NUR 421 STUDY GUIDE #3

Please Review Study Guide for Exam 1 & Exam 2! These are highlights, but not necessarily
everything that will be on the exam. There will be case studies, and an emphasis on recognizing
cues, understanding what assessment data/clinical symptoms mean and indicate as well as
appropriate nursing interventions depending on the diagnosis. You are expected to have read ALL
the assigned chapters in your text.

“ Critical components” “Nursing Judgements” and Medication sections- as well as the case studies
at the end of each chapter -are excellent resources.

Labor and Birth at Risk

GTPAL
Obstetrical Emergency: Tools: resuscitation cart (crash cart) or kit, rapid response team, standard
communication tools like SBAR, implementation of protocols, emergency drills and simulations

Red trigger: temperature (<35 or >38), systolic BP (<90 or >160), diastolic BP (>100), HR (<40 or >120),
RR (<10 or >30), SpO2 (<95%)
Yellow trigger: temperature (35-36), systolic BP (150-160 or 90-100), diastolic BP (90-100), HR (100-
120 or 40-50), RR (21-30)

Abnormal bleeding and hemorrhage

Initial interventions:
Secure airway, start oxygen via nonrebreather at 10 L/min
Establish IV access if not already existing. Infuse LR or NS wide open, start another IV
with a 16g.
Obtain CBC, fibrinogen, PT, PTT
Draw 5 mL of blood in a red-top tube. If no clot forms in 5-10 minutes suspect
coagulopathy.
Type and crossmatch 4 units of packed red blood cells (PRBC)
Administer blood products as ordered
Secondary interventions:
Foley catheter with urometer (at least 30 mL/hr)
O2 monitor
Call be additional help
CBC, PT, PTT, fibrinogen, ionized calcium, and potassium after 5-7 units of PRBCs
Anticipate surgical intervention
Assessment findings and nursing priority emergency care
● Prolapsed cord: Cord is below the presenting part of the fetus. Can prolapse in front of the
presenting part, into the vagina, or through the introitus. Occult prolapse: cord is palpated through the
membranes but does not drop into the vagina. This is typically with AROM or SROM. Presenting part
and circulation is occluded which results in FHR bradycardia (severe sudden decelerations).
Emergency c-section is typically done. Vaginal or instrumental delivery can be tried if it’s deemed
quicker, usually in the second stage of labor.
 Risk factors: breech (malpresentation), fetal anomalies, intrauterine growth restriction, small for
gestational age, unengaged presenting part. AROM, multiple gestation, preterm ROM, grand
multiparity.
Occult: cannot be seen or felt during examination.
Complete: can be felt as a pulsating mass.
Frank: cord proceeds the fetal head or feet and can be seen protruding from the vagina.
Nursing actions: elevate the presenting part until delivery by c-section, monitor fetus, knee-
chest position or Trendelenburg to relieve pressure, O2 at 10 L/min by mask, IV fluid hydration
bolus, discontinue oxytocin (consider tocolytic agent to decrease uterine activity), emergency
delivery, evaluate immediately following membrane rupture.

● Shoulder dystocia: Difficulty delivering the shoulder(s) after the birth of the head. The anterior
shoulder can be obstructed by the symphysis pubis. Could be from impaction of the posterior shoulder on
the maternal sacral promontory. First sign: retraction of the fetal head against perineum after delivery
(turtle sign).
Neonatal morbidity: brachial plexus injuries, clavicle fracture, increased intracranial pressure,
neurological injury related to asphyxia, death. Reduction of the time of delivery of the head to the
body is crucial.
Risk factors: fetal macrosomia (over 4,500 grams), maternal diabetes, hx of shoulder dystocia,
protracted labor or prolonged second stage, excessive weight gain.
Maternal complications: severe perineal lacerations (including 4th degree), symphyseal
separation and peripheral neuropathy, sphincter injuries, infection, bladder injury, postpartum
hemorrhage.
First intervention: McRoberts maneuver. Two assistants each grasp a maternal leg and sharply
flex back the thigh against the maternal abdomen (cephalad rotation of the symphysis pubis and
flattens out the lumbar lordosis to free an impacted shoulder). Pressure applied above the pubic
bone with palm for fist, pressure is then directed on the anterior shoulder downward (below pubic
bone) and laterally (toward fetus’s face or sternum) to abduct and rotate the anterior shoulder.
Avoid fundal pressure.
Posterior arm delivery if above fails. Episiotomy intervention is controversial
Straight catheter if bladder is distended to make more room. Mother should not push, only when
instructed or shoulder is released. There is also a Zavanellie maneuver (pushing the head back
into the birth canal) followed by c-section.

Review Dysfunctional labor/ Slow to progress/ Protracted Active phase: Nursing interventions to
assist progress
Labor dystocia: slow abnormal progression of labor. Leading indication of c-section births. Related to
Powers of labor (uterine contractions and maternal expulsive effort), Passenger (fetal presentation,
position, development), and Passage (maternal bony pelvis or soft tissue).
Risk factors: congenital uterine abnormalities (bicornuate uterus), malpresentation of the fetus
such as occiput posterior, or face presentation, cephalopelvic disproportion, tachysystole of the
uterus with oxytocin, maternal fatigue and dehydration, early labor anesthesia or analgesic,
extreme maternal fear or exhaustion (catecholamine release that interferes with uterine
contractility)

Uterine dystocia: slow and abnormal labor including the lack of progressive cervical dilation.
 Hypertonic uterine dysfunction: uncoordinated uterine activity. Contractions: frequent and
painful. Dilation and effacement: ineffective. Promote rest, administer pain medication like
morphine to decrease labor contractions and allow uterine rest, promote relaxation with a warm
shower or bath, quiet environment, and minimal interruptions. Hydrate with IV or PO,
dehydration can result in dysfunctional labor. Assess FHR and uterine contractions, evaluate
labor progress with sterile vaginal examination (SVE).

Hypotonic uterine dysfunction: uterine contraction pressure is insufficient (intrauterine pressure

catheter (IUPC) is less than 25 mm Hg) and does not promote cervical dilation and effacement.
Assess uterine activity and maternal and fetal status. Stimulate uterine activity to achieve normal
labor pattern by ambulating and changing the women’s position to promote comfort and labor
progress, oxytocin for labor as protocol, hydrate with IV or PO, administer IV fluids to
maximize maternal fluid volume, correct maternal hypotension, and improve placental perfusion.
Evaluate labor with SVE.

Active phase disorders: arrest of labor in the first stage in spontaneous labor. Dilation of more than or
equal to 6 cm with membrane rupture and one of the following: 4 hours or more of adequate contractions,
6 hours or more of inadequate contractions and no cervical change. Oxytocin, vacuum or forceps, c-
section when interventions are ineffective, assess fetal descent and station with SVE. Evaluate fetal
response to pushing. Facilitate the second stage of labor by coaching in bearing-down efforts, minimizing
the Valsalva maneuver by using open glottis push strategies, maintain pain relief, upright position, and
support involuntary pushing efforts.

What is the definition for “Second stage arrest? “ For a multip vs. A Nullip/ With regional
anesthesia/ without? Box 10-1.pg 328
Nulliparous: lack of continuing progress for 3 hours with regional anesthesia or 2 hours without regional
analgesia or anesthesia. Increased risk for operative birth, peripartum morbidity, and adverse neonatal
outcomes with no progress for 4 hours or more with an epidural. 3 hours or more without an epidural.

Multiparous: lack of continuing progress for 2 hours with regional anesthesia or 1 hour without regional
anesthesia. Second stage of 3 hours or longer increases the risk for operative birth, peripartum morbidity,
and adverse neonatal outcomes. 3 hours or more with an epidural. 2 hours or more without an epidural.

Oxytocin Drug Calculations: IV piggyback. High-alert.

10 units in 1,000 mL of LR with an infusion rate of 1 mU/min = 6 mL/hr
20 units in 1,000 mL of LR with an infusion rate of 1 mU/min = 3 mL/hr
Low dose start: 0.5 mU/min → increase 1-2 mU/min every 30-60 minutes (most appropriate
and commonly used)

Labor induction: hypothalamus → posterior lobe of the pituitary gland → maternal circulation →
stimulates uterine contractions. Uterine response 3-5 minutes after IV administration. 10 minute
half-life.
Safe administration of Oxytocin…
Decrease dosage rate when contractions are too frequent, discontinue when fetal status is indeterminate or
abnormal, increase when uterine activity AND labor progress are inadequate. Goal: establish uterine
contraction patterns that promote cervical dilation of 1 cm/hr once in active labor. Titrate dose to
maternal-fetal response to labor. If discontinued for 20-30 minutes, FHR is reassuring, and uterine
tachysystole is not present, oxytocin can be restarted. If discontinued for 30-40 minutes, it has been
metabolized and oxytocin will need to be restarted at the initial dose.
MUST be at least 39 completed weeks’ gestation
Necessary nursing assessments of fetal well-being and uterine contractions
3 uterine contractions in 10 minutes, last 40 to 60 seconds, 25-75 mm Hg intensity with IUCP, less than
20 mm Hg for resting tones, 1 minute between contractions.
Contractions should not be more frequent than every 2 minutes.
Reevaluate when dosage rate reaches 20 mU/min.
Frequency, intensity, during, and resting tone of the contraction can impede uterine blood flow →
fetal compromise.
Intermittent auscultation with FHR and uterine contraction evaluation at least every 30 minutes in active
labor and every 15 minutes in the second stage of labor.
Monitor contractions (strength, frequency, duration) and FHR every 30 minutes.
Palpate of IUPC for resting tone.
Monitor labor progress (1 cm/hr)
What is tachysystole?
More than 5 contractions in a 10 minute time period (averaged over 30 minutes), a series of single
contractions lasting 2 minutes or more, contractions of normal duration occurring within 1 minute of
each other, insufficient uterine resting tone.
Leads to category II (indeterminate) or category III (abnormal) FHR pattern (primary complication of
oxytocin in labor). Blood flow is interrupted to the fetus.
Interventions: discontinue oxytocin, left lateral position, IV hydration (at least 500 mL LR), non
rebreather 10 L/min, consider terbutaline (no response), notify, observe, reevaluate

What medications are used to ripen a cervix? Is Misoprostil FDA approved? What is a
mechanical option to ripen the cervix?
Cervidil (dinoprostone): 10 mg reservoir. Remain supine or lateral position for 2 hours after insert. FHR
and uterine contraction monitoring while in place and 15 minutes after removal. Delay oxytocin for 30-
60 minutes after removal. Not recommended with previous c-section or uterine scar. Tachysystole can
occur within 1 hour in 5% of patients.
Misoprostol (cytotec): 25 mcg in the posterior vaginal fornix Q3-6 hrs. Do not exceed 50 mcg.
Tachysystole can occur, more common than with prostaglandins or oxytocin.. PO is not as effective but
has fewer risks. Continuous FHR and uterine contraction monitoring. Delay oxytocin at least 4 hours
after the last dose. 2 hours after PO. Not recommended with previous c-section or uterine scar. Peak
action 1-2 hours. NOT FDA approved.

Mechanical: hygroscopic dilators (laminaria, lamicel, dilapan) are placed into the cervix as many that
will fit and will expand over 12-24 hours from water absorption. Water absorption from the cervical tissue
helps with the dilators expansion and cervix opening (prostaglandin release).
Transcervical balloon catheters: Cook balloon or deflated Foley catheter, 16-18 french with a
30 mL balloon. Inserted into the extra-amniotic space with 30-60 mL of sterile water. Rests
between the internal os. Effective for preinduction, cervical ripening from direct pressure,
overstretching of the lower uterine segment and cervix, releases local prostaglandin. Balloon falls
out when cervical dilation occurs.
Artificial rupture of membranes and nursing care/ monitoring
● Risks: severe variable decelerations, bleeding (undiagnosed placental abnormality), umbilical
cord prolapse, intraamniotic infection
● Assess FHR before, during, and immediately following ROM (umbilical cord prolapse)
● Assess color, amount, and odor of amniotic fluid
● Document time of AROM, indication for, amount, color, odor, FHR characteristics before, fetal
response after, cervical status, fetal station
● Temperate Q 4 hrs
● Pericare from continued fluid leakage

What are clinical indicators for Chorioamnionitis/ Triple I?

Chorioamnionitis: inflammation with bacteria, virus, fungus, or other infectious agent invasion.
● Maternal fever (greater than 100.4 F/37.8C)
● Maternal (greater than 120) and/or fetal tachycardia (greater than 160 to 180)
● Elevated WBC (15,000 to 18,000)
● Uterine tenderness
● Purulent fluid or purulent discharge
● Hypotension
● Diaphoresis
● Cool or clammy skin
Triple 1: fever without a clear source with:
● Baseline fetal tachycardia (greater than 160 for 10 minutes or longer, excluding accelerations,
decelerations, and periods of marked variability)
● Maternal WBC greater than 15,000 (corticosteroid absence)
● Purulent fluid
● Amniocentesis infection with positive Gram stain
● Low glucose or positive amniotic fluid culture
● Placental pathology revealing infection features

Nursing post-operative care for C-S in prevention of Bleeding, Infection, (REEDA assessment)
DVT complications. Read pg. 388
Most common PPH: uterine atony, genital tract lacerations, retained placental tissue, placental abruption.
1,500 mL or more. Tachycardia, hypotension. Blood transfusion. Common for DIC to develop d/t blood
loss depleting coagulation factors.

VTE risk is 4 times greater after a c-section compared with a vaginal birth. DVT is at 80% and PE is at
20%. PE is an acute event. S&S: dyspnea, tachypnea, chest tightness, SOB, hypotension, decreasing
oxygen saturation levels.

C-sections are a huge risk factor for infection. S&S: purulent drainage, erythema, fever, pain, and wound
dehiscence. Develops 4-7 days after c-section. Endometritis is usually diagnosed within the first few days
after delivery. Fever is the most common sign along with chills, uterine tenderness, and foul-smelling
lochia.

Understand Preeclampsia and calculating Magnesium Sulfate

Preeclampsia: hypertensive pregnancy disorder. New-onset of HTN after 20 weeks with two
BP readings of at least 140 and/or at least 90 with taken 4 hours apart. Proteinuria greater than
300 mg in 24 hours, protein creatinine ratio of 0.3 mg/dL or higher, or new-onset systemic
disease. Severe: 160 or higher and/or 110 or higher. Syndrome of reduced organ perfusion
secondary to vasospasm and endothelial activation. Proteinuria is no longer an inclusion criteria
for diagnosis. Increases fat deposition within the liver, renal insufficiency, coagulation system is
activated, endothelial damage to the brain, retinal arterial spasms (blurring, double vision),
pulmonary edema.

Magnesium sulfate: IV access, load 4-6 grams 10% magnesium sulfate in 100 mL solution
over 20 minutes. Maintenance dose is 1-2 grams/hr. No IV access: 10 grams of 50% solution IM
(5 g each buttocks). Contraindications: pulmonary edema, renal failure, myasthenia gravis.
Used to prevent seizures. Calcium gluconate for magnesium toxicity.

What is the benefit to the baby for growing to term, “The full 40” pg.333
Before 40 weeks is associated with prematurity, c-section, hemorrhage, and infection. Before 37 weeks,
babies are at risk for breathing problems, feeding issues, jaundice, low blood sugar, and problems
stabilizing body temperature.
Preterm: less than 37 weeks. Late preterm: 34 weeks through 36 weeks and 6 days. Term: greater than or
equal to 37 weeks. Early term: 37 weeks through 38 weeks and 6 days. Full term: 39 weeks through 40
weeks and 6 days. Late term: 41 weeks through 41 weeks and 6 days. Post term: greater or equal to 42
weeks.

Postpartum at Risk

Review Postpartum normal involution – uterine positions, lochia

Firm and midline. 12 hours: level of umbilicus or 1 cm above umbilicus. 24 hours: fundus 1 cm
below umbilicus.

Rubra: days 1-3, bloody with small clots, moderate to scant amount, increased flow on standing
or breast feeding, fleshy odor.

Seriosa: days 4-10, pink or brown, scant amount,, increased flow during physical activity, fleshy
odor.

Alba: day 10, yellow to white in color, scant amount, fleshy odor.

Review normal postpartum breast changes

24 hours: soft and nontender. Postpartum day 2: slightly firm and nontender. Postpartum day 3:
firm, tender, and warm to touch.

Recognize differences and nursing care between engorgement and mastitis

Mastitis: inflammation or infection of the breast tissue, usually in just one of the breasts. Usually
develops in the first 3-6 months. Staphylococcus aureus is the most common organism.
 Contributing factors: hx of mastitis or partial plugged duct, cracked or sore nipples, oversupply
of milk, infrequent or missed feedings, using only one position, tight-fitting bra, rapid weaning
Assessment: breast tenderness or warm to touch, malaise, muscle ache, breast swelling and
hardness, pain or burning sensation continuously or while breastfeeding, skin redness, fever of
101F (38.3C)
Actions: PO antibiotics, culture of expressed milk from affected breast if infection does not
resolve, continue to pump and breastfeed, hand washing importance, methods to decrease nipple
irritation (correct infant latch-on and removal from breast, more than one breastfeeding position,
air-drying nipples after feedings), consider larger bra size for breast size changes, massaging the
breast during feedings especially over tender areas, empty both breasts fully during breastfeeding,
warm compresses

Engorgement: tenderness, firmness, warmth, enlargement. Can be from an increased lymphatic and
systems within the breast and milk accumulation. Warm to touch, throbbing sensation in the breasts,
elevated temperature, difficulty latching with severe engorgement.

Review PPH causes: Tone, Tissue, Trauma, Thrombin disorder and nursing
interventions for each.
Tone: uterine atony
Factors: larger baby, high parity, rapid labor, fever, fibroids
S&S: bleeding may be slow and steady or profuse. Large, boggy uterus. Clots.
Actions: Fundal massage and medications, monitor bleeding (weight pads and chux), maintain
fluid balance, monitor VS and lab results, O2 10L/min via face mask, keep warm

Tissue: retained placental fragments

Factors: retained or abnormal placenta
S&S: uterus may not respond to interventions, uterus may remain larger than normal, strings of
tissue may be seen in blood
Actions: provider → may need D&C, monitor signs for shock, oxygen if indicated

Trauma: lower genital tract lacerations

Factors: lacerations
S&S: firm uterus with continued bleeding, steady trickle of unclotted, bright red blood
Actions: call provider to evaluate, locate, and repair, monitor VS and lochia, weigh pads and
chux for blood loss

Factors: hematoma (vulva, vaginal, cervical, or retroperitoneal)

S&S: firm uterus, sudden onset of painful perineal pressure, bulging area just under the skin,
difficulty voiding or sitting
Actions: assess for visible hematoma, call provider to assess, possible excision and ligation if
greater than 3 cm, consider indwelling catheter, assess VS, blood loss, and fluid maintenance,
provide pain management, including ice

Thrombin disorders: DIC

Factors: preeclampsia, stillbirth
 S&S: disseminated (systemic) intravascular coagulopathy (DIC), oozing from IV sites,
nosebleeds, petechiae, bleeding gums, hypotension and other signs of shock, abnormal clotting
values
Actions: early recognition for survival, confirm accurate blood loss estimates, monitor lab values,
VS, and I&Os, manage systemic manifestations (volume replacement, platelets IV, and oxygen
by mask 10 L/min)

Uterine atony causes and nursing interventions for prevention and care (Review Priority
Care)
Decreased tone in the uterine muscle. Major cause of PPH.
● Sofy, boggy
● Saturation of peripad in 15 minutes
● Slow and steady or sudden and massive bleeding
● Blood clots
● Pale color and clammy skin
● Anxiety and confusion
● Tachycardia
● Hypotension
Often occurs in women who:
● Uterus was overdistended by a multiple pregnancy or large fetus
● Given birth more than 5 times
● Prolonged or dysfunctional labor with or without oxytocin
Medical management:
● Active bleeding: oxytocin, methylergonovine, misoprostol, and carboprost to stimulate
uterine contractions
● Bimanual compression of the uterus
● NS or LR at a ratio of 3 to 1, 3 L IV replacement per liter of estimated blood loss
● Blood replacement
● Platelets, FFP, cryoprecipitate replacement for massive obstetric shock
● Uterine packing with gauze or uterine tamponade (catheter with a 300 mL balloon of
saline for pressure on the vessels to stop the bleeding)
● D&C or hysterectomy if indicated, when all over treatments fail
Nursing actions:
● Assess for displaced uterus (can be to the left if bladder is overdistended and cause it to
relax). Bathroom, bedside commode, or bedpan and then reassess location and firmness
of fundus and amount and characteristics of lochia. Catheterize if she cannot void.
● If boggy, massage and reassess every 5 to 15 minutes. Baby to breast for oxytocin
release.
● Assess lochia for amount and clots. Express clots (can interfere with uterine
contractions), weigh bloodied pads and linen. 1g = 1mL of blood.
● Review H&H
● IV site with large bore
● Administer medications to stimulate uterine contractions
● Start and monitor blood transfusions as ordered and per protocol
● Emotional support
Medications for postpartum hemorrhage: TXA, Pitocin, Methergine, hemabate and
misoprostol
Oxytocin (pitocin):
Classification: Hormone.
Route: IM or IV, not by IV push. High-alert medication. Store separately so it cannot be
mistaken as an IV fluid bag. Vasopressor and antidiuretic properties.
Dosage: Administer IV with a bolus dose followed by a minimum infusion time of 4 hours after
birth. Beyond 4 hours after birth for high-risk of PPH. Common dose: 20 units in 1 L NS or LR
with an initial bolus rate of 1,000 mL/hr for 30 minutes, followed by a maintenance rate of 125
mL/hr over 3 hours (remaining 10 units).
10 units IM for no IV access.
Action: Stimulates uterine smooth muscle to produce intermittent contractions.
Indication: To control postpartum bleeding after placental expulsion.

Methylergonovine (methergine):
Classification: oxytocic or ergot alkaloids
Route/dosage: PO 200-400 mcg (0.4-0.6 mg) Q6-12 hours for 2 to 7 days. IM 200 mcg (0.2 mg)
Q2-4 up to 5 doses. IV (emergency only) is the same as IM dosage
Action: stimulates smooth and vascular smooth muscles to sustain uterine contractions
Indications: prevent or treat PPH, uterine atony, or subinvolution
Contraindication: HTN

Carboprost (hemabate):
Classification: prostaglandin
Route/dosage: IM 250 mcg into a large muscle or the uterus
Actions: contracts uterine muscle
Indication: uterine atony

Misoprostol (cytotec):
Classification: antiulcer or prostaglandins
Route/dosage: PO or rectally 200 to 1,000 mcg
Action: causes uterine contractions
Indication: to control PPH. Used off label and not approved by the FDA

Tranexamic Acid (TXA) (not a uterotonic):

Classification: antifibrinolytic agent
Considerations: given within 3 hours from the time of delivery
Route/dosage: IV or PO. 1 g IV over 10 minutes (1 g vial to 100 mL non-saline solution over 10
minutes), can be repeated once after 30 minutes

Nursing interventions for→(hematoma)

Trauma from episiotomies, forcep use, and prolonged second stage of labor are common causes.

Ice to perineum for the first 24 hours to decrease risk, assess degree of pain, monitor for decreased BP or
increased HR, pain management, H&H review
Subinvolution expected findings and nursing interventions including drug
administration/teaching
The uterine does not decrease in size and does not descend into the pelvis (arrest or dely of involution)
later in the postpartum period. Can occur in women who have fibroids, endometritis, or retained placental
tissue

Expected findings: uterus is soft and larger than normal for the days postpartum, lochia returns to the
rubra stage and can be heavy, back pain is present

Medical management: ultrasound for intrauterine tissue of subinvolution of the placental site, D&C,
methergine PO for fibroids, antibiotic therapy for endometritis

Nursing actions: review risk factors, monitor those at risk, patient education of involution and to report
increased bleeding, clots, or a change in lochia to bright red bleeding, education on infection reduction

Puerperal Pelvic Infections – UTI, endometritis

UTI:
Risk factors: epidural (decreases urge to void, increased risk for overdistended bladder),
overdistended bladder or incomplete emptying, operative vaginal deliveries, forceps, or vacuum
extractor, intrapartum vaginal exams, urinary catheter, genital tract injury, c-section
Assessment findings: low-grade fever, 101.3F (38.5C), burning on urination, suprapubic pain,
urgency to void, small and frequent voiding less than 150 mL
Medical management: UA, CBC, urine culture and sensitivity, antibiotics
Actions: catheterize if unable to void within 2-3 hours post birth, measure voiding, encourage
hydration, change peripads every 3-4 hours, encourage foods to increase urine acidity (cranberry
juice, apricots, plums)

Endometritis: most common cause of postpartum fever usually starting at the placental site and then
spreads to the entire endometrium
Risk factors: c-sections (primary risk factor), prolonged labor or ROM, internal monitoring,
amnioinfusion, poor nutrition, smoking, anemia, multiple cervical examinations during labor,
pyelonephritis or diabetes
Assessment findings: elevated temperature 100.4F (38C) with or without chills, midline lower
abdominal pain or discomfort, tachycardia, uterine tenderness, subinvolution, malaise, headache,
chills, and lochia is heavy and foul-swelling. Foul-smelling: later sign with the entire
endometrium is involved. Lochia: scant and odorless when streptococcus is present.
Medical management: CBC (WBC greater than 20,000), endometrium cultures, blood cultures,
UA, antibiotic therapy.
Actions: Educate proper pericare, hand washing, and changing peripad every 3-4 hours. Early
ambulation, hydration, high protein and vitamin C diet for tissue healing. Oxytocics to promote
uterine contraction and drainage. Pain management.

DVT : signs and symptoms and nursing interventions

S&S: dependent edema, abrupt unilateral leg pain, erythema, low-grade fever, and positive Homan’s sign
(pain with dorsiflexion)
Tests: doppler ultrasound, magnetic resonance venography, pulsed doppler study
Interventions: anticoagulation therapy. Maintain for 5-7 days IV then convert to subq. Want to achieve
1.5-2.5 PTT. Low-molecular-weight heparins are safe and effective to use throughout pregnancy.
Slightly elevate involved leg, warm packs, measure and compare calf circumferences (2 cm more
different is considered leg swelling), compare pulses, bed rest, ambulation as soon as it is allowed,
anticoagulation therapy with heparin and then use PO warfarin, assess unusual bleeding, generalized
petechiae, bleeding from the mucous membranes, hematuria, or oozing from IV sites. Elastic stockings.
Manage pain.

What are clinical signs of pulmonary emboli?

SOB, tachypnea, tachycardia, dyspnea, pleural chest pain, fever, anxiety

Postpartum blues/depression/psychosis/PTSD – assessment of each and nursing

interventions including safety for infant
Postpartum blues: disappear without medical intervention, within the first 2 weeks postpartum, can
safely care for self and baby.

Postpartum depression: psychiatric interventions, within 12 months postpartum, unable to safely care
for self or baby.
Assessment: sleep and appetite disturbance, fatigue greater than expected, despondency,
uncontrolled crying, anxiety, fear, panic, inability to concentrate, inability to care for self or baby,
decreased affectionate contact with the infant, decreased responsiveness to the infant, thoughts of
harming baby or self, SI
Actions: monitor mother-infant interactions, support groups, interpersonal psychotherapy,
antidepressants, crisis interventions, electroconvulsive therapy, alternative approaches to
treatment (massage therapy, exercise, acupuncture)
Psychosis: rare, but onset is rapid for symptoms and can occur as early as 2-3 days postpartum. Need
acture inpatient psychiatric treatment because maternal suicide and infanticide are major concerns.
Preexisting bipolar disorder is the highest risk.
Assessment: paranoia, bizarre delusions, mood swings, extreme agitation, depressed or elated
moods, distraught feelings about ability to enjoy the infant, confusing thinking, strange beliefs
(mother or her infant must die), disorganized behavior.
Actions: hospitalization to psychiatric unit, psychiatric evaluation, psychotherapy, antidepressant
and antipsychotic drug treatment, electroconvulsive therapy
PTSD:

Parent loss of newborn/ Grief response & Stages and nursing supportive care

Refer to the baby by name, information about the grieving process, opportunity to spend time
with the infant before and after the child dies, provide with memorabilia, hospital chaplain, plan
for autopsy, memorial, funeral, burial, or cremation, support groups.

Sadness and despair, denial, numbness, shock, disbelief, anger, fatigue, sleep disturbances

Postpartum care for a mother with a substance use disorder. Universal Narcan
accessibility/ distribution on discharge
Newborn at Risk

Newborns at risk for cold stress; Reduction of cold stress

Dry immediately after birth, remove wet linen, cover the infant’s head with a heat to
prevent heat loss from evaporation. Plastic barriers of polyethylene for preterm infants
(less than 32 weeks). Chemical warming mattress during resuscitation or NICU
transport. Prewarm supplies. Control environment temperature with a servo-control
probe (below the underarm, midaxillary line). 97.7-99.5F (36.5-37.5C). Place premature
and LBW in an incubator. Kangaroo care. Wean from incubator to an open crib when
medically stable and has a weight of 1,600 g or greater.

Newborn resuscitation; initial measures, Initial questions to ask:

Oxygen saturation, blood gas monitoring, CPAP (endotracheal tube and mechanical
ventilation when CPAP is not effective and then high-frequency oscillatory ventilation if
mechanical ventilation is not successful), chest x-ray, blood cultures, antibiotics.

Patent airway, correct placement of endotracheal tube if applicable, maintain oxygen

saturation, suction the airway as needed, monitor VS and blood gas, reduce cold tress,
monitor I&Os, promote rest.

Audible expiratory grunting, nasal flaring, retracting, duskiness or cyanosis, tachypnea

(greater than 60 breaths per minute)

—Is baby term? Color of fluid? Is there a cry? Tone? Color?

—-Place skin to skin while verifying clear airway, dry, warmth, stimulate

Nursing assessment of newborn suspected of birth trauma from labor/birth

interventions→careful scalp eval if forceps or vacuum used. Expected outcomes vs.
Complication for the newborn.

Neurological and behavioral evaluation, serum glucose, electrolyte levels, arterial blood gas,
lactate, blood, urine, CSF cultures, CBC with differential, CT, ultrasound, MRI, skull
radiographs, lumbar puncture, EEG, medications for seizure activity. Respiratory support if
indicated, assess tone, reflexes, and behavior. BP, perfusion, VS.

Hypoglycemia symptoms, diagnosis and care–Glucose Gel

Symptoms: passive, lethargic, difficult to arouse, irritability, high-pitched cry, tremors,

seizure, tachypnea, apnea, cyanosis

Diagnosis: POC glucometer, plasma glucose confirmed by laboratory

Care: oral feed skill need to be assessed and supported, gavage feedings may be
indicated, IV fluid, monitor Q 30 Min after feeding to evaluate response to
treatmentment, 40% dextrose gel by syringe (first option in the first 48 hours of life), 10%
dextrose and water IV. The gel is made up of 40% glucose, water, and glycerin.
 Infants born of diabetic mothers – risks for newborn and nursing interventions

Congenital anomalies, skeletal defects, neural tube defects, small left colon syndrome,
seizures

Assessment finding: macrosomia, fractured clavicle or brachial nerve damage,

hypoglycemia, polycythemia, hypocalcemia, hypomagnesemia, hyperbilirubinemia, low
muscle tone, lethargy, poor feeding abilities, respiratory distress

Interventions: Hematocrit, calcium, and magnesium labs, x-ray if indicated, POC glucose
testing, early breastfeeding (1-2 hours of age), frequent oral feedings

Hyperbilirubinemia: distinguish between physiological jaundice and pathological

jaundice. What is the time frame for physiologic jaundice and pathologic jaundice?

Physiological: after the first 24 hours of birth and during the first week of life.
Breakdown of RBCs (hemolysis). 6-8 mg/kg/day of high bilirubin production. Shorter
RBC life span of 70-90 days.

Pathological: when various disorders exacerbate physiological processes that lead to

hyperbilirubinemia.

Conjugated:Parenteral nutrition, idiopathic neonatal hepatitis, biliary atresia, bile

duct stenosis, metabolic and genetic defects, endocrine disorders, infection,
some medications, shock, hypoxic ischemic liver injury

Unconjugated: breastfeeding jaundice (early onset), breast milk jaundice (late

onset), Rh and ABO incompatibilities, glucose-6-phosphate dehydrogenase
deficiency, hemoglobinopathies, bruising, cephalhematoma, intracranial
bleeding, polycythemia, metabolic and endocrine disorders, GI obstruction,
infection

What are risk factors for hyperbilirubinemia. Study important safety measures for
phototherapy for jaundice
Risk factors maternal: american indian, east asian, mediterranean, ABO
incompatibility, Rh incompatibility, breastfeeding, diabetes, oxytocin or bupivacaine
during labor
Risk factors neonatal: delayed cord clamping (increased RBC volume), hypoxia,
asphyxia, acidosis, temperature instability, delayed or infrequent feedings, lethargy,
excessive weight loss, bruising, cephalohematoma, prematurity, G6PD deficiency,
prematurity, bacterial or viral infection
Safety measures for phototherapy: eye shields, only in a diaper, photometer to
measure lamps, plexiglas covering of lights, change neonates position frequently,
observe eyes for discharge and tearing, assess for loose stools, dehydration,
hyperthermia, lethargy, and skin rashes.
Assessment and Care for a substance exposed infant. What does Eat Sleep Console
mean? GIve 3 examples of how to teach caregivers/ parents how to console….
Symptoms within 24-72 hours, but can be delayed up to 2 weeks
Cocaine: irritability, tremors, hypotonia, high-pitched cry, hyperreflexia, frantic fist
sucking, feeding problems, sneezing, tachypnea, abnormal sleep patterns
Alcohol: irritability, hypotonia, hypertonia, tremors, twitching, seizures, intracranial
hemorrhage (pre-term)
Cannabis: can have a negative impact on the fetal brain and adverse outcomes such as
decreased reasoning skills, hyperactivity, impulsivity, decreased attention, lower scores
in reading, math, and spelling
Methamphetamine: limited long-term studies, but associated with anxiety, depression,
attention disorders, visual motor processing
Nicotine and smoking: SIDS, LBW, altered pulmonary function
SSRIs: anxiety at 36 months, increased risk of autism, language difficulties, alterations
in executive functioning
Withdrawal signs: apnea, diarrhea, excessive crying, excoriated skin, fever, high-pitched cry,
hyperreflexia, hypertonia, increased rooting reflex, frantic sucking, irritability or restlessness,
nasal congestion, sneezing, poor feeding, seizures, skin mottling, sleep problems, wakefulness,
sweating, tachypnea, tremors, vomiting or regurgitation, weight loss or failure to gain weight,
yawning, hiccups
Actions: Meconium screening can detect drug use from 20 weeks gestation. Cranial
ultrasound, EEG. Finnegan Neonatal Abstinence Scoring System. Eat, sleep, console.
Morphine (first-line, most common).
Buprenorphine (suboxone), methadone, clonidine, and phenobarbital for opioid use.
Benzodiazepines for alcohol.
Small, frequent feedings with high caloric formula (22-24 calories/oz). Monitor feedings, output,
and weight daily).
Swaddle, pacifier, music therapy, prone, swaddle-bath, acupuncture, minimize stress, holding,
decreased light and noise.
Breastfeeding: contraindicated if taking illicit drugs, polydrug abuse, or HIV. Methadone and
buprenorphine can reduce NOWS signs. Sertraline (Zoloft) and paroxetine (Paxil) do not readily
transfer to the milk. Fluoxetine (Prozac) and breastfeeding is discouraged. THC can stay in milk
for up to 6 weeks.
Eat: 1 to 1.5 oz of formula or breastfeed?
Sleep: sleep for 1 hour? Can be independently or while being held
Console: consoled within 10 to 20 minutes?

Newborn clinical signs of infection/sepsis and nursing interventions

Respiratory: apnea, grunting, retractions, tachypnea, cyanosis

Thermoregulation: hypothermia, fever, temperature instability

Cardiovascular: bradycardia, tachycardia, arrhythmias, hypotension, HTN, decreased perfusion

Neurological: tremors, lethargy, irritability, high-pitched cry, hypertonia, hypotonia, seizures,
bulging fontanels

Gastrointestinal: poor feeding, vomiting, diarrhea, abdominal distention, enlarged liver or spleen

Skin: rash, pustules, vesicles, pallor, jaundice, petechiae, vasomotor instability

Metabolic: glucose instability, metabolic acidosis

Actions: monitor VS, I&Os, and weight. Respiratory support if needed. Monitor glucose
and electrolytes. Labs as ordered. Lumbar puncture for CSF. Antibiotics as ordered.
Feedings, IV fluids, parenteral nutrition as ordered.

GBS newborn infection :clinical symptoms/Nursing care

Primary cause of neonatal meningitis and sepsis. Maternal screening at 36-37 6/7 weeks of
gestation, unless indicated earlier. Early onset sepsis by 12 to 24 hours of age. Penicillin is the
choice medication for intrapartum, IV ampicillin is an acceptable alternative. Penicillin allergy →
cephalosporins (cefazolin). $ hours of antibiotics administration before birth. Use a sepsis early-
onset calculator.

CBC, blood cultures, chest x-ray if respiratory symptoms are present. Ampicillin and
gentamicin should be started right after blood cultures are obtained.

Review Metabolic screening for 1) PKU, 2) Galactosemia 3) CAH 4)Hypothyroid

PKU: lack of an enzyme needed to convert phenylalanine to tyrosine. Can cause physical and
cognitive problems

Galactosemia: lack of enzyme that converts galactose to glucose. Inability to metabolize

lactose. Can result in liver disease, mental retardation, and cataracts.

CAH: congenital adrenal hyperplasia. Cortisol production in inhibited and adrenal hypertrophy
results with excessive adrenal androgen production. Electrolyte imbalances are common.
Females exhibit ambiguous genitalia.

Review the broad spectrum of Congenital anomalies & Nursing care: Cleft lip/palate,
Congenital heart disease, Patent Ductus Arteriosus

Cleft lip/palate: failure to fuse; surgical repair. Feed with a special nipple and upright, burp
frequently.

Congenital heart disease:

PDA: closes within 12-24 hours. Can take up to 96 hours. Findings: heart murmurs, bonding
pulses, widened pulse pressure with decreased diastolic, tachycardia, tachypnea, increased
oxygen demand, apnea. Echo to confirm. Chest x-ray can show left atrium, left ventricle, and
ascending aorta prominence. Diuretics, ibuprofen and indomethacin when indicated. Surgical
ligation is indicated.
Complications of Preterm delivery: Respiratory Distress, Preterm labor and
interventions for fetal lung development- Medication ( prior to birth Betamethasone and
once baby is born- survanta)

Survanta:

Action: reduce surface tension of the alveoli to prevent expiration collapse. Enhances
lung compliance for easier inflation, improves overall oxygenation

Indication: respiratory distress syndrome

Route: endotracheal tube or via a thin catheter or laryngeal mask to avoid intubation
and mechanical ventilation

Dosing: within 15 minutes of birth based on factors such as gestational age less than 27
to 30 weeks (especially if mother did not receive steroids). Rescue therapy for confirmed
RDS initiated within 6 hours of birth for infants with increased oxygen demands (Fi)2
greater than 40%) or need mechanical ventilation

Adverse effects: bradycardia, decreased oxygen saturation, tachycardia, reflux,

gagging, cyanosis, blockage of the endotracheal tube, hypotension

Betamethasone: steroid to help speed up lung development in preterm babies, intrapartum.

Corticosteroid. Reduces incidence of respiratory distress syndrome and intraventricular
hemorrhage

What part of the heel do you stick for a newborn?

Side of the heel.

Please Review Study Guide for Exam 1 & Exam 2! These are highlights, but not necessarily
everything that will be on the exam. There will be case studies, and an emphasis on
recognizing cues, understanding what assessment data/clinical symptoms mean and
indicate as well as appropriate nursing interventions depending on the diagnosis. You are
expected to have read ALL the assigned chapters in your text.

“Critical components” “Nursing Judgements” and Medication sections- as well as the case
studies at the end of each chapter -are excellent resources.

Specially chap 17 especially the boxes (critical component, etc.) and case studies.

Antibiotic and Venous Thromboembolic Prophylaxis

Administer prophylactic antibiotics before surgery to prevent infection in all women undergoing
cesarean birth.
Prophylactic antibiotics given within 60 minutes before the skin incision.
Use narrow spectrum cephalosporin or alternate antibiotics for women with allergies.
Consider adding extended-spectrum prophylaxis for unscheduled cesarean deliveries.
Assess for risk of VTE and consider anticoagulant therapy if necessary.
Apply sequential compression devices before surgery.
Use antiseptic solution for vaginal cleansing preoperatively to reduce surgical site infection.
Initiate continuous electronic fetal heart rate monitoring.
Administer oxygen and assess vital signs as needed.
Consider wet clipping with suction device for pubic hair removal in emergencies.
Ensure timely transition to unscheduled surgical birth.

Sudden unexpected postnatal collapse (SUPC) is a rare occurrence where a seemingly healthy
full-term infant suddenly goes into respiratory and cardiac arrest. The highest risk period is
within the first few hours after birth. To reduce the chances of SUPC during skin-to-skin contact
between the mother and baby, it is crucial to position the baby correctly. The nurse should place
the infant face down on the mother's chest, with the head upright, turned to the side, neck
straight, mouth and nose visible, and limbs flexed. Additionally, the mother should be in a semi-
upright and supported position.

Fetopelvic disproportion arises from diminished pelvic capacity, excessive fetal size, or
both. It can rarely be diagnosed until labor has progressed for some time.
Fetopelvic or Cephalopelvic disproportion (CPD) assessment findings:
FHR may not be in the vertex but may be above the umbilicus.
The SVE reveals the buttocks or face when malpresentation is the cause of dystocia.
The presenting part is not engaged in the maternal pelvis.
There is no fetal descent through the pelvis.

Nursing Actions for Fetopelvic disproportion

Perform Leopold’s maneuver as described to determine the fetal position.

Assess the location of the FHR.
Assess the fetal position with SVE.
Alert the care provider if there is question regarding fetal presentation, position, or absence of
fetal descent.

Labor and Birth at Risk GTPAL

Obstetrical Emergency: Assessment findings and nursing priority emergency care

Vasa Previa → most commonly diagnosed when ROM is accompanied by vaginal bleeding or
fetal distress or death, but it is increasingly diagnosed by antenatal ultrasonography.

Vasa previa nursing actions:

Diagnosed by ultrasound, admitted hospital for surveillance, given corticosteroids to promote
fetal lung maturity, and schedule planned cesarean at 35 weeks.
If bleeding occurs with SVE by nurse, stat bedside evaluation by provider due to urgent cesarean
delivery is needed in cases of vaginal bleeding with suspected vasa previa.
Vasa previa should be suspected when vaginal bleeding with a sinusoidal pattern in FHT tracing.

Rupture of the uterus:

Severe tearing sensation, burning or stabbing pain, contractions, uterine tachysystole or
hypertonus, vaginal bleeding. Maternal assessment findings include hypotension, tachypnea,
tachycardia, and pallor (signs of hypovolemic shock). Fetal response is related to hemorrhage
and placental separation (sudden fetal bradycardia or prolonged late or variable Decelerations
seen before vaginal bleeding/abdominal pain). Ascending station of the fetal presenting part.

Nursing care for rupture of the uterus:

Explain to women/family the interventions that will speed up delivery and the importance of
their assistance.
Request assistance and notify the medical provider and request an immediate bedside eval.
Gain/maintain large-bore IV access.
Stabilize mom with O2, IV fluids, and blood products.
Maintain the women in the lateral position to maximize blood flow.
Prepare for emergency C-section: Insert foley as bladder rupture is associated with uterine
rupture.

Risk Factors for Prolapse of the Umbilical Cord

The primary iatrogenic cause is AROM.
Polyhydramnios, multiple gestation, SROM, preterm ROM, and grand multiparity
Malpresentation of the fetus (such as breech), fetal anomalies, intrauterine growth restriction and
small for gestational age (IUGR/SGA), unengaged presenting part.

Assessment Findings associated Prolapse of the Umbilical Cord

Occult. is neither visible nor palpable and occurs when the cord passes through the cervix
alongside the presenting part of the fetus.
Overt prolapse: the cord presents before the fetus and is visible or palpable within the vagina or
even past the labia.
Complete. During a vaginal examination, the cord is felt as a pulsating mass.
Frank. The cord precedes the fetal head or feet and can be seen protruding from the vagina.
Prolapse of the umbilical cord can lead to FHR decelerations including severe sudden
deceleration. This often occurs with prolonged bradycardia or recurrent moderate-to-severe
variable decelerations.

Nursing Actions for Prolapsed cord

Elevation of the presenting part. Occlusion of the cord may be partially relieved by lifting the
presenting part off the cord with a vaginal exam. The examiner’s hand remains in the vagina,
lifting the presenting part off the cord until delivery by cesarean.
Notify the health-care provider and request immediate bedside evaluation and assistance.
Explain to the woman and family that interventions are necessary to expedite delivery. Ensure
the woman understands the importance of her assistance.
Continue to monitor the fetus.
Recommend position changes such as knee–chest position or Trendelenburg to try to relieve
pressure on the occluded cord, administer O2 at 10 L/min by mask, and give IV fluid hydration
bolus.
Discontinue oxytocin and consider tocolytic agent to decrease uterine activity.
Move toward emergency delivery. If birth is imminent, the provider may proceed with vaginal
delivery. If birth is not imminent, anticipate and prepare for emergency cesarean.
Because a significant percentage of umbilical cord prolapse cases are diagnosed at the time of
amniotomy or SROM, FHR should be evaluated immediately following membrane rupture.

Risk Factors Associated with Shoulder Dystocia

• Fetal macrosomia (weight greater than 4,500 grams).
• Maternal diabetes.
• History of shoulder dystocia.
• Protracted labor or prolonged second stage.
• Excessive weight gain.

Assessment Findings Associated with Shoulder Dystocia

The first sign is retraction of the fetal head against the maternal perineum after delivery of the
head, sometimes referred to as the turtle sign.
Delay in delivery of the shoulders may occur after delivery of the head.

Nursing Actions for Shoulder Dystocia

• Explain the situation to the woman and the family, including the interventions to resolve
dystocia and the importance of the woman’s assistance with maneuvers. Request that the
mother not push.
• The time of shoulder dystocia diagnosis and completion of delivery should be noted.
• Additional nursing, obstetric care provider, and anesthesia assistance should be requested.
• The patient should be positioned so that the health-care provider has adequate access for
performing maneuvers.
• Insert a straight catheter into the woman to empty the bladder if it is distended to make more
room for the fetus.
• A variety of techniques may free the impacted shoulder from beneath the symphysis pubis;
pressure can be applied above the pubic bone or laterally to the pubic bone to dislodge the
anterior shoulder and push it beneath the symphysis.
• The mother should not push except when instructed to and only when it is believed the
shoulder has been released.
• The McRoberts maneuver consists of sharply flexing the thigh onto the maternal. abdomen
to straighten the sacrum.
• The Gaskin all-fours maneuver, in which the woman is placed on her hands and knees, can
facilitate delivery.
• Fundal pressure is controversial and not indicated in shoulder dystocia.
• More aggressive approaches may be warranted in cases of severe shoulder dystocia that are
not responsive to commonly used maneuvers. The Zavanelli maneuver (cephalic
replacement followed by cesarean delivery) has been described for relieving catastrophic
cases but is rarely implemented.
• Notify the neonatal team and prepare for neonatal resuscitation.
• Document the series of interventions and clinical events with time intervals.

Sudden profound fetal bradycardia (less than 80 bpm) is an obstetrical emergency.

Trigger Threshold Parameters
A “red” trigger typically mandates an immediate bedside evaluation.
Temperature; °C <35 or >38
Systolic BP; mm Hg <90 or >160
Diastolic BP; mm Hg >100
Heart rate <40 or > 120
Respiratory rate <10 or >30
Oxygen saturation; % <95
A “yellow” trigger indicates further clinical evaluation.
Temperature; °C 35–36
Systolic BP; mm Hg 150–160 or 90–100
Diastolic BP; mm Hg 90–100
Heart rate 100–120 or 40–50
Respiratory rate 21–30
Oxygen saturation; %

Indications of Primary Postpartum Hemorrhage

A 10% decrease in the hemoglobin or hematocrit postbirth.
Saturation of the peripad within 15 minutes.
A fundus that remains boggy after fundal massage.
Tachycardia (late sign).
Decrease in BP (late sign).

DIC is a dire obstetrical emergency that is a significant cause of maternal morbidity and
mortality and is associated with up to 25% of maternal deaths.
Disseminated intravascular coagulation (DIC) Risk factors.
• Abruptio placentae and AFE.
• Hemorrhage and Sepsis.
• Preeclampsia or eclampsia
• Saline termination of pregnancy
• HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.
• Dead fetus syndrome
• Cardiopulmonary arrest
• Massive transfusion therapy
Disseminated intravascular coagulation (DIC) Assessment Findings
• Prolonged, uncontrolled uterine bleeding
• Bleeding from the IV site, incision site, gums, and bladder
• Purpuric areas at pressure sites, such as BP cuff site
• Abnormal clotting study results, such as low platelets and activated PTT
• Increased anxiety
• Signs and symptoms of shock related to blood loss:
• Pale and clammy skin (patients with white or light skin pigmentation)
• Blue discolored clammy skin (patients with brown or dark skin pigmentation)
• Tachycardia
• Tachypnea
• Hypotension

Disseminated intravascular coagulation (DIC) nursing actions.

• Reduce the risk of DIC.
• Review prenatal and labor records for risk factors.
• Monitor more frequently who are at risk for DIC: maternal VS, urine output assessed hourly to
determine adequate renal perfusion.
• Assess for PPH and intervene appropriately. Early intervention can decrease the risk of DIC.
• Monitor vital signs and immediately report to the MD or CNM abnormal findings, such as
increased heart rate, decreased BP, and change in quality of respirations.
• Obtain IV site with large bore intracatheter as per orders.
• Administer IV fluids as ordered.
• Administer oxygen as ordered.
• Obtain laboratory specimens as ordered.
• Review laboratory results and notify the physician of results.
• Start blood transfusion as ordered.
• Provide emotional support and information to patients and family to decrease anxiety.
• Facilitate transfer to ICU.

Review Dysfunctional labor/ Slow to progress/ Protracted Active phase: Nursing

interventions to assist progress.

What is definition for “Second stage arrest? “For a multip vs. A Nullip/ With regional
anesthesia/ without? Box 10-1.pg 328
First-Stage Arrest:
Spontaneous labor: Greater than 6 cm dilation with ROM and more than 4 hours of adequate
contractions (e.g., more than 200 Montevideo units) or more than 6 hours if contractions are
inadequate with no cervical change.
Induced labor: Greater than 6 cm dilation with ROM or greater than 5 cm without ROM and
more than 4 hours of adequate contractions (e.g., more than 200 Montevideo units), or more than
6 hours if contractions are inadequate with no cervical change.
Second-Stage Arrest
No progress (descent or rotation) for 4 hours or more in nulliparous with an epidural
3 hours or more in nulliparous without an epidural
3 hours or more in multiparous with an epidural
2 hours or more in multiparous without an epidural.

Oxytocin Drug Calculations

Safe administration of Oxytocin
Oxytocin should be discontinued once active labor is established. Close monitoring is required
with a history of prior cesarean birth or uterine scar. Tachysystole (excessively frequent
contractions) should be avoided as it can impede uterine blood flow and compromise the fetus.
Continuous electronic fetal monitoring (EFM) is used during oxytocin administration. If there
are signs of fetal compromise, interventions should be implemented, and the medication may
need to be discontinued. Emotional support and reassurance should also be provided to the
patient. In certain circumstances, the oxytocin infusion may need to be terminated.
1. Requirement that women having elective labor induction be at least 39 completed weeks’
gestation
2. Standard order sets and protocols that reflect a standardized clinical approach to labor
induction and augmentation based on current pharmacological and physiological evidence
3. Standard concentration of oxytocin prepared by the pharmacy
4. Standard definition of uterine tachysystole that does not include a Category III or II (abnormal
or indeterminate) FHR pattern (a contraction frequency of more than five in 10 minutes, a series
of single contractions lasting 2 minutes or more, contractions of normal duration occurring
within 1 minute of each other)
5. Standard treatment of oxytocin-induced uterine tachysystole guided by fetal status
Necessary nursing assessments of fetal well-being and uterine contractions

What is tachysystole?
• Five or more UCs in 10 minutes over a 30-minute window
• A series of single UCs lasting 2 minutes or longer
• UCs occurring within 1 minute of each other
• Insufficient return of uterine resting tone between contractions via palpation or intraamniotic
pressure above 25 mm Hg between contractions via IUPC.

Nursing actions for tachysystole with Category I (normal) FHR pattern:

• Assist mother to a lateral position.
• Provide IV fluid bolus of at least 500 mL lactated Ringer’s (unless contraindicated).
• If uterine activity has not returned to normal after 10 to 15 minutes, decrease oxytocin rate by
at least half; if uterine activity has not returned to normal after 10 to 15 more minutes,
discontinue oxytocin until uterine activity is normal.
Nursing actions for tachysystole with a Category II (indeterminate) or Category III
(abnormal) FHR pattern would also include:
• Discontinue oxytocin and notify the provider.
• Assist with maternal repositioning (left or right lateral).
• Administer an IV fluid bolus of at least 500 mL lactated Ringer’s (unless contraindicated).
• Give O2 at 10 L/min by non rebreather mask (discontinue as soon as possible based on the
FHR pattern).
• Notify the provider of actions taken and maternal-fetal response.
• With category III FHR pattern, request an immediate bedside evaluation.
• Consider terbutaline if no response to above measures.

What medications are used to ripen a cervix?

Agents available to induce cervical ripening include prostaglandin E2 (PGE2) preparations
 (dinoprostone, e.g., Prepidil gel or Cervidil insert) and prostaglandin E1 (PGE1)
preparations
(misoprostol, e.g., Cytotec). These preparations, which are placed in or near the
cervix, produce
cervical ripening by causing softening and thinning of the cervix. Occasionally
these agents can
stimulate labor contractions.
Cervidil; vaginal insert a polymer hydrogel that releases Dinoprostone from 10-
mg reservoir.
Contraindications of Cervidil: Not for women with previous C section or
uterine scar.

Nursing actions on Cervidil

Oxytocin should be delayed for 30–60 minutes after removal.
Cervidil inserted by perinatal nurse when new nurse has demonstrated
competence in insertion.
The woman remains in the supine or lateral position for 2 hours after insert.
Continuous FHR and UC monitoring while med is in place and for 15 minutes
after removal.
1 major advantage of Cervidil is that system can be easily and quickly removed in
the event of
uterine tachysystole or other complications. UCs after 5–7 hours, tachysystole can
occur within
1 hour in up to 5% of patients. Remove if tachysystole or Category II or III FHR.

Misoprostol: 25 (mcg) inserted in the posterior vaginal fornix Q3–6 hrs. Not to exceed 50 mcg.
When used for cervical ripening or induction of labor, 25 mcg placed in the
posterior vaginal
fornix should be considered for the initial dose. Tachysystole and indeterminate or
abnormal
FHR changes have been associated with this medication.
A recent review reports the possibility of rare but serious adverse events,
particularly uterine
rupture, with misoprostol use.
PO route is not as effective, and It associated with fewer indeterminate or
abnormal FHR
patterns and episodes of tachysystole.

Contraindications:
Not recommended for women with previous cesarean section or uterine scar.
Nursing actions on Misoprostol:
Continuous FHR and UC monitoring.
Oxytocin should be delayed until at least 4 hours after the last dose.
 Wide variations in onset of UCs. Peak action 1–2 hours.
Tachysystole more common with misoprostol than with prostaglandins or
oxytocin.
• Obtain informed consent.
• Evaluate prenatal record for indications and contraindications for induction.
• Prostaglandin preparations for cervical ripening (e.g., misoprostol or vaginal
insert) should be
administered where FHR and uterine activity can be monitored continuously for
an initial
observation period (4 hours after intravaginal misoprostol and 2 hours after oral
misoprostol).
With the dinoprostone (Cervidil, PGE) vaginal insert, FHR and uterine activity
should be
monitored continuously while in place and for at least 15 minutes after removal.
• The major risk of the previously noted prostaglandin preparations is uterine
hyperstimulation.
The woman and fetus must be monitored for contractions, fetal well-being, and
changes in the
cervical Bishop score.
• Document baseline cervical exam and Bishop score with SVE.
• Obtain baseline FHR.
• Monitor FHR and uterine activity as indicated based on medication and
institutional policies.

Is Misoprostol FDA approved? This medication is used off label and is not yet approved by the
U.S. Food and Drug Administration (FDA) for this use.

What is a mechanical option to ripen the cervix?

Hygroscopic dilators are products that are placed in the cervix to promote dilation
by absorbing
water. They expand over 12 to 24 hours and release local prostaglandin. They are
primarily used
for pregnancy termination.
Transcervical balloon catheters: A Cook balloon or deflated Foley are also used
for cervical
ripening by applying direct pressure and stimulating the release of prostaglandin.
The balloon
catheter falls out when cervical dilation occurs.
Sweeping or Stripping the Membranes.

Artificial rupture of membranes (Amniotomy) and nursing care/ monitoring:

• Assess the FHR before, during, and immediately following ROM because of the risk of
umbilical cord prolapse.
• Offer comfort and support to the woman, as the procedure may be uncomfortable.
• Assess the color, amount, and odor of amniotic fluid.
• Monitor FHR and UC pattern.
• Document the time of the AROM as well as the indication for amniotomy; amount, color, and
odor of amniotic fluid; FHR characteristics before amniotomy; fetal response after the procedure;
cervical status; and fetal station.
• Assess maternal temperature every 4 hours or more frequently if signs and symptoms of
infection occur.
• Administer pericare as the woman continues to leak fluid after AROM.
• Typically, nurses do not perform an amniotomy. However, there may be individual
institutional policies allowing nurses to perform AROM under specific criteria.

What are clinical indicators for Chorioamnionitis and Triple I?

It explains that chorioamnionitis can have different levels of severity and duration and is often
diagnosed based on certain symptoms such as fever, rapid heart rate, elevated white blood cell
count, uterine tenderness, and discharge. However, the presence of these symptoms does not
always indicate the presence of infection. To clarify terminology, experts suggest using the term
"intrauterine inflammation or infection" or "Triple I" instead of chorioamnionitis. It also defines
isolated maternal fever as a temperature of 102.2°F or higher and emphasizes the importance of
reporting fever to healthcare professionals.
Suspected Triple I is fever without a clear source plus any of the following:
• Baseline fetal tachycardia (greater than 160 beats per minute [bpm] for 10 minutes or longer,
excluding accelerations, decelerations, and periods of marked variability)
• Maternal WBC counts greater than 15,000 per mm3 in the absence of corticosteroids
• Definite purulent fluid from the cervical os
Confirmed Triple I include all of the previously noted items as well as at least one of the
following:
• Amniocentesis-proven infection through a positive Gram stain
• Low glucose or positive amniotic fluid culture
• Placental pathology revealing diagnostic features of infection.
Fever in pregnant women without any specific criteria should be categorized as "isolated
maternal fever." This can be caused by various factors such as epidural anesthesia, prostaglandin
use, dehydration, hyperthyroidism, and excess heat. In cases where a pregnant woman in labor
has a fever and unknown Group B Streptococcus (GBS) status at 37 weeks or later, intrapartum
prophylaxis should be initiated as per CDC guidelines. The text also suggests that the term
"chorioamnionitis" is outdated and overused, and instead recommends using the term "Triple I"
to refer to inflammation of the fetal membranes. The term chorioamnionitis should be reserved
for pathological diagnosis.

Assessment Findings for Chorioamnionitis and Triple I:

• Fetal tachycardia (greater than 160 bpm for 10 minutes or longer)
• Maternal WBC count greater than 15,000 in the absence of corticosteroids
• Purulent fluid from the cervical os (cloudy or yellowish thick discharge confirmed visually on
speculum examination to be coming from the cervical canal)
• Biochemical or microbiologic amniotic fluid results consistent with microbial invasion of the
amniotic cavity.
• Be alert for and report characteristic clinical signs of chorioamnionitis, including:
• Maternal fever (intrapartum temperature higher than 100.4°F [37.8°C])
• Significant maternal tachycardia (greater than 120 bpm)
• Fetal tachycardia (greater than 160 to 180 bpm)
• Purulent or foul-smelling amniotic fluid or vaginal discharge
• Uterine tenderness
• Maternal leukocytosis (total blood leukocyte count greater than 15,000 to 18,000 cells/μL)
• Hypotension
• Diaphoresis
• Cool or clammy skin

Nursing Actions for Intraamniotic Infection, Chorioamnionitis, and Triple 1

• Communicate findings of maternal tachycardia, fetal tachycardia, maternal WBC count above
15,000, maternal GBS status, duration of ROM, duration of labor, purulent fluid, amniotic fluid
evaluation, highest maternal temperature, epidural use of anesthesia, prostaglandin use,
antimicrobial agent(s) or antipyretic used, spontaneous preterm birth, and prior spontaneous
preterm birth to all obstetrical and neonatal team members.
• Administer antipyretics and antibiotics as ordered.

Nursing post-operative care for C-S in prevention of Bleeding, Infection, (REEDA

assessment)
REEDA → Redness, Ecchymoses, Edema, Discharge, Approximation

Guidelines for Cesarean Delivery on Maternal Request. CDMR refers to elective cesarean
delivery without any medical need, based solely on the woman's request. CDMR should not be
performed before 39 weeks’ gestation unless there are other indications for early delivery. It is
important to inform patients about the increased risks of complications: such as placenta previa,
placenta acreta spectrum, and gravid hysterectomy. Women who desire multiple children are not
recommended to undergo CDMR due to the increased risks. Vaginal delivery is considered safe
and appropriate in the absence of medical or fetal reasons for a cesarean. If a woman's main
reason for choosing cesarean delivery is fear of pain, healthcare providers should offer analgesia
for labor and provide emotional support and childbirth education.

Signs of SSIs include serous or purulent drainage, erythema, fever, pain, and wound dehiscence.
Wound infection complicates 2% to 7% of patients and generally develops 4 to 7 days after
cesarean. Endometritis is usually diagnosed within the first few days after delivery. Fever is the
most common sign. Other signs include chills, uterine tenderness, and foul-smelling lochia.

DVT complications. Read pg. 388

The risk of VTE is four times greater after cesarean birth compared with vaginal birth. The
incidence of VTE, including deep-vein thrombosis (DVT) (80%) and pulmonary embolism (PE)
(20%), is 2.6 per 1,000 cesarean births, with the highest risk occurring in the first few weeks
postpartum. Thromboembolic disease is a leading cause of maternal mortality; 9% of maternal
deaths are attributed to embolism. Therefore, vigilance in risk assessment and prophylactic
measures are indicated for all pregnant and postpartum women. PE presents as an acute event.
Signs and symptoms are dyspnea, tachypnea, chest tightness, shortness of breath, hypotension,
and decreasing oxygen saturation levels.

Understand Preeclampsia and calculating Magnesium Sulfate

Magnesium sulfate is used for severe features of preeclampsia. Although the exact method of
action in seizure prophylaxis is not clearly understood, therapeutic levels of the drug will result
in cerebral vasodilation, thereby reducing ischemia caused by vasospasm.
Magnesium sulfate also slows neuromuscular conduction, depresses the vasomotor center, and
decreases CNS irritability. Magnesium sulfate is given per protocol as an IV piggyback always
via a controlled infusion device.

Continuous intravenous administration:

• Loading dose: 4 to 6 g diluted in 100 mL of IV fluid administered over 15 to 20 minutes
• Continuous infusion: 1 to 2 g/hr in 100 mL of IV fluid for maintenance
• When used for seizure prophylaxis, magnesium sulfate is administered as a secondary
infusion by an infusion-controlled device to achieve serum levels of approximately 4.8 to 8.4
mg/dL (4 to 7 mEq/dL).
• Laboratory evaluation: Measure serum magnesium level at 4 to 6 hours, after onset of
treatment. Dosage should be adjusted to maintain a therapeutic range of 4.8 to 9.6 mg/dL (4 to
8 mEq/L).
• Duration: Intravenous infusion should continue for 24 to 48 hours postdelivery.
• The antidote for magnesium toxicity is calcium gluconate 1 g of 10% solution given IV slowly
over 5 to 10 minutes.

Magnesium Sulfate Contraindications: Pulmonary edema, renal failure, myasthenia gravis

Magnesium Sulfate adverse effect: Maternal:

Nausea/Flushing.
Diaphoresis.
Blurred vision/ Lethargy.
Hypocalcemia.
Depressed reflexes.
Respiratory depression-arrest.
Cardiac dysrhythmias.
Decreased platelet aggregation.
Circulatory collapse.
Fetal/neonatal:
 FHR decreased and variability.
Respiratory depression
Hypotonia
Decreased suck reflex.
Signs and symptoms of magnesium toxicity.

Magnesium Sulfate nursing actions:

Monitor serum magnesium levels for a therapeutic level of 4.8 to 9.6 mg/dL (4 to 8 mEq/L).
Keep calcium gluconate immediately available (1 g of 10% solution).
Maintain continuous FHR monitoring.
Assess baseline VS, DTRs, neurologic status, and urine output before beginning infusion and
every 5 to 15 minutes during loading dose, then every 30 to 60 minutes until the patient
stabilizes. Frequency is then determined by the patient’s status and protocol.
Assess deep tendon reflexes (DTRs) every 2 hours. DTRs can be elicited by striking the tendon
of a partially stretched muscle briskly using the flat or pointed surface of the reflex hammer.
Patellar, or knee-jerk, reflexes may be unreliable in women who have had regional anesthesia,
and brachial reflexes should be used. Reflexes are graded on a scale of 0 to +4, with 0 being an
absent reflex and +4 being a hyperactive reflex.

What is the benefit to the baby for growing to term, “The full 40” pg.333

Reduced many complications: such as breathing problems, feeding issues, jaundice, low blood
sugar, and problems stabilizing their own body temperature, infections, SIDS, cesarean surgery,
hemorrhage, etc.

Postpartum at Risk. Review Postpartum normal involution – uterine positions, lochia.

Review normal postpartum breast changes.

Breasts→ Lactation (skin to skin), infection, clogged, crack.

Uterus→ Boggy? Firm? Hold the bottom of the uterus when massaging!!, If off centered (to
the right→ full bladders).
Bladder→ Distended? Peeing? Applies pressure to the uterus bleeding more.
Bowels→ Narcotics cause constipation, Need stool softener? Hemorrhoids?
Lochia→ Odor (should be no odor), Amount (500 mL→ vaginal birth, C-section→1,000
mL), Clotting, Color (Rubra→ bright red, Serosa→ pink, Alba →white, yellow→ normal 2
weeks after), Hemorrhaging is most common 1 hour after birth.
Episiotomy→ Laceration REEDA (redness, edema, ecchymosis, discharge,
approximation→degrees: 1st→not bad, 2nd→1/2 through vagina and anus, 3rd→closer to
anus, 4th→one hole), C-section scar.
Recognize differences and nursing care between engorgement and mastitis.

Massage the fundus with the palm of the hand. Give oxytocin as per the physician’s or midwife’s
postpartum orders [Oxytocin promotes contraction of the uterus, which prevents and controls
postpartum hemorrhage].

Review PPH causes: Tone, Tissue, Trauma, Thrombin disorder and nursing interventions
for each.

Preexisting risk factors for PPH include the following:

• High parity and Previous PPH.
• Previous uterine surgery
• Coagulation defects or medical disorders of clotting
Current pregnancy risk factors for PPH include the following:
• Antepartal hemorrhage and fetal death.
• Uterine overdistention (macrosomia, multiple gestation, or polyhydramnios).
• Chorioamnionitis or intra-amniotic infection.
• Placental abnormality (succenturiate lobe, placenta previa, placenta accreta, abruptio
placentae, hydatidiform mole).
Risk factors for PPH associated with labor and birth include the following:
• Rapid or prolonged labor.
• Use of tocolytic or halogenated anesthetic agents.
• Large episiotomy.
• Operative vaginal birth.
• Cesarean birth.
• Abnormally located or attached placenta.
• Inversion of uterus.

Nursing actions for PPH

Stage 1 May Be Labeled Mild Hemorrhage
Hemorrhage: Blood loss greater than 500 mL to 1,000 mL vaginal OR blood loss greater than
1,000 mL cesarean with normal vital signs and laboratory values.
Initial Steps: Ensure 16G or 18G IV access.
Increase IV fluid (crystalloid without oxytocin).
Insert indwelling urinary catheter.
Perform fundal massage.
Medications: Increase oxytocin, additional uterotonics.
Oxytocin (Pitocin), 10 to 40 units per 500 to 1,000 mL solution.
Methylergonovine (Methergine), 0.2 mg IM (may repeat)
15-methyl PGF2α (Hemabate, Carboprost), 250 mcg IM (may repeat in q15 minutes, maximum
8 doses).
Misoprostol (Cytotec), 800 to 1,000 mcg PR 600 mcg PO or 800 mcg PL.
Blood Bank: Type and crossmatch two units RBCs.
Action: Determine etiology and treat. Consider the 4 Ts—tone (i.e., atony), trauma (i.e.,
laceration), tissue (i.e., retained products), and thrombin (i.e., coagulation dysfunction).
Prepare the operating room, if clinically indicated (optimize visualization and examination).

Stage 2 Moderate Hemorrhage

Hemorrhage: Continued bleeding EBL up to 1,500 mL OR greater than 2 uterotonics with
normal vital signs and laboratory values.
May see some hypotension, tachycardia, and anxiety.
Initial Steps: Mobilize additional help.
Place second IV (16G to 18G).
Draw STAT labs (CBC, coagulation studies, fibrinogen).
Prepare OR.
Medications: Continue Stage 1 medications
Blood Bank: Obtain 2 units RBCs (DO NOT wait for labs. Transfuse per clinical signs and
symptoms). Thaw 2 units FFP.
Action: Escalate therapy with goal of hemostasis.
Huddle and move to Stage 3 if continued blood loss or abnormal vital signs.
Stage 3 or Severe Hemorrhage
Hemorrhage: Continued bleeding with EBL greater than 1,500 mL or greater than 200 mL OR
greater than 2 units RBCs given OR patient at risk for occult bleeding or coagulopathy OR any
patient with abnormal vital signs, labs, or oliguria.
Typically see hypotension; tachycardia; tachypnea; decreased urine output; cool, pale skin;
restlessness; or anxiety.
With hemorrhage of greater than 2,500 mL, patient has lost 40% of blood volume and may be in
shock.
Initial Steps: Mobilize additional help.
Move to operating room.
Announce clinical status (vital signs, cumulative blood loss, etiology).
Outline and communicate plan.
Medications: Continue Stage 1 medications
Blood Bank: Initiate massive transfusion protocol (if clinical coagulopathy, add cryoprecipitate,
and consult for additional agents).
Action: Achieve hemostasis, interventions based on etiology.
Stage 4
Hemorrhage: Cardiovascular collapse (massive hemorrhage, profound hypovolemic shock, or
AFE).
Initial Steps: Mobilize additional resources.
Medications: ACLS.
Blood Bank: Simultaneous aggressive massive transfusion.
Action: Immediate surgical intervention to ensure hemostasis (hysterectomy).

Thrombin disorders symptoms

• Disseminated (systemic) intravascular coagulopathy (DIC)
• Oozing from IV sites
• Nosebleeds
• Petechiae
• Bleeding gums
• Hypotension and other signs of shock
• Abnormal clotting laboratory values

Nursing interventions for Thrombin disorders

• Early recognition is a key factor in survival.
• Confirm accurate blood loss estimates.
• Monitor laboratory values, vital signs, and intake and output.
• Manage systemic manifestations such as volume replacement, platelets IV, and oxygen by
mask at 10 L/min.

Uterine atony causes and nursing interventions for prevention and care (Review Priority
Care)
Tone (uterine atony) etiology:
• Large baby
• High parity
• Rapid labor
• Fever
• Fibroids

Tone (uterine atony) symptoms

• Bleeding may be slow and steady, or profuse
• Large, boggy uterus
• Clots

Nursing actions for Uterine atony

• Assist the uterus to contract via massage or medications.
• Monitor bleeding—weigh pads and Chux (1 gm = 1 mL).
• Maintain fluid balance (may need second IV, Foley catheter).
• Monitor vital signs and laboratory results; blood type and screen if ordered.
• Administer oxygen 10–12 L via face mask.
• Keep patient warm.
• Emptying bladder

Medications for postpartum hemorrhage: TXA, Pitocin, Methergine, hemabate and misoprostol

Nursing interventions for→ (hematoma)

Subinvolution expected findings and nursing interventions including drug

administration/teaching.
Puerperal Pelvic Infections – UTI, endometritis

DVT : signs and symptoms and nursing interventions

What are clinical signs of pulmonary emboli?

Postpartum blues/depression/psychosis/PTSD – assessment of each and nursing interventions

including safety for infant

Parent loss of newborn/ Grief response & Stages and nursing supportive care

Postpartum care for a mother with a substance use disorder. Universal Narcan accessibility/
distribution on discharge

Newborn at Risk

Newborns at risk for cold stress; Reduction of cold stress

Newborn resuscitation: initial measures, Initial questions to ask:

—Is baby term? Color of fluid? Is there a cry? Tone? Color?

—-Place skin to skin while verifying clear airway, dry, warmth, stimulate,

Nursing assessment of newborn suspected of birth trauma from labor/birth interventions

careful scalp eval if forceps or vacuum used. Expected outcomes vs. Complication for the
newborn.

Hypoglycemia symptoms, diagnosis and care–Glucose Gel

Infants born of diabetic mothers – risks for newborn and nursing interventions.

Hyperbilirubinemia: distinguish between physiological jaundice and pathological jaundice. What

is the time frame for physiologic jaundice and pathologic jaundice?
What are risk factors for hyperbilirubinemia. Study important safety measures for
phototherapy for jaundice.

Assessment and Care for a substance exposed infant. What does Eat Sleep Console mean? GIve
3 examples of how to teach caregivers/ parents how to console….

Newborn clinical signs of infection/sepsis and nursing interventions

GBS newborn infection: clinical symptoms/Nursing care

Review Metabolic screening for 1) PKU, 2) Galactosemia 3) CAH 4) Hypothyroid

Review the broad spectrum of Congenital anomalies & Nursing care: Cleft lip/palate,
Congenital heart disease, Patent Ductus Arteriosus

Complications of Preterm delivery: Respiratory Distress, Preterm labor and interventions for
fetal lung development- Medication (prior to birth Betamethasone and once baby is born-
survanta)

What part of the heel do you stick for a newborn?

Chapter 17 notes this will be on final exam.

Breastfeeding moms need extra 500 cal.
When mom pregnant, she needs extra 300 cal.
Anemia might cause postpartum depression. What else can cause postpartum depression?
Telehealth, referrals can help postpartum depression.
The difference between post-partum blue and postpartum depression.
Postpartum blue duration 2 weeks.
What are the nursing interventions for those complications?
What is the s/s of postpartum blue and postpartum depression?
Postpartum free care policy extents to 12 months.
Preterm = low birthweight, and at risk for jaundice and infection.
Infection s/s high pitch cry, fever and hypothermia, tachypnea, bradycardia, hypoglycemia,
Jaundice starts from head to toe, heal stick to confirm.
Nursing intervention promote stool out to expel bilirubin by increase breast feeding volume,
photo light therapy help metabolize the bilirubin. What are the safety concerns for photo light
therapy?
Low Apgar score need assess cord gasses.
Hypoxic need to assess cord gasses will give concrete evidence.
Why cooling the baby? To slow metabolic rate in order to conserve anergy for body. Less
inflammation.
Neonate do not shiver until after 6 months to conserve heat thus lead to cold stress and
hypoglycemia.
Nursing diagnosis:
What are the 3 shunts in fetal circulation for transitioning? Ducts venous, ducts arteriosus,
foramen ovule
What is the newborn screening for all babies? Congenital screening,
What is the infant thresholds worrisome?
How to reduce SIDS?
Resuscitation Initial steps: clear airway from mouth and then nares, warm, position, dry,
stimulate.
Brown fat help baby to stay warm.
Hyperglycemia cause fetal heart abnormally.
Ibuprophen is not good for pregnancy.
Arteries will reflex baby arterial gases.
Vein will reflex mom’s gas exchange status.
Baby chest retraction will have grounding songs for R distress. Nursing intervention with CPAP
oxygen. Prone position for respiration distress. Offer posifier to stimulants brain to stimulants
respiratory systems. Kangaroos care improve respiratory. Keep blood sugar up for respiratory
distress.
Preterm babies need IV nutrition due to lack of sucking reflex.
Screening group B strep bacterial infection can prevent all baby’s meningitis and death.
Tachypnea is indication of infection for baby.
Baby can get virus infections. What are the viruses?
Cold stress cause hyperbilirubinemia