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NSG432 Exam 2 Material - PowerPoint slides, and information the professor gave in class. HIGHLY recommend
Nursing Care of the Childbearing Family (NSG-432)
Grand Canyon University
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DISCLAIMER: FOCUS ON THE PURPLE NOTES! These are the
things that Professor Webster said/highlighted in class. IT IS MOST
LIKELY going to be on the exam. The BLACK is the powerpoints,
the PINK is the speaker notes. The ORANGE (bottom of the
document) is exam questions.
NSG432 Exam 2 Material
TOPIC 3 MATERIAL
Topic 3: Care of postpartum family part 1 MATERNAL PHYSIOLOGIC CHANGES
Postpartum begins after the placenta is delivered Vaginal recovery: 1-2 days > check-up 6 weeks after C/S recovery: 3-4 days > 2 weeks check-up Newborn is assessed 1-2 days after their birth
INVOLUTION > return to the normal state (the end of the third stage of labor- placenta delivery) ◦ Return of the uterus to a non-pregnant state after brith ◦ End of the third stage, funduc is midline, and descends 2 weight approximately 1000 gm ◦ Within 12 hours fundus is above 1 cm ◦ In 24 hours uterus is size of 20 week gestatino (umbilical leve)
◦ After birth fundus moves 2 cm below the umbilicus ◦ 12 hours after delivery, the fundus (top of the uterus) is 1 cm above the umbilicus ◦ 24 hours after delivery, the fundus (top of uterus) is at the umbilicus ◦ Very important to remember is the time
Subinvolution > failure of the uterus to return to a non-pregnant state ◦ Main causes: o retained placental fragments o Infection (because with infection there is swelling, and this inhibits the uterus from returning to its normal state)
Contractions, After pains, Placental Site ◦ Postpartum hemostasis ◦ After pains- more noticeable in multigravida (because the uterus has lost some of its elasticity, so it has to work harder to stay contracted) ◦ Placental site > There is a wound at the placental site. And this wound has to heal. With healing, there is drainage (Lochia). Looks like blood. The main difference between lochia and blood is that lochia does not clot like blood does. o Lochia SHOULD NOT HAVE AN ODOR. If there’s an odor it’s a s/s of infection o Educate them to call the OB doctor if they notice an odor
They will start the patient on broad spectrum antibiotics, and then once the swab culture comes back, determine if further action is needed *** Pitocin is given to keep the uterus contracting and control the bleeding (for vaginal and c/s) ◦ Compression of intra-myometrial blood vessels from uterine muscle contractions ◦ Resolve in 3-7 days ◦ Healed 6 weeks after birth with no scarring ◦ Afterpains more noticeable in births where the uterus was overdistended – macrosomic infant, multifetal gestation, polyhydramnios
Lochia drainage from the placental site (because its healing and with healing theres going to be drainage) (heaviest during the first 24 hours) ◦ Lochia rubra – Red last 1-3 days after delivery (heavier flow) ◦ Lochia serosa – after 3-4 days, turns pinkish color; containing old blood and serum tissue debris. Lasts from day 4- 2 weeks ◦ Lochia alba – about 10-14 days (week 2) after birth discharge becomes yellow to white containing leukocytes, mucus, serum, and bacteria; lasting up to 4-8 weeks ◦ After 8 weeks, the placenta site wound should be healed. ◦ If you get a question about lochia, pay attention to when the patient delivered, that will tell you what stage they should be in note the amount ◦ Scant ◦ Light ◦ Moderate ◦ Heavy
Fundal checks ◦ Follow your hospitals protocol/policy ◦ After delivery, you are required to do 4 checks every 15 minutes x4, then 30 minutes x ◦ You can educate your patient to do their own fundal checks ◦ When doing fundal checks, set your hand at the synthesis pubis- to stabilize and prevent uterine prolapse (be firm but careful with the checks)
Cervix ◦ The cervix is soft immediately after birth ◦ Within 12-18 hours postpartum, it shortens and firms ◦ 2 fingers may still be inserted into the cervix for 4-6 days
◦ Colostrum is available for the baby, at first, but after 1-3 days, prolactin will get to work and have breastmilk for baby ◦ Prolactin interferes with ovulation- BUT DO NOT USE THIS AS BIRTH CONTROL because you are still very fertile after delivery ◦ Ovulation occurs 27 days after delivery in a non-lactating women ◦ Placental hormones- expulsion of the placenta ◦ Estrogen and progesterone levels lowest 1 week post partum ◦ Prolactin rises throughout pregnancy ◦ After birth, levels of estrogen and progesterone decrease, and prolactin increases ◦ Lactating and non-lactating women differ for first ovulation and establishment of menstruation ◦ Ovulation can occur in 27 days in a non-lactating women ◦ Persistence of elevated serum prolactin levels in BF women, suppresses ovulation
Urinary System ◦ 6 weeks for the urinary system to return to the non-pregnant state ◦ Delayed emptying of the bladder and never fully emptied during pregnancy- so it takes 6 weeks for the urinary system to return to a non-pregnant state ◦ Pregnancy ◦ After delivery ◦ Return to non-pregnant state ◦ p kidney function returns to normal by 8 weeks 6 weeks for ureters and pelves. ◦ Diuresis occurs within 12 hours after birth
Urethra and Bladder ◦ Scared to void because of the burning sensation > Educate mom to use the spray bottle (it’s their best friend) ◦ We want moms to void because bladder distention leads to displacement of the uterus and prevents the uterus from staying contracted and this can cause postpartum hemorrhage (potentially leading to DIC) ◦ Trauma to the urethra and bladder ◦ Bladder wall ◦ The decreased urge to void ◦ Bladder tone returns about 5-7 days after birth. Stress incontinence may occur after vaginal birth. Is less common after c/s
Gastrointestinal System ◦ Their appetite returns to normal ◦ Some women get constipated- iron s/e ◦ Keep patient on Iron because of blood loss ◦ Hemorrhoids are likely- another reason we do not want constipation (use Colace, stool softener) ◦ Bowel movements usually return to normal within 2-3 days ◦ Appetite ◦ Bowel evacuation
◦ Decreased peristalsis for 2-3 days after birth and fear of pain with bowel movements.
Breasts ◦ Breastfeeding mothers ◦ Non-breastfeeding mothers ◦ Colostrum- still offers passive immunity (some cultures do not feed their babies colostrum and wait for breast milk- Native Americans) ◦ Milk 72-96 hours after birth with possible engorgement making latch difficult for the infant. ◦ Engorgement-occurs 3-4th postpartum day caused by an increase in blood and lymphatics not milk accumulation ◦ Breast binder, ice, cabbage leaves. Lactation ceases within a week in non-breastfeeding mothers
Cardiovascular System ◦ Blood volume ◦ Pulse rate, stroke volume, and cardiac output ◦ Vital signs ◦ ACOG states that o PPH = 1000 mL o Vaginal delivery: 500 cc = PPH o C/S delivery: 1000 cc = PPH ◦ CBC 24 hours after delivery (both vaginal and c/s) to see if the patient is anemic or lacking blood products/components > blood transfusion ◦ p. ◦ Blood volume-decreases due to multiple factors ad returns to normal by 3rd postpartum day ◦ Output increased by 60-80% over pre-labor values returns to pre-labor values within 1 hour however it takes 6-8 weeks to return to pre-pregnant levels. ◦ Vital signs- Table 18.
Blood Components ◦ Hematocrit ◦ WBC ◦ Coagulation factors ◦ Varicosities ◦ CBC normalizes in about 8 weeks. White count elevated 15-30,000 can obscure signs of infection ◦ Coags remain elevated in immediate postpartum so risk for DVT is still a concern.
Respiratory System ◦ Decrease in intraabdominal pressure ◦ Decrease in intraabdominal pressure ◦ Decline in progesterone causes PaCO2 to rise ◦ Basal metabolic rate
c) Express milk from the breast occasionally to relieve discomfort d) Place absorbent pads with plastic liners into her bra to absorb leakage
A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman’s bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: a) Urinary tract infection. b) Excessive uterine bleeding. c) A ruptured bladder. d) Bladder wall atony.
What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? a) “My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter.” b) “My first menstrual cycle will be heavier than normal and will return to my pre-pregnant volume within three to four cycles.” c) “I will not have a menstrual cycle for 6 months after childbirth.” d) “My first menstrual cycle will be heavier than normal and then light for several months.”
Nursing Care of the postpartum woman ◦ Assist with rest and recovery after birth ◦ Assessment of physiologic & Psychologic adaptation ◦ Prevention of Complications ◦ Education regarding self-care & newborn care ◦ Support of mother & her partner during the transition to parenthood
Recovery care ◦ In a traditional setting, a woman is moved to the postpartum room after recovery (which starts after the placenta is deliver, and lasts 1-2 hours) ◦ In labor, delivery, recovery, and postpartum (LDRP) setting, the woman and infant remain together in a room where the birth occurred ◦ Post-anesthesia recovery ◦ Regardless of obstetric status, no woman should be discharged from the recovery area until completely recovered from anesthesia ◦ Example of charting:
Couplet care ◦ Couplet or mother-baby care ◦ Ongoing physical assessment (of both baby and mother) ◦ Routine lab tests (CBC for mom, and baby gets a lot of tests done- jaundice, O2 etc.) ◦ Nursing interventions ◦ Infant security ◦ Prevention of infant abduction (cord clamp) ◦ Prevention of infection (don’t invite sick families to see the baby, especially premature, because they are at great risk for infection)
◦ Prevention of excessive bleeding (teach mom to be careful and not carry heavy objects) ◦ Uterine atony (when the uterus fails. Something is going on with the uterus so it can not contract > PPH) ◦ Maintenance of uterine tone ◦ Fundal massage ◦ Prevention of bladder distention (encourage mom to void, to avoid displacement of uterus >PPH) (there is often an order for a straight catheter because mom is susceptible to infection ) Labs – CBC, Rhogam workup, rubella status BUBBLE HE assessment table 19. Hypovolemic shock
Physical needs ◦ “Rooming in”: baby stays in the room at all times unless the baby is sick ◦ Promotion of comfort ◦ Non-pharmacologic interventions (ambulation) ◦ Pharmacologic interventions (pain medication > most common PP pain medication is, ibuprofen (Motrin); helps with abdominal cramps) ◦ Promotion of rest (encourage mom to rest whenever baby is sleeping) ◦ Postpartum fatigue ◦ Promotion of ambulation (we encourage mom to ambulate as soon as possible after delivery [c/s or vag.] to prevent DVT) ◦ Reduction of venous thromboembolism ◦ Promotion of exercise ; educate them not to resume until they have visited the OB (vag: 6 weeks, c/s: 2 weeks (?) [baby is 1-2 days] ◦ Safe exercises p.
Planning for discharge ◦ Newborns and Mothers’ Health Protection Act of 1996 ◦ Allows for a minimum of 48 hours stay after vaginal birth and 96 hours after cesarean birth ◦ Criteria for discharge ◦ American Academy of Pediatrics recommendations
Discharge teaching ◦ Self-care, care of newbron and signs of complicatinos ◦ Sexual activity/contraception ◦ Prescribed medications ◦ Routine mother and baby check ups ◦ Activities of daily living at home
Follow up ◦ Home visits ◦ Telephone follow-up ◦ Warm lines ◦ Support groups ◦ Referral to community resources
Which of the following responses after birth indicates that a new mother understands the correct way to do pelvic floor exercises? a) “I contract my thighs, buttocks, and abdomen.” b) “I do 10 of these exercises every day.” c) “I stand while practicing this new exercise routine.” d) “I pretend that I am trying to stop the flow of urine midstream.” ANS: D Feedback A Incorrect: Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. B Incorrect: Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. C Incorrect: The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees. D Correct: The woman can pretend that she is attempting to stop the passing of gas or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward. DIF: Cognitive Level: Analysis OBJ: Patient Needs: Health Promotion and Maintenance TOP: Nursing Process: Evaluation
Topic 3: Transition to parenthood
Parental Attachment if you do not see a mother loving and holding her baby, that should be a red flag- they are not bonding IT IS A NATURAL EVENT
◦ Attachment ◦ Boning ◦ Proximity ◦ Mutuality ◦ Acquaintance (making eye contact with the baby, touching) ◦ claiming process (attachment- identify the newborn in terms of uniqueness) ◦ P 487 ◦ Mutuality – infant’s behaviors and characteristics elicit a corresponding set of parental behaviors and characteristics. ◦ Claiming process – the child is identified in terms of likeness to other family members
Assessment of Attachment ◦ Eye contact ◦ Appropriate behavior ◦ History of parents ◦ 487-490 eye contact, touch, voce, maternal odor. ◦ Parental Role after Birth ◦ Dad might feel a bit neglected because mom is focused on baby and baby bonds with mom ◦ Might need to get another job ◦ Provide support for the dad too because it is also a life change for him ◦ With siblings, there might be a rivalry o Siblings have different responses o Sometimes siblings will start acting out, trying to get more attention because of the shift in attention ◦ Transition to parenthood > for everyone involved; parents, siblings, grandparents ◦ Parental task and responsibilities ◦ Accept the child into the family and reconcile the actual child with the fantasy and dream child.
Postpartum Complications ◦ Hemorrhage ◦ Hypovolemic Shock ◦ Coagulopathies ◦ Venous Thromboembolic Disease ◦ Infections ◦ Mood Disorders
Postpartum Hemorrhage can occur suddenly and without warning every pregnant women are at risk (some are at greater risk, but everyone is at risk) ◦ Using quantitative info instead of estimated- more accurate ◦ Can be early or primary o Early (primary): within 24 hours of giving birth
Etiology & Risk Factors (cont.) ◦ inversion of uterus o turning inside out of the uterus ◦ potentially life-threatening ◦ 1 in 3000 births ◦ Sub-involutions of uterus ◦ Late postpartum bleeding ◦ Retained placental fragment and pelvic infection
Care Management PPH management be vigilant If the patient is standing, put the patient back to bed DO NOT LEAVE THE ROOM/PATIENT 1- Fundal massage (because we want the uterus to contract to stop the bleeding) 2- Do V.: assess (because the goal is to prevent hypovolemic shock) 3- Activate the protocol (every hospital has a protocol- get help and protects you as a nurse because it allows you to give medications without an order) 4- If the patient has IV access, give PITOCIN- LR (30 units- 1000cc) 5- Start a second IV line (it will be available for a blood transfusion- using a rapid infuser [a whole L of blood I infused in 5 minutes]) MAKE SURE THE IV LINE IS PATENT to avoid 6- Foley catheter- to ensure that the patient has an empty bladder (not a straight cath) *a distended bladder prevents uterus contraction)
MEDICATIONS THAT CAN BE GIVEN DURING PROTOCOL (in no particular order) ◦ Cytotec (misoprostol) - 1000 mcg per rectum ◦ Methergine – 0 mg IM (never IV) can be given PO but for PPH PO is too slow o Make sure the patient is not hypertensive for methergine (increases BP, can cause a heart attack, stroke) ◦ Hemobate – 250 mcg IM o Make sure the patient is not asthmatic because it triggers asthma attacks o Common SE Diarrhea Nausea So ask the doctor to order Lomotil or Imodium to make your life easier ◦ Tranexamic acid (TXA)- 1 g (100 mg/mL) IV o VERY EFFECTIVE to control bleeding in a PPH ◦ Pitocin is included
NOTE FROM WEBSTER: If a patient is on magnesium sulfate because of preeclampsia (BP is elevated), their risk for PPH increases because the patient stays on the mag 24 hours after delivery (because of seizure precautions) and magnesium sulfate relaxes the smooth muscles of the uterus (increasing the risk for PPH)
o So they will be given Pitocin, Hemobate, Cytotec, and TXA BUT NOT METHERGINE (will increase BP more)
◦ Bakri balloon (can be used if a patient continues to bleed> and is referred to radiology [they will cauterize]) o 500 cc NS or sterile water o 24 hours, NOT LONGER Because it builds a lot of pressure if it is longer than 24 it could damage uterus more o Taper down 250 cc 125 cc 125 cc ◦ Hysterectomy is a LAST RESORT o Because it is invasive and no more babies ◦ Medical management ◦ Early recognition is critical ◦ First step is evaluation of the contractility of the uterus ◦ Firm massage of fundus ◦ Management is directed toward increasing contractility and minimizing blood loss ◦ p drugs know indications & contraindications.
Management of Causes ◦ Hypotonic uterus ◦ Bleeding with a contracted uterus ◦ Uterine inversion ◦ Sub-involution ◦ Herbal remedies (at home, hospitals don’t do this) ◦ Has been used with some success after initial control of bleeding ◦ Nursing interventions
Hemorrhagic Shock (hypovolemic shock) ◦ Medical management ◦ Nursing interventions ◦ Fluid or blood replacement therapy ◦ Legal tip – standard of care for bleeding emergencies allows for provisions to be made for nurses to initiate actions independently ◦ p. 511 An emergency in which the perfusion of body organs can become severely compromised, and death can occur
Coagulopathies- bleeding disorders ◦ Idiopathic thrombocytopenic purpura (ITP) ◦ Von Willebrand disease—type of hemophilia Will be treated prophylactically ^^^ PITOCIN
◦ Biochemical, psychological, social, cultural ◦ Vulnerable period ◦ If it prolongs (2 weeks or more), it is diagnosed as postpartum depression. o Medication is required ◦ If it continues over a month, and the mom hallucinates (auditory or visual) and hears thoughts about killing the baby = Postpartum psychosis ◦ SUPPORT SUPPORT SUPPORT!!!!
Postpartum Depression ◦ Screening for postpartum depression ◦ Nursing care on the postpartum unit ◦ Nursing care in the home community ◦ Referrals ◦ Providing safety ◦ Psychiatric hospitalization ◦ Psychotropic medications ◦ Other treatments for postpartum depression
TOPIC 4 MATERIAL
Topic 4: Nursing Care of High-Risk Newborns
High-Risk Newborn ◦ High-risk neonate -a newborn, regardless of gestational age or birth weight, who has a greater-than-average chance of morbidity or mortality due to conditions or circumstances associated with birth and adjustment following birth ◦ Classified according to o Birth weight and gestational age o Birth trauma o Maternal substance abuse o Infection o Congenital anomalies
Birth Injuries ◦ Injury sustained during labor and birth ◦ Birth injuries may be avoidable o Ultrasonography allows antepartum diagnosis of macrosomia, hydrocephalus, and unusual presentations o Elective cesarean birth chosen for some pregnancies to prevent significant birth injury ◦ Scalp ◦ Skull ◦ Intracranial ◦ Spinal cord ◦ Plexus
◦ Cranial and peripheral nerve
Birth Injuries ◦ Care management o Skeletal injuries o Peripheral nervous system injuries Erb-Duchenne paralysis (Erb palsy) Facial nerve paralysis Phrenic nerve paralysis o Neurologic injuries
Neonatal Infections ◦ Sepsis- a cause for neonatal mortality
- Herpes, cmv, syphilis
- The baby rash- erythema toxicum
- Common rash
Neonatal Infections ◦ Sepsis o Patterns Early onset or congenital Nosocomial infection—late onset o Care management Signs of neonatal sepsis Treatment Assessment o Prevention
o ◦ Fetal alcohol syndrome babys have a peciliur look o Thin upper lip o Flat midface o Growth restation o Microencephaly
Hemolytic Disorders ◦ Blood incompatibility o Rh incompatibility (isoimmunization) Only Rh-positive offspring of Rh-negative mother are at risk If fetus is Rh positive and mother Rh negative, mother forms antibodies against fetal blood cells o ABO incompatibility ◦ Prevention o Intrauterine transfusion o Exchange transfusion o Care management
Infants of Diabetic Mothers (IDM) ◦ Characteristic appearance o Macrosomia o Increased risk for birth injuries o Increase in congenital anomalies o Adequate thermoregulation o Carbohydrate feedings as appropriate o Serum glucose levels ◦ Clinical manifestations o LGA o Very plump/full face o Abundant vernix
o Plethora- red coloration o listless and lethargic o Possible meconium stained o Hypotonia
Preterm and Post term Infants ◦ Preterm infants o Care management ◦ Late preterm infants ◦ Post term infants ◦ Complications of preterm birth o Respiratory distress syndrome Care management o Necrotizing enterocolitis Care management o Maintaining body temperature ◦ CNS function ◦ Maintaining adequate nutrition ◦ Maintaining renal function ◦ Maintain hematologic status ◦ Resisting infection
Preterm Infant ◦ Infants born before 37 weeks of gestation ◦ Immaturity of most organ systems ◦ Actual cause unknown ◦ Distinct characteristics o Small, scrawny o Large head o Translucent skin o Lanugo ◦ Not all preterm babies end up surviving, it is important for us to anticipate grief, but remain positive for the parents
Late Preterm Infant ◦ Born between 34 and 36 6/7 weeks of gestation ◦ Referred to as late preterm rather than near term ◦ Higher risk for problems related to o Thermoregulation o Hypoglycemia o Hyperbilirubinemia o Sepsis o Respiratory function ◦ Late preterm:
NSG432 Exam 2 Material - PowerPoint slides, and information the professor gave in class. HIGHLY recommend
Course: Nursing Care of the Childbearing Family (NSG-432)
University: Grand Canyon University
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