prepare for an emergency C-section.
* If something is pressing on the cord (baby’s head), try to move it off of the cord.
120
What is a Coombes test?
A blood test used to detect specific antibodies that attack and destroy red blood cells, causing anemia or jaundice.
121
What is an indirect Coombes test?
It's a test that identifies clients who are sensitive to Rh blood.
122
What is the rupture of membranes?
The breaking of the amniotic sac that holds the baby and fluid.
123
What signs of infection should you look for with a rupture of membranes?
* Tachycardia (in mother or fetus)
* Fever
* Abdominal pain
* Foul-smelling or unusual vaginal discharge.
124
How often should you monitor a patient who had a rupture of membranes?
Monitor every 2-4 hours and as needed.
125
What is premature rupture of membranes (PROM)?
A spontaneous rupture of the membranes an hour or more before the onset of labor.
126
What is preterm premature rupture of the membranes (preterm PROM)?
A prelabor spontaneous rupture of the membranes after 20 weeks gestation and prior to 37 weeks of gestation.
127
What 4 things would you assess if you think your patient has ruptured of the membranes?
1. The color of fluid
2. Verify if it's amniotic fluid and not urine.
3. Cultures for GBS, gonorrhea, and chlamydia.
4. Temperature of mom.
128
Why do you assess the color of the fluid if you believe your patient has a rupture of the membranes?
You're looking for meconium.
129
Why are pregnant women tested for chlamydia and gonorrhea?
Because it can be passed to the babies (through their eyes) and cause eye infections.
130
What is given to babies at birth as a precautionary measure in case the mother has chlamydia and/or gonorrhea?
Erythromycin ointment
131
Does the mom need to give consent to administer erythromycin ointment to the newborn?
Yes
132
What are nursing interventions for a patient who has a rupture of the membranes?
* Prepare for birth if indicated. * * Avoid vaginal exams unless patient is ready for labor because of risk of infections.
* Any temp over 100.00 will be reported to the health care provider.
* Administer antibiotics if needed.
* If it's preterm, give the betamethasone.
* Limited physical activity once membranes have ruptured.
133
What are the 4 types of vaginal delivery?
1. Induction of labor
2. Vacuum assisted
3. Forceps
4. Episiotomy
134
What 3 ways can labor be induced?
1. Mechanically through nipple stimulation to release oxytocin in the body to start labor.
2. Chemically with Pitocin or oxytocin to start labor.
3. Amniotomy (hook) to start the artificial rupture of the membranes.
135
How long will it take labor to start after an amniotomy?
Within 12 hours after the membranes rupture.
136
What is a vacuum assisted birth?
Suction cap goes on baby’s head, as the mom pushes the baby, the baby is vacuumed out.
137
What 3 complications do you worry about with a vacuum assisted birth?
1. Subdural hematomas
2. Cephalhematomas
3. Lacerations.
138
What is a vaginal birth with forceps?
It consists of using an instrument with 2 curves spoon-like blades to assist in the delivery.
139
What are the risks for the mother with a vaginal birth using forceps?
Urinary retention, bladder injury, and lacerations of the cervix, vagina and perineum.
140
What are the risks for the baby with a vaginal birth using forceps?
Facial nerve palsy, facial bruising, and subdural hematoma.
141
What is an episiotomy?
A cut from the vaginal down to the rectum to enlarge the vaginal opening.
142
When is an episiotomy performed?
Only when necessary.
143
What are TORCH infections?
A group of infections that can negatively impact the pregnant women and the fetus in-utero.
144
TORCH infections have ____ effects on the fetus.
Teratogenic
145
What infections does TORCH include?
Toxoplasmosis, other infections (hepatitis), rubella virus, cytomegalovirus, and herpes simplex virus (HPV).
146
What is group B streptococcus (GBS)?
It's a bacterial infection that can be passed to a fetus during labor and delivery.
147
Group B streptococcus (GBS) is universally screened in all pregnant women between ____ and ____ weeks.
35 and 37 weeks.
148
If your patient wasn't screened for Group B streptococcus during pregnancy, when will they be screened? Who might this apply to?
Before birth of the baby. Someone who didn't receive prenatal care.
149
If a patient is positive for Group B streptococcus, what medication will they be given to treat it?
Penicillin G or ampicillin.
150
Incisions for a c-section can be made either ____ or ____. Which takes longer to heal?
Vertical or horizontal. Vertical.
151
What are some reasons as to why a c-section may be performed?
* Baby is breech.
* Non-reassuring fetal status
* Placenta previa
* Placental abruption
* High-risk pregnancy
* Previous c-sections
* Multiple gestations
* Umbilical cord prolapse
* Maternal cardiac or respiratory distress
* Dystocia
152
What are pre-procedure nursing interventions for a patient receiving a c-section?
* Mom in supine position with wedge under one hip to prevent compression of the vena cava.
* Monitor vital signs
* Start an IV
* Pain medication ready
* Indwelling catheter
* Informed consent
* Get blood ready
* May give antibiotics beforehand
153
What are post-procedure nursing interventions for a patient receiving a c-section?
* Monitor for evidence of infection and excessive bleeding at incision site.
* Assess uterine fundus for firmness or tenderness.
* Assess lochia for amount and characteristics.
* Respiratory
* Incentive spirometer
* Hug me pillow
* Encourage deep breath exercises.
* Pain management
* Monitor I&O
* Encourage ambulation
* Apply sequential compression device (SCD)
154
What can a tender uterus and foul-smelling lochia indicate after a c-section?
Endometritis
155
What is endometritis?
It's an inflammation or irritation of the lining of the uterus caused by an infection.
156
What is a VBAC?
Vaginal birth after c-section.
157
What are you assessing postpartum?
* Fundal assessment
* Vagina and lochia
* Vital signs, especially temp
158
What are you assessing the fundus for after birth?
For tone, position, and consistency.
159
If the fundus position is to the side, what should you have the patient do?
Empty their bladder.
160
Fundal height is always measured to the ____.
Umbilicus
161
What are you feeling the fundus for after birth?
Making sure it's not soft and boggy.
162
What should you do if the fundus is soft and boggy?
Massage it to start contractions to firm it up.
163
After birth, the mother's temperature can increase and can be a sign of infection. What other reason will the mother's temp go up? So what do you need to monitor?
Dehydration. Monitor I&O.
164
What reason would you give the mother warm blankets?
Postpartum chills can occur. It's a reaction to the stress of giving birth.
165
What does BUBBLE stand for?
Breasts
Uterus
Bowel and GI function
Bladder function
Lochia
Episiotomy
166
What are the 3 stages of lochia?
1. Lochia rubra
2. Lochia serosa
3. Lochia alba
167
What is the color of lochia rubra, what does it contain, and when does it appear?
Bright red blood, contains clots, last 1-3 days after birth.
168
What is the color of lochia serosa, what does it contain, and when does it appear?
Pinkish brown color, contains small clots and leukocytes, lasts from day 4 to day 10 after birth.
169
What is the color of lochia alba, what does it contain, and when does it appear?
Yellowish white creamy color, fleshy odor, contains mucus and leukocytes, lasts from day 10 up to 6 weeks postpartum.
170
What are the physical changes of breast after giving birth?
Secretion of colostrum (really nutritious), start producing milk within 3-5 days, breast will become engorged, cracked nipples (is a sign of mastitis).
171
What are you assessing a mother's bowels and GI function after giving birth?
* Making sure they are moving their bowels, not constipated.
* Assess rectal area for hemorrhoids. Hemorrhoids can strangulate and become a huge clot, clots can rupture and release into the body, and the patient can die.
172
What 3 things are you assessing a mother's lochia for after giving birth?
The color, consistency, and amount.
173
What are you assessing a mother's episiotomy for after giving birth?
Checking for erythema, edema, swelling.
174
Define postpartum hemorrhage.
A cumulative blood loss of 1000 mL or greater or blood loss with findings of hypovolemia within 24 hours following any type of birth.
175
What are the 4 T's of postpartum hemorrhage?
1. Tone
2. Trauma
3. Tissue
4. Thrombin
176
What is the tone part of postpartum hemorrhage?
Boggy fundus, uterine atony (not firm).
177
What is the trauma part of postpartum hemorrhage?
Lacerations and hematomas.
178
What is the tissue part of postpartum hemorrhage?
Retaining products of conception (some of the placenta stayed in the uterus).
179
What is the thrombin part of postpartum hemorrhage?
The ability to clot.
180
What tell tale sign will make you suspect postpartum hemorrhaging for your patient?
If the patient is soaking up a full pad within in an hour.
181
After birth your patient is losing blood volume. What signs can you potentially see.
Tachycardia, LOC changes, pallor, hypotension, clammy skin.
182
What would you give your patient for hypotension and fluid volume depletion after birth?
IV fluids
183
How do you know what nursing intervention to perform first after your patient has given birth?
It depends on what is going on with your patient. It’s not always the same thing for each patient.
184
What is a deep-vein thrombosis (DVT)?
A blood clot.
185
What are nursing interventions to prevent a deep-vein thrombosis (DVT)?
* Put on the sequential to promote circulation to prevent the blood clots.
* Get the patient up and out of bed as soon as possible because this will help prevent blood clots.
* May put on TED ( socks.
* Can do range of motion.
* Passive ROM if the patient is still feeling the effects of an epidural.
* Active they can do on their own.
186
What is mastitis?
It's inflammation of the mammary gland in the breasts.
187
What are the signs of mastitis?
Breast become engorged, cracked nipples, painful/tender localized hard mass, flu-like manifestations (chills, fever, headache body ache), and fatigue.
188
What are nursing interventions for mastitis?
* Can administer antibiotics (this is a collaborative intervention).
* Antipyretics because they could potentially have a fever.
* Likely will give acetaminophen.
* Likely wouldn’t use a NSAID because of bleeding.
* Compress on the breast
* Cabbage leaves.
* Can also use a breast pump to alleviate engorgement.
189
What is the Apgar test?
It is a rapid, standardized assessment performed on newborns at 1 and 5 minutes after birth to evaluate their immediate health.
190
What 5 things does the Apgar test assess?
1. Heart rate
2. Respiratory rate
3. Muscle tone
4. Reflex irritability
5. Color
191
What does an Apgar score of 0 to 3 indicate?
It indicates severe stress
192
What does an Apgar score of 4 to 6 indicate?
It indicates moderate difficulty.
193
What does an Apgar score of 7 to 10 indicate?
It indicates minimal or no difficulty with adjusting to extrauterine life.
194
What is the most accurate temp route on a newborn?
Axillary
195
Why is vitamin K given to newborns?
It's administered to prevent hemorrhagic disorders; to promote clotting.
196
What is the dose range given of vitamin K?
0.5 to 1 mg
197
How is the dose amount of vitamin K determined for a newborn?
It's calculated based on the weight of the baby.
198
How is vitamin K administered to newborns?
Given IM (intramuscularly) into the vastus lateralis.
199
When is vitamin K administered to newborns.
Within the first hour after birth.
200
What is the needle length, needle gauge, and needle angle of a IM injection on infants, toddlers, and children?
Length: 5/8" - 1 1/4"
Gauge: 22 - 25g
Angle: 72 - 90 degrees
201
What is the needle length, needle gauge, and needle angle of a IM injection on adults?
Oil based medication is a different gauge, what is it?
Length: 5/8" - 1 1/2"
Gauge: 20 - 25g
Angle: 72 - 90 degrees
Gauge for oil based medications: 18 - 25g
202
What is the location of injection for IM injections in infants and toddlers?
Vastus lateralis
203
What is the location of injection for IM injections in children?
Vastus lateralis or deltoid (preferred)
204
What is the location of injection for IM injections in adults?
Deltoid for vaccines or ventrogluteal (general).
205
What is the needle length, needle gauge, and needle angle of a subcutaneous (SC or SQ) injection on age birth to 12 months?
Length: 3/8" - 5/8"
Gauge: 23 - 25g
Angle: 45 - 90 degrees
206
What is the needle length, needle gauge, and needle angle of a subcutaneous (SC or SQ) injection on age 12 months to 18 years and older than 18 years old?
Length: 3/8" - 1"
Gauge: 25 - 30g
Angle: 45 - 90 degrees
207
What is the location of injection for subcutaneous injections for ages birth to 12 months?
Anterior aspect of thigh
208
What is the location of injection for subcutaneous injections for ages 12 months to 18 years?
Outer triceps area, anterior aspect of thigh
209
What is the location of injection for subcutaneous injections for ages older than 18 years?
Outer tricep area, anterior aspect of thigh, abdomen, upper back, upper ventral or dorso-gluteal area
210
Is hepatitis B immunization required or recommended for all newborns?
Recommended
211
What is the dosage schedule for hepatitis B?
Birth, 1 month, and 6 months.
212
In order to administer hepatitis B to newborns, the nurse needs ____ from the parents.
Informed consent.
213
Can vitamin K and hepatitis B injections be given in the same thigh?
No
214
What is erythromycin ointment given for?
Erythromycin ointment is given to prevent ophthalmia neonatorum. Gonorrhea and chlamydia (cause ophthalmia neonatorum) can be passed to babies through the eyes and cause infections and blindness.
215
What are the side effects of erythromycin ointment?
Chemical conjunctivitis, causing redness, swelling, drainage, and blurred vision.
216
What are signs of an infection in newborns?
* Fever
* Tachycardia
* Can't tolerate feedings
* Crying all the time
* Lethargic
* Inconsolable crying
217
What temp is considered hypothermia/cold stress in infants? Via what route?
Less than 97.7 degrees via axillary.
218
Hypothermia in newborns is called ____.
Cold stress.
219
What can cold stress lead to?
* Hypoxia
* Acidosis
* Hypoglycemia
220
What does acidosis in newborns mean?
Acidosis in newborns means their blood is too acidic, often from oxygen deprivation during or before birth (fetal acidosis), causing lactic acid buildup (metabolic acidosis) or inability to clear CO2 (respiratory acidosis).
221
Newborns who have ____ are at higher risk for hypoglycemia.
Respiratory distress
222
What is a preferred interventions for cold stress in newborns to get their temp to go up?
Skin to skin
223
How often should temps be monitored in newborns with cold stress?
Every hour until stabilized.
224
What are the signs/symptoms of neonatal substance withdrawal?
* High pitched cry
* Tremors
* Irritability
* Inconsolable
* Disturbed sleep problems
* Hypertonicity
* Hyperactive reflexes
* Increase in deep tendon reflexes
* Yawning
* Retractions (you can see the ribs when breathing)
225
What are newborns given if they are born on drugs?
Low doses of methadone
226
A newborn has a higher risk of having hypoglycemia if their mother had ____ during pregnancy.
Gestational diabetes
227
If a newborn has hypoglycemia, what is given to them?
Sugar water
228
Is an initial drop in blood glucose normal after birth? Why or why not?
Yes due to the cessation of the maternal supply of glucose.
229
When should newborns who have risks factors for hypoglycemia have their blood glucose level checked?
Within the first hour after birth.
230
What are the manifestations of hypoglycemia in newborns?
* Jitteriness
* Tremors
* Weak or high-pitched cry
* Decreased tone
* Poor feeding
* Apnea
* Respiratory distress
* Low temperature
* Seizures
* Blood glucose level of less than 40 to 45 mg/dL
231
What is meconium aspiration syndrome?
When a newborn breathes the meconium (first poop) mixed with amniotic fluid into their lungs.
232
Non-reassuring fetal status is present when ____.
* The FHR is below 110/min or above 160/min.
* The FHR shows decreased or no variability.
* There is fetal hyperactivity or no fetal activity.
233
What are the non-reasurring signs of fetal distress?
* Fetal hypoxia
* Reduced fetal movement
* Late decelerations
* Recurrent variables
* Prolonged decelerations
234
What is hyperbilirubinemia?
Elevated levels of bilirubin.
235
What does hyperbilirubinemia look like? Where will you see it?
Jaundice. You will see it in the sclera (whiteness of the eyes) and the mucous membranes.
236
Jaundice can be ____ or ____.
Physiologic or pathologic.
237
Physiologic jaundice is considered ____.
Benign
238
Pathological jaundice is a result of an _____.
Underlying disease.
239
Why does jaundice occur?
Because the liver is immature and unable to efficiently process and remove excess bilirubin.
240
When does physiologic jaundice occur?
It exhibits an increase in unconjugated bilirubin levels 72 to 120 hours after birth.
241
When does pathologic jaundice occur?
It appears before 24 hours of age or is persistent after day 14.
242
What are the advantages of breastfeeding?
* It helps strengthen babies’ immune system.
* Its free.
* Reduced risks of SIDS
* Promotes rapid growth of brain
* Promotes bonding.
* Decreases the risk of post-partum bleeding for mom.
* Easy to digest
* Contains electrolytes and minerals
* Provides protein and nitrogen for neurological cell building.
243
How often should mom breastfeed?
Every 2 - 3 hours.
8 - 12 times in a 24 hour period.
244
How often should a formula fed baby be fed?
Every 3 - 4 hours.
245
What are some teachings for a patient who is formula feeding their baby?
* How to make formula
* How to clean bottles properly.
* Discard any unused formula left in the bottle.
* Don’t heat formula in the microwave.
