Exam 2: NSG222/ NSG 222 (Latest 2024/ 2025 Update) Family Nursing | Review with Questions and Verified Answers| 100% Correct| Grade A- Herzing
Exam 2: NSG222/ NSG 222 (Latest 2024/
2025 Update) Family Nursing | Review with
Questions and Verified Answers| 100%
Correct| Grade A- Herzing
Q: Performing Leopold Maneuvers
Answer:
Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus
through the use of four specific steps. This method involves inspection and palpation of the
maternal abdomen as a screening assessment for malpresentation. The flat palmar surfaces of the
nurse’s hands with the fingers together palpate the uterus A longitudinal lie is expected, and the
presentation can be cephalic, breech, or shoulder. Each maneuver answers a question:
· Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)?
· Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best
auscultated through the back of the fetus.)
· Maneuver 3: What is the presenting part?
· Maneuver 4: Is the fetal head flexed and engaged in the pelvis?
Q: Fetal Assessment During Labor and Birth
Answer:
A fetal assessment identifies well-being or signs that indicate compromise. The character of the
amniotic fluid is assessed, but the fetal assessment focuses primarily on determining the FHR
pattern. Umbilical cord blood analysis and fetal scalp stimulation are additional assessments
performed as necessary in the case of questionable FHR patterns.
Q: Analysis of Amniotic Fluid
Answer:
Amniotic fluid should be clear when the membranes rupture. Rupturing of membranes is either
spontaneous or artificial by means of an amniotomy, during which a disposable plastic hook (an
Amnihook) is used to perforate the amniotic sac. Cloudy or foul-smelling amniotic fluid
indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to
transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction
(IUGR), maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal
occurrence if the fetus is in a breech presentation. If it is determined that meconium- stained
amniotic fluid is due to fetal hypoxia, the maternity and pediatric teams work together to prevent
meconium aspiration syndrome, which can lead to respiratory distress. This would necessitate
suctioning after the head is born before the infant takes a breath and perhaps direct tracheal
suctioning after birth if the Apgar score is low. In some cases, an amnioinfusion (introduction of
warmed, sterile normal saline or Ringer’s lactate solution into the uterus) is used to dilute
moderate to heavy meconium released in utero to assist in preventing meconium aspiration
syndrome.
Q: Analysis of Fetal Heart Rate
Answer:
Monitoring of the FHR throughout labor and birth is essential to assure fetal well-being to
optimize neonatal outcomes. Analysis of the FHR is one of the primary evaluation tools used to
determine fetal oxygen status indirectly. FHR assessment can be done intermittently using a
fetoscope (a modified stethoscope attached to a headpiece) or a Doppler (ultrasound) device, or
continuously with an electronic fetal monitor applied externally or internally
Q: Category 1 Fetal Heart Rate
Answer:
Category 1 Normal:
Baseline 110-160 bpm
Baseline variability moderate
Present or absent accelerations
Present or absent early decelerations
No late or variable decelerations
Can be monitored with intermittent auscultation during labor
Q: Category 2 Fetal Heart Rate
Answer:
Category 2 Indeterminate: Not predictive of abnormal fetal acid-base status, but requires
evaluation and continued surveillance
Fetal tachycardia (over 160)
Fetal bradycardia (less than 110) not accompanied by absent baseline variability
Absent baseline variability not accompanied by recurrent decelerations
Minimal or marked variability
Recurrent late decelerations with moderate baseline variability
Recurrent variable decelerations accompanied by minimal or moderate baseline variability,
overshot, or shoulders
Prolonged decelerations over 2 min but less than 10 min
Q: Category 3 Fetal Heart Rate
Answer:
Category 3 Abnormal: Abnormal fetus acid-base status, requires intervention
Fetal bradycardia (less than 110)
Recurrent late decelerations
Recurrent variable decelerations (absent or declining)
Sinusoidal Pattern (smooth, undulating baseline)
Q: Non-Pharmacological Measures for Birth
Answer:
Nonpharmacologic measures are usually simple, safe, and inexpensive to use. Many of these
measures are taught in childbirth classes, and women should be encouraged to try a variety of
methods prior to the real labor. Many of the measures need to be practiced for best results and
coordinated with the partner or coach. The nurse provides support and encouragement for the
woman and her partner using nonpharmacologic methods. Continuous Labor SupportContinuous labor support involves offering a sustained presence to the laboring woman by
providing emotional support, comfort measures, advocacy, information and advice, and support
for the partner. Hydrotherapy-Hydrotherapy is the external use of any form of water for health
promotion. Ambulation and Position Changes-Positioning during labor is influenced by cultural
factors, obstetric practices, place of childbirth, technology, and the preferences of the mother and
health care providers.
Application of Heat and Cold
Breathing Techniques
Attention Focusing and Imagery-Visualization or guided imagery uses many of the senses and
the mind to focus on stimuli Effleurage and Massage
Effleurage is a light, stroking, superficial touch of the abdomen, in rhythm with breathing during
contractions. Effleurage and massage use the sense of touch to promote relaxation and pain
relief.
Q: Opioids and Birth
Answer:
Opioids given close to the time of birth can cause CNS depression in the newborn, necessitating
the administration of naloxone (Narcan) to reverse the depressant effects of the opioids.
Opioids may be used for systemic analgesia:
Opioids, such as butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol), morphine,
or fentanyl (Sublimaze)
Opioids are morphine-like medications that are most effective for the relief of moderate to severe
pain. Opioids typically are administered IV. All opioids are lipophilic and cross the placental
barrier but do not affect labor progress in the active phase. Opioids are associated with newborn
respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding
Q: Molding Definition
Answer:
Molding is the elongated shaping of the fetal head to accommodate passage through the birth
canal. It occurs with a vaginal birth from a vertex position in which elongation of the fetal head
occurs with prominence of the occiput and overriding sagittal suture line. It typically resolves
within a week after birth without intervention.
Q: Caput Succedaneum Definition
Answer:
Caput succedaneum describes localized edema on the scalp that occurs from the pressure of the
birth process. It is commonly observed after prolonged labor. Clinically, it appears as a poorly
demarcated soft tissue swelling that crosses suture lines. Pitting edema and overlying petechiae
and ecchymosis are noted. .The swelling will gradually dissipate in about 3 days without any
treatment. Newborns who were delivered via vacuum extraction usually have a caput in the area
where the cup was used.
Q: Cephalhematoma Definition
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Braxton Hicks Contractions Braxton Hicks contractions are typically felt as a tightening or pulling sensation of the top of the uterus. They occur primarily in the abdomen and groin and gradually spread downward before relaxing. In contrast, true labor contractions are more commonly felt in the lower back. These contractions aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix.Braxton Hicks contractions usually last about 30 seconds but can persist for as long as 2 minutes
True Labor Regular contractions, becoming closer together, usually 4-6 minutes apart lasting 30-60 secondsStronger contractions with time, vaginal pressure is feltDiscomfort starts in the back and radiates around towards the front of the abdomenContractions continue no matter what positional change is madeStay home till contractions are 5 min apart lasting 45-60 seconds and are strong enough that conversation during one is not possible
False Labor Irregular, far apart contractionsWeak contractions not getting stronger with time or alternating between strong and weakAbdominal discomfort not in the backContractions may slow or stop with walking or changing positions
What is the Passanger? The fetus (with placenta) is the passenger.
Partner in Birth A caring partner can use massage, light touch, acupressure, hand-holding, stroking, and relaxation; can help the woman communicate her wishes to the staff; and can provide a continuous, reassuring presence, all of which bring some degree of comfort to the laboring woman. Although the presence of the mother’s significant other at the birth provides special emotional support, a partner can be anyone who is present to support the woman throughout the experience
Basic Prenatal Education Basic prenatal education can help women manage the labor process and feel in control of the birthing experience. The literature indicates that if a woman is prepared before the labor and birth experience, the labor is more likely to remain natural without the need for medical intervention Prenatal education teaches the woman about the childbirth experience and increases her sense of control. She is then able to work as an active participant during the labor and birth experience
Vaginal Examination The purpose of performing a vaginal examination is to assess the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status and to gather information on presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding Prepare the woman by informing her about the procedure, what information will be obtained from it, how she can assist with the procedure, how it will be performed, and who will be performing it.
Performing Leopold Maneuvers Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. The flat palmar surfaces of the nurse’s hands with the fingers together palpate the uterus A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder. Each maneuver answers a question:· Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)?· Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.)· Maneuver 3: What is the presenting part?· Maneuver 4: Is the fetal head flexed and engaged in the pelvis?
Fetal Assessment During Labor and Birth A fetal assessment identifies well-being or signs that indicate compromise. The character of the amniotic fluid is assessed, but the fetal assessment focuses primarily on determining the FHR pattern. Umbilical cord blood analysis and fetal scalp stimulation are additional assessments performed as necessary in the case of questionable FHR patterns.
Analysis of Amniotic Fluid Amniotic fluid should be clear when the membranes rupture. Rupturing of membranes is either spontaneous or artificial by means of an amniotomy, during which a disposable plastic hook (an Amnihook) is used to perforate the amniotic sac. Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation. If it is determined that meconium- stained amniotic fluid is due to fetal hypoxia, the maternity and pediatric teams work together to prevent meconium aspiration syndrome, which can lead to respiratory distress. This would necessitate suctioning after the head is born before the infant takes a breath and perhaps direct tracheal suctioning after birth if the Apgar score is low. In some cases, an amnioinfusion (introduction of warmed, sterile normal saline or Ringer’s lactate solution into the uterus) is used to dilute moderate to heavy meconium released in utero to assist in preventing meconium aspiration syndrome.
Analysis of Fetal Heart Rate Monitoring of the FHR throughout labor and birth is essential to assure fetal well-being to optimize neonatal outcomes. Analysis of the FHR is one of the primary evaluation tools used to determine fetal oxygen status indirectly. FHR assessment can be done intermittently using a fetoscope (a modified stethoscope attached to a headpiece) or a Doppler (ultrasound) device, or continuously with an electronic fetal monitor applied externally or internally
Category 1 Fetal Heart Rate Category 1 Normal:Baseline 110-160 bpmBaseline variability moderatePresent or absent accelerationsPresent or absent early decelerationsNo late or variable decelerationsCan be monitored with intermittent auscultation during labor
Category 2 Fetal Heart Rate Category 2 Indeterminate: Not predictive of abnormal fetal acid-base status, but requires evaluation and continued surveillanceFetal tachycardia (over 160)Fetal bradycardia (less than 110) not accompanied by absent baseline variabilityAbsent baseline variability not accompanied by recurrent decelerationsMinimal or marked variabilityRecurrent late decelerations with moderate baseline variabilityRecurrent variable decelerations accompanied by minimal or moderate baseline variability, overshot, or shouldersProlonged decelerations over 2 min but less than 10 min
Category 3 Fetal Heart Rate Category 3 Abnormal: Abnormal fetus acid-base status, requires interventionFetal bradycardia (less than 110)Recurrent late decelerationsRecurrent variable decelerations (absent or declining)Sinusoidal Pattern (smooth, undulating baseline)
Non-Pharmacological Measures for Birth Nonpharmacologic measures are usually simple, safe, and inexpensive to use. Many of these measures are taught in childbirth classes, and women should be encouraged to try a variety of methods prior to the real labor. Many of the measures need to be practiced for best results and coordinated with the partner or coach. The nurse provides support and encouragement for the woman and her partner using nonpharmacologic methods. Continuous Labor Support- Continuous labor support involves offering a sustained presence to the laboring woman by providing emotional support, comfort measures, advocacy, information and advice, and support for the partner. Hydrotherapy-Hydrotherapy is the external use of any form of water for health promotion. Ambulation and Position Changes-Positioning during labor is influenced by cultural factors, obstetric practices, place of childbirth, technology, and the preferences of the mother and health care providers.Application of Heat and ColdBreathing TechniquesAttention Focusing and Imagery-Visualization or guided imagery uses many of the senses and the mind to focus on stimuli Effleurage and MassageEffleurage is a light, stroking, superficial touch of the abdomen, in rhythm with breathing during contractions. Effleurage and massage use the sense of touch to promote relaxation and pain relief.
Opioids and Birth Opioids given close to the time of birth can cause CNS depression in the newborn, necessitating the administration of naloxone (Narcan) to reverse the depressant effects of the opioids.Opioids may be used for systemic analgesia:Opioids, such as butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol), morphine, or fentanyl (Sublimaze)Opioids are morphine-like medications that are most effective for the relief of moderate to severe pain. Opioids typically are administered IV. All opioids are lipophilic and cross the placental barrier but do not affect labor progress in the active phase. Opioids are associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding
Molding Definition Molding is the elongated shaping of the fetal head to accommodate passage through the birth canal. It occurs with a vaginal birth from a vertex position in which elongation of the fetal head occurs with prominence of the occiput and overriding sagittal suture line. It typically resolves within a week after birth without intervention.
Caput Succedaneum Definition Caput succedaneum describes localized edema on the scalp that occurs from the pressure of the birth process. It is commonly observed after prolonged labor. Clinically, it appears as a poorly demarcated soft tissue swelling that crosses suture lines. Pitting edema and overlying petechiae and ecchymosis are noted. .The swelling will gradually dissipate in about 3 days without any treatment. Newborns who were delivered via vacuum extraction usually have a caput in the area where the cup was used.
Cephalhematoma Definition Cephalhematoma is a localized subperiosteal collection of blood of the skull which is always confined by one cranial bone. This condition is due to pressure on the head and disruption of the vessels during birth. It occurs after prolonged labor and use of obstetric interventions such as low forceps or vacuum extraction. The clinical features include a well-demarcated, often fluctuant swelling with no overlying skin discoloration. The swelling does not cross suture lines and is firmer to the touch than an edematous area (see Fig. 18.14B). Aspiration is not required for resolution and is likely to increase the risk of infection. Hyperbilirubinemia occurs following the breakdown of the red blood cells within the hematoma. This type of hyperbilirubinemia occurs later than classic physiologic hyperbilirubinemia. Cephalhematoma usually appears on the second or third day after birth and disappears within weeks or months. Large cephalhematomas can lead to increased bilirubin levels and subsequent jaundice
Physiologic Jaundice Physiologic jaundice is very common in newborns, with the majority demonstrating yellowish skin, mucous membranes, and sclera within the first 3 days of life.Jaundice is the visible manifestation of hyperbilirubinemia. It typically results from the deposition of unconjugated bilirubin pigment in the skin and mucous membranes.Physiologic jaundice can be best understood as an imbalance between the production and elimination of bilirubin, with a multitude of factors and conditions affecting each of these processesIn most infants, an increase in bilirubin production (e.g., due to hemolysis) is the primary cause of physiologic jaundice, and thus reducing bilirubin production is a rational approach for its management.
Hypoglycemia Baby Hypoglycemia: Temporary low plasma glucose concentrations are common in healthy newborns. Hypoglycemia affects as many as 40% of all full-term newborns. It is defined as a blood glucose level of less than 30 mg/dL or a plasma concentration of less than 45 mg/dL in the first 72 hours of life. Most newborns experience transient hypoglycemia and are asymptomatic. The symptoms, when present, are nonspecific and include jitteriness, lethargy, cyanosis, apnea, seizures, high-pitched or weak cry, hypothermia, and poor feeding. If hypoglycemia is prolonged or is left untreated, serious, long-term adverse neurologic sequelae such as learning disabilities and intellectual disabilities can occur.Prevent hypoglycemia in newborns at risk by initiating early feedings with breast milk or formula.
Risk Factoris for Hypoglycemia New Born This period of transition is usually smooth, but certain newborns are at greater risk for hypoglycemia: infants of mothers who have diabetes, preterm newborns, and newborns with intrauterine growth restriction (IUGR), inadequate caloric intake, sepsis, asphyxia, hypothermia, polycythemia, glycogen storage disorders, and endocrine deficiencies
Treatment of Hypoglycemia Newborn Treatment of hypoglycemia in the newborn includes administration of a rapid-acting source of glucose such as dextrose gel, breastfeeding or early formula-feeding. In acute, severe cases, intravenous administration of glucose may be required.
How often should breast feeding baby eat Newborns differ in their feeding needs and preferences, but most breastfed ones need to be fed every 2 to 3 hours, nursing for 10 to 20 minutes on each breast.
Formula Fed New Bords Feed How Often and How to determine if they are eating enough Formula-fed newborns usually feed every 3 to 4 hours, finishing a bottle in 30 minutes or less. Daily formula intake for an infant should be 1.5 to 2 oz/lb of body weight, but growth is a better measure of health than the amount of formula consumed. If the newborn seems satisfied, wets six to 10 diapers daily, produces several stools a day, sleeps well, and is gaining weight regularly, then he or she is probably receiving sufficient breast milk or formula.
Feeding Newborn Overview The newborn can be fed at any time during the transition period if assessments are normal and a desire is demonstrated. Before the newborn can be fed, determine his or her ability to suck and swallow. Clear any mucus in the nares or mouth with a bulb syringe before initiating feeding. Auscultate bowel sounds, check for abdominal distention, and inspect the anus for patency. If these parameters are within normal limits, newborn feeding may be started. Most newborns are on demand feeding schedules and are allowed to feed when they awaken. When they go home, mothers are encouraged to feed their newborns every 2 to 4 hours during the day and only when the newborn awakens during the night for the first few days after birth.Generally, newborns should be fed on demand whenever they seem hungry. Most newborns will give clues about their hunger status by crying, placing their fingers or fist in their mouth, rooting around, and sucking.
LATCH Score This assessment is used to help determine if a breast feeding newvorn is feeding appropriately. This assessment helps ensure healthy growth for newborns and prevents nipple integrity of mother
Involution Definition 6 week progress in which there is contraction of muscle fibers, regreneration of epithelium fibers, and shift of hormones that bring uterus back to pre-pregnancy state
What are used to help with fetal descent during labor and labor pains, several different option s dueing the first stage of labor Maternal Position Changes
Largely composed of Wharton’s Jely and is the life line to the fetus till birth Umbilican Cord
Baby Blues Lasts for about 2 weeks after delivery and affects 85% of mothers.
Baby Blue Symptoms Anxiety, depression, mood swings, irritability, tearfulness, fatigue, and increased sensitivity
Nursing Interventions during First Stage of Labor Key nursing interventions include:· Identifying the estimated date of birth from the client and the prenatal chartValidating the client’s prenatal history to determine fetal risk statusDetermining fundal height to validate dates and fetal growthPerforming Leopold maneuvers to determine fetal position, lie, and presentationChecking FHRPerforming a vaginal examination (as appropriate) to evaluate effacement and dilation progressInstructing the client and her partner about monitoring techniques and equipmentAssessing fetal response and FHR to contractions and recovery timeInterpreting fetal monitoring stripsChecking FHR baseline for accelerations, variability, and decelerationsRepositioning the client to obtain an optimal FHR patternRecognizing FHR problems and initiating corrective measuresChecking amniotic fluid for meconium staining, odor, and amountComforting client throughout testing period and laborDocumenting times of notification for team members if problems ariseKnowing appropriate interventions when abnormal FHR patterns presentSupporting the client’s decisions regarding intervention or avoidance of interventionAssessing the client’s support system and coping status frequently
Assessment During First Stage of Labor Nursing care during this stage will include taking an admission history (reviewing the prenatal record); checking the results of routine laboratory tests and any special tests such as chorionic villi sampling, amniocentesis, genetic studies, and biophysical profile done during pregnancy; asking the woman about her childbirth preparation (birth plan, classes taken, coping skills); and completing a physical assessment of the woman to establish baseline values for future comparison.
Nursing Interventions Birth Nursing interventions during this stage focus on motivating the woman, assisting her with positioning, encouraging her to put all her efforts to pushing this newborn to the outside world, and giving her feedback on her progress. If the woman is pushing without progress, suggest that she keep her eyes open during the contractions and look toward where the newborn is coming out. Changing positions frequently will also help her make progress. Positioning a mirror so the woman can visualize the birthing process and how successful her pushing efforts are can help motivate her.The second stage of labor ends with the birth of the newborn. The maternal position for birth varies from the standard lithotomy position to side-lying to squatting to standing or kneeling depending on the birthing location, the woman’s preference, and standard protocols. Once the woman is positioned for birth, cleanse the vulva and perineal areas. The primary health care provider then takes charge after donning protective eyewear, masks, gowns, and gloves and performing hand hygiene.Once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery. As soon as the head emerges, the health care provider suctions the newborn’s mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium. The umbilical cord is double-clamped and cut between the clamps by the birth attendant or the woman’s partner if desired. With the first cries of the newborn, the second stage of labor ends.
Interventions During 3rd Stage of Labor Interventions during the third stage of labor include:Providing support and information about episiotomy and/or laceration if applicableCleaning and assisting the client into a comfortable position after birth, making sure to lift both legs out of stirrups (if used) simultaneously to prevent strainAssessing the woman’s knowledge of breast-feeding to determine educational needs · Educating the woman about latching on, positioning, infant sucking, and swallowingRepositioning the birthing bed to serve as a recovery bed if applicableAssisting with transfer to the recovery area if applicableProviding warmth by replacing warmed blankets over the womanApplying an ice pack to the perineal area to provide comfort to episiotomy if indicated · Explaining what assessments will be carried out over the next hour and offering positive reinforcement for actions · Ascertaining any needs · Monitoring maternal physical status by assessing: o Vaginal bleeding: amount, consistency, and color o Vital signs: blood pressure, pulse, and respirations taken every 15 minutes o Uterine fundus, which should be firm, in the midline, and at the level of the umbilicusRecording all birthing statistics and securing primary caregiver’s signature · Documenting birthing event in the birth book (official record of the facility that outlines every birth event), detailing any deviations
Third Stage of Labor During the third stage of labor, strong uterine contractions continue at regular intervals under the continuing influence of oxytocin. The uterine muscle fibers shorten, or retract, with each contraction, leading to a gradual decrease in the size of the uterus, which helps shear the placenta away from its attachment site. The third stage is complete when the placenta is delivered. Nursing care during the third stage of labor primarily focuses on immediatenewborn care and assessment and observing for signs of placental separation, being available to assist with the delivery of the placenta, recording the time of expulsion, and inspecting the placenta for intactness. The nurse should also be assessing the mother by palpating the uterus before and after placental expulsion. Three hormones play important roles in the third stage. During this stage, the woman experiences peak levels of oxytocin and endorphins, while the high adrenaline levels that occurred during the second stage of labor to aid with pushing begin falling. The hormone oxytocin causes uterine contractions and helps the woman enact instinctive mothering behaviors such as holding the newborn close to her body and cuddling the baby.Skin-to-skin contact immediately after birth and the newborn’s first attempt at breastfeeding further augment maternal oxytocin levels, strengthening the uterine contractions that will help the placenta separate and the uterus contract to prevent hemorrhage. Endorphins, the body’s natural opiates, produce an altered state of consciousness and aid in blocking out pain. In addition, the drop in adrenaline level from the second stage, which had kept the mother and baby alert at first contact, causes most women to shiver and feel cold shortly after giving birth.
Uterine involution The uterus returns to its normal size through a gradual process of involution, which involves retrogressive changes that return it to its non-pregnant size and condition. Involution involves three retrogressive processes:Contraction of muscle fibers to reduce those previously stretched during pregnancyCatabolism, which shrinks enlarged, individual myometrial cellsRegeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochial dischargeOver the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (one fingerbreadth) per day. By 3 days, the fundus lies two to three fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
Late Decelerations This takes less than 30 seconds to reach the nadir and often a sign of decreased perfusion
Amniotic Fluid This fluid is most of the time is usually clear and amount can change between pregnancy and pregnancy. If this changes color its not a good sign
This used to assist in a delivery, often related to maternal fatigue and or fetal distress and delivery is needed to avoid further compromise to the fetus Vacuum Extraction
Acrocyanosis This is a normal finding in newborns as their circulatory system starts to regulate. It is the body’s way of having adequate blood flow to the vital organs byt often leaves the extremities bluish in color
Closure of the Ductus Arteriosus This is a change in fetal circulation that happens between the pulmonary artery and the aorta in the newborn once the placenta is no longer attached
Boggy Uterus Often this presents as not well defined, not at the midline and with increased maternal vaginal bleeding
What is the longest phase of labor Stage One
This often presents with rapid onset of fever, red, painful breasts, and can affect surrounding lymph nodes Engorgement or Mastitis
This is used to monitor progress of labor. This assesses the dilation and effacement of the cervix and can help determine the station of the fetus and presenting part Cervical or Vaginal Exam
Shoulder Dystocia When fetal decent during birth is compromised with fetal body part not fitting through the maternal pelvis, often at the pubic symphysis after the delivery of the head. It is a medical emergency
Meconium This is the first stool that is passed. It is black and tarry-like and a normal finding
This is an accumulation of fluid causing edema on the newborns skull often crossing the suture lines. It tends to be slef limiting and may disappear within a few hours to a few days Caput
Rooting Reflex This happens when the side of the newborns cheek is stroked or touched and causes the newborn to turn their head in that direction often searching for breast or bottle
Postpartum Hemorrhage The blood loss is greater than 500cc for vaginal birth or 1000cc for a caesarean birth
Position (maternal) During Birth Maternal positioning during labor has only recently been the subject of well-controlled research. Scientific evidence has shown that nonmoving, back-lying positions during labor are not healthy. In an upright position, gravity can help in bringing the fetus down, and there is less risk of compressing the maternal aorta which supplies oxygen to the fetus. However, despite this evidence to the contrary, many women continue to lie flat on their backs during labor.Although many labor and birthing facilities claim that all women are allowed to adopt any position of comfort during their laboring experience, many women spend their time on their backs during labor and birth. Women should be encouraged to assume any position of comfort for themChanging positions and moving around during labor and birth offer several benefits. Maternal position can influence pelvic size and contours. Changing position and walking affect the pelvis joints, which may facilitate fetal descent and rotation. Squatting enlarges the pelvic inlet and outlet diameters, and a kneeling positionremoves pressure on the maternal vena cava and helps rotate the fetus from a posterior position to an anterior one to facilitate birthUsing the research available can promote better outcomes, heightened professionalism, and evidence-based practice to childbearing practices. The National Institute for Health and Care Excellence (NICE) guidelines recommend discouraging women from lying supine or semisupine during labor and encourage them to adapt to any other position that they find comfortable since lying on the back is associated with longer labor, increase in surgical births, increased pain, and a higher incidence of fetal heart rate abnormalities.
Benefits for Lie Flat Birth “Some of the reasons why this practice continues include the beliefs that:laboring women need to conserve their energy and not tire themselves.nurses cannot keep track of the whereabouts of ambulating women.it is the preference of the health care provider.the fetus can be monitored better in this position.the supine position facilitates vaginal examinations and external belt adjustment.a bed is “”where one is supposed to be”” in a hospital setting.the position is more convenient for the delivering health care provider.laboring women are connected to medical equipment that impedes movement”
Benefits to Upright/Lateral Position for Birth The use of any upright or lateral position compared to supine or lithotomy positions may:reduce the length of the first stage of labor.reduce the duration of the second stage of labor.reduce the number of assisted deliveries (vacuum and forceps).reduce episiotomies and perineal tears.contribute to fewer abnormal fetal heart rate patterns.increase comfort and reduce requests for pain medication.enhance a sense of control by the mother.alter the shape and size of the pelvis, which assists in descent.assist gravity to move the fetus downward.
Stage One of Labor is Which 2 Phases? Latent and Active
Latent Phase of Labor Latent Phase: Cervix 0-6cm dilated and 0-40% effacement. Nullipara up to 20 hours, Multipara up to 14 hours. Contraction frequency every 5-10 minutes lasting 30-45 secnods. Mild intensity
Active Phase of Labor Active Phase: 6-10cm dilated, 40-100% effacement. Nullipara up to 6 hours, Multipara up to 4 hours. Contractions every 2-5 minutes lasting 45-60 seconds. Intensity is moderate
Stage Two of Labor is Which 2 Phases? Pelvic and Perineal Phases
Pelvic Phase of Labor Fetal Descent
Perineal Phase of Labor Active pushing. Nullipara up to 3 hours, Multipara up to 2 hours. Contractions every 2-3 minutes or less lasting 60-90 seconds. Strong intensity and strong urge to push during late perineal phase
Stage 3 of Labor Placental Separation and Expulsion. Lasts 5-10 minutes or up to 30 min
Stage 4 of Labor After Birth
Purpose of Vaginal Exam The purpose of performing a vaginal examination is to assess the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status and to gather information on presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding Prepare the woman by informing her about the procedure, what information will be obtained from it, how she can assist with the procedure, how it will be performed, and who will be performing it.
Breastfeeding Breastfeeding is a dynamic process, which requires coupling between periodic motions of the infant’s jaws, undulation of the tongue, and breast milk ejection reflex. All mechanisms must be coordinated to be successful. All major health organizations recommend breastfeeding. Nurses have an important role in promoting, supporting, and protecting breastfeeding. They must have the necessary knowledge and skills to provide breastfeeding education to all mothers. Proper positioning, latching-on, sucking, and swallowing are the foundation for successful breastfeeding. Although breastfeeding is recommended by international and national organizations, the nurse must respect and support all mothers in either of the infant feeding methods chosen.
Perinatal Mood Disorders “Perinatal mood disorders are one of the most common complications to occur during the postpartum period, impairing maternal caregiving skills. In the postpartum period, mood disorders can be divided into three distinct entities in ascending order of severity: “”maternal (baby) blues,”” postpartum depression, and psychosis. These disorders, however, have not been clearly demarcated, and it is a matter of much debate whether they are discrete disorders or a single disorder that ranges along a continuum of severity. These symptoms typically peak on postpartum days 4 and 5, may last hours to days, and usually resolve by day 10. Although these symptoms may be distressing, they do not reflect psychopathology, and they typically do not affect the mother’s ability to function and care for her child.”
Taking-In Phase of Becoming a Mother Stage 1: The taking-in phase is the time immediately after birth when the client needs sleep, depends on others to meet her needs, and relives the events surrounding the birth process. This phase is characterized by dependent behavior. During the first 24 to 48 hours after giving birth, mothers often assume a passive role in meeting their own basic needs for food, fluids, and rest, allowing the nurse to make decisions for them concerning activities and care. The taking-in phase typically lasts 1 to 2 days and may be the only phase observed by nurses in the hospital setting because of the shortened postpartum stays that are the norm today.
Taking-Hold Phase of Becoming a Mother Second StageThe taking-hold phase, the second phase of maternal adaptation, is characterized by dependent and independent maternal behavior. This phase typically starts on the second to third day postpartum and may last several weeks.As the client regains control over her bodily functions during the next few days, she will be taking hold and becoming preoccupied with the present. She will be particularly concerned about her health, the infant’s condition, and her ability to care for them
Letting-Go Phase Phase of Becoming a Mother In the letting-go phase, the third phase of maternal adaptation, the woman reestablishes relationships with other people. She adapts to parenthood in her new role as a mother. She assumes the responsibility and care of the newborn with a bit more confidence. The focus of this phase is to move forward by assuming the parental role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy. She establishes a lifestyle that includes the infant. The mother relinquishes the fantasy infant and accepts the real one.
Post Partum Danger Signs Fever more than 100.4°F (38°C)Foul-smelling lochia or an unexpected change in color or amountLarge blood clots, or bleeding that saturates a peripad in an hourSevere headaches or blurred visionVisual changes, such as blurred vision or spots, or headachesCalf pain with dorsiflexion of the footSwelling, redness, or discharge at the episiotomy, epidural, or abdominal sitesDysuria, burning, or incomplete emptying of the bladderShortness of breath or difficulty breathing without exertionDepression or extreme mood swings
Timing of Post Partum Assessments Although the exact protocol may vary among facilities, postpartum assessment typically is performed as follows:During the first hour: every 15 minutesDuring the second hour: every 30 minutesDuring the first 24 hours: every 4 hoursAfter 24 hours: every 8 hours
Postpartum Assessment This postpartum assessment includes vital signs and physical and psychosocial assessments. It also includes assessing the parents and other family members, such as siblings and grandparents, for attachment and bonding with the newborn.As with any assessment, always review the woman’s medical record for information about her pregnancy, labor, and birth. Note any preexisting conditions, any complications that occurred during pregnancy, labor, birth, and immediately afterward, and any treatments provided.Postpartum assessment of the mother typically includes vital signs, pain level, epidural site inspection for infection, and a systematic head-to-toe review of body systems. The acronym BUBBLE-EE
BUBBLE-EE Accronym The acronym BUBBLE-EE—breasts, uterus, bladder, bowels, lochia, episiotomy/perineum/epidural site, extremities, and emotional status—can be used as a guide for this head-to-toe review
What does APGAR stand for? Five parameters are assessed with Apgar scoring. A quick way to remember the parameters of Apgar scoring is as follows:A = appearance (color)P = pulse (heart rate)G = grimace (reflex irritability)A = activity (muscle tone)R = respiratory (respiratory effort)
Scoring for APGAR Each parameter is assigned a score ranging from 0 to 2 points. A score of 0 points indicates an absent or poor response; a score of 2 points indicates a normal response. A normal newborn’s score should be 8 to 10 pointsIf the Apgar score is 8 points or higher, no intervention is needed other than supporting normal respiratory efforts and maintaining thermoregulation. Scores of 4 to 7 points signify moderate difficulty and scores of 0 to 3 points represent severe distress in adjusting to extrauterine life
APGAR Timing Although Apgar scoring is done at 1 and 5 minutes, it also can be used as a guide during the immediate newborn period to evaluate the newborn’s status for any changes because it focuses on critical parameters that must be assessed throughout the early transition period. An additional Apgar assessment is done at 10 minutes if the 5-minute score is less than 7 points..
Congenital Reflexes In the newborn, congenital reflexes are the hallmarks of maturity of the CNS, viability, and adaptation to extrauterine life.The presence and strength of a reflex is an important indication of neurologic development and function. A reflex is an involuntary muscular response to a sensory stimulus.The physical assessment of the neurologic system of the newborn includes evaluating the major reflexes (gag, Babinski, Moro, and Galant) and minor ones (finger grasp, toe grasp, rooting, sucking, head righting, stepping, and tonic neck).To assess each reflex, the nurse progresses methodically, taking care to document each finding
Newborn Neck Assessment Inspect the newborn’s neck for movement and ability to support the head. The newborn’s neck will appear almost nonexistent because it is so short. Creases are usually noted. The neck should move freely in all directions and should be capable of holding the head in a midline position. The newborn should have enough head control to be able to hold it up briefly without support. Report any deviations such as restricted neck movement or absence of head control.Also inspect the clavicles (collarbone), which should be straight and intact.
Newborn Chest Assessment Inspect the newborn’s chest for size, shape, and symmetry. The newborn’s chest should be round, symmetric, and 2 to 3 cm smaller than the head circumference. The xiphoid process may be prominent at birth, but it usually becomes less apparent when adipose tissue accumulates. Nipples may be engorged and may secrete a white discharge. The newborn chest is usually barrel shaped, with equal anteroposterior and lateral diameters, and symmetric. Auscultate the lungs bilaterally for equal breath sounds. Fine crackles can be heard on inspiration soon after birth as a result of amniotic fluid being cleared from the lungs
Promoting Sleep in Newborn “Although many parents feel their newborns need them every minute of the day, babies actually need to sleep much of the day initially. Usually newborns sleep up to 15 hours daily. They sleep for 2 to 4 hours at a time, but do not sleep through the night because their stomach capacity is too small to go long periods without nourishmentParents should place the newborn on his or her back to sleep. To prevent suffocation, all fluffy bedding, quilts, sheepskins, stuffed animals, and pillows should be removed from the crib. Parents should be informed that the practice of “”co-sleeping”” (sharing a bed) is not safeAll newborns develop their own sleep patterns and cycles, but it may take several months before the newborn sleeps through the night. Frequently, newborns have their day and night hours reversed and tend to sleep more during the daytime and less during the night.”
Nursing Interventions for Immediate Newborn During the immediate newborn period, care focuses on helping the newborn to make the transition to extrauterine life. The nursing interventions include maintaining airway patency, ensuring proper identification, administering prescribed medications, and maintaining thermoregulation.Maintaining Airway: Immediately after birth, a newborn is suctioned to remove fluids and mucus from the mouth and nose Typically, the newborn’s mouth is suctioned first with a bulb syringe to remove debris and then the nose is suctioned. Suctioning in this manner helps prevent aspiration of fluid into the lungs by an unexpected gasp.Ensure Proper ID of baby: These ID bracelets are provided for the safety of the newborn and must be secured before the mother and newborn leave the birthing area. The ID bracelets are checked by all nurses to validate that the correct newborn is brought to the right mother if they are separated for any period of timeAdminister Proper medications: Vitamin KEye Prophylaxis: All newborns in the United States, whether delivered vaginally or by cesarean birth, must receive an installation of a prophylactic agent in their eyes within an hour or two of birth.Maintaining Thermoregulation: Assess body temperature frequently during the immediate newborn period. The baby’s temperature should be taken every 30 minutes for the first 2 hours or until the temperature has stabilized, and then every 8 hours until discharge or follow hospital protocols
Nursing Interventions to Maintain Body Temp in Baby Nursing interventions to help maintain body temperature include:Dry the newborn immediately after birth to prevent heat loss through evaporation.Wrap the baby in warmed blankets to reduce heat loss via convection.Skin-to-skin contact with mother as soon as stabilized.Use a warmed cover on the scale to weigh the unclothed newborn.Warm stethoscopes and hands before examining the baby or providing care.Avoid placing newborns in drafts or near air vents to prevent heat loss through convection.Delay the initial bath until the baby’s temperature has stabilized to prevent heat loss through evaporation.Avoid placing cribs near cold outer walls to prevent heat loss through radiation.Put a cap on the newborn’s head after it is thoroughly dried after birth.Place the newborn under a temperature-controlled radiant warmer.
Vernix Caseosa Definition Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus’s oil glands and is found during the first 2 or 3 days after birth in body creases and the hair. It does not need to be removed because it will be absorbed into the skin.
Mongolian Spot Definition Mongolian spots are benign blue or purple splotches that appear solitary on the lower back and buttocks of newborns but may occur as multiple over the legs and shoulders
Milia Definition Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn’s nose. They may also appear on the chin and forehead
Erythma Toxicum Definition Erythema toxicum (newborn rash) is a benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life. It consists of small papules or pustules on the skin resembling flea bites. It is often mistaken for staphylococcal pustules. The rash is common on the face, chest, and back
Harlequin Sign Definition Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. It gives a distinct midline demarcation, which is described as pale on the nondependent side and red on the opposite, dependent side. It results from immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns when there is a positional change. It is transient, lasting as long as 20 minutes, and no intervention is needed.
Skin Condition Assessment Skin Condition and Color: Check skin turgor by pinching a small area of skin over the chest or abdomen and note how quickly it returns to its original position. In a well-hydrated newborn, the skin should return to its normal position immediately. The newborn’s skin often appears blotchy or mottled, especially in the extremities. Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness is called acrocyanosis. It may be seen in newborns during the first few weeks of life in response to exposure to cold. Acrocyanosis is normal and intermittent. Any change in color of the newborn skin needs further investigation.Common skin variations include vernix caseosa, stork bites or salmon patches, milia, Mongolian spots, erythema toxicum, harlequin sign, nevus flammeus, and nevus vasculosus
What to Know About Breastfeeding Breastfeeding is a dynamic process, which requires coupling between periodic motions of the infant’s jaws, undulation of the tongue, and breast milk ejection reflex. All mechanisms must be coordinated to be successful. All major health organizations recommend breastfeeding. Nurses have an important role in promoting, supporting, and protecting breastfeeding. They must have the necessary knowledge and skills to provide breastfeeding education to all mothers. Proper positioning, latching-on, sucking, and swallowing are the foundation for successful breastfeeding. Although breastfeeding is recommended by international and national organizations, the nurse must respect and support all mothers in either of the infant feeding methods chosen.
Urinary System Changes Pregnancy and After Urinary System: During pregnancy, the glomerular filtration rate and renal plasma flow increase significantly. Both usually return to normal by 6 weeks after birth. There is a gradual return of bladder tone and normal size and function of the bladder, ureters, and renal pelvis, all of which were dilated during pregnancy.Many women have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (which inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment labor (antidiuretic effect). These women will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention
Things that Inhibit Urination After Birth perineal lacerations.generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus.hematomas.decreased bladder tone as a result of regional anesthesia.diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor
Urinary Retention Postpartum Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow, and catheterization may be necessary to empty the bladder to restore tone.
Postpartum Diuresis Postpartum diuresis occurs as a result of several mechanisms: the large amounts of intravenous fluids given during labor; a decreasing antidiuretic effect of oxytocin as its level declines; the buildup and retention of extra fluids during pregnancy; and a decreasing production of aldosterone, the hormone that decreases sodium retention and increases urine production. All of these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum. Normal function returns within a month after birth
Postpartum Hair Loss As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen (linea nigra), face (melasma), and nipples gradually fades. Some women experience hair loss during pregnancy and the postpartum periods. The most common period for hair loss is within 3 months after birth, when estrogen returns to normal levels and more hairs are allowed to fall out. This hair loss is temporary, and regrowth generally returns to normal levels in 4 to 6 months in two thirds of women and by 15 months in the remainder, though hair may be less abundant than before pregnancy
Postpartym Striae Gravidarum Striae gravidarum (stretch marks) that developed during pregnancy on the breasts, abdomen, and hips gradually fade to silvery lines. However, these lines do not disappear completely. Although many products on the market claim to make stretch marks disappear, their effectiveness is highly questionable.
Postpartum Diaphoresis The profuse diaphoresis (sweating) that is common during the early postpartum period is one of the most noticeable adaptations in the integumentary system. Many women will wake up drenched with perspiration during the puerperium. This postpartum diaphoresis is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels. It can be profuse at times. It is common, especially at night during the first week after birth. Reassure the client that this is normal and encourage her to change her night clothes to prevent chilling.
Use of Topical Preparations Postpartum Topical Preparations Postpartum: Several treatments may be applied topically for temporary relief of perineal pain and discomfort. One such treatment is a local anesthetic spray such as benzocaine topical. These agents numb the perineal area and are used after cleansing the area with water via the peribottle and/or a sitz bath.Nipple pain is difficult to treat, though a wide variety of topical creams, ointments, and gels are available to do so. This group includes beeswax, glycerin-based products, petrolatum, lanolin, and hydrogel products. Many women find these products comforting.Beeswax, glycerin-based products, and petrolatum all need to be removed before breastfeeding.
Use of Ice Postpartum An ice pack is commonly the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration. An ice pack can minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing
Use of Heat Post Partum The peribottle is a plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad.After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. The change from cold to room temperature therapy enhances vascular circulation and healing. Before using a sitz bath, the woman should cleanse the perineum with a peribottle or take a shower using mild soap. Advise the woman to use the sitz bath several times daily to provide hygiene and comfort to the perineal area.
19 Breastfeeding Teachings “1. Explain that breastfeeding is a learned skill for both parties.2. Offer a thorough explanation of the actions involved.3. Instruct the mother to wash her hands before starting.4. Inform her that her afterpains will increase during breastfeeding.5. Make sure the mother is comfortable (pain-free) and not hungry.6. Tell the mother to start the feeding with an awake and alert infant showing hunger signs.7. Assist the mother in positioning herself correctly for comfort.8. Urge the mother to relax to encourage the let-down reflex.9. Offer a thorough explanation about the procedure.10. Guide the mother’s hand to form a “”C”” to access the breast with thumb on top and other four fingers under the breast.11. Have the mother lightly tickle the infant’s upper lip with her nipple to stimulate the infant to open the mouth wide.12. Aid her in helping the infant latch on by bringing the infant rapidly to the breast with a wide-open mouth.13. Show her how to check that the newborn’s mouth position is correct, and tell her to listen for a sucking noise.14. Demonstrate correct removal from the breast, using her finger to break the suction.15. Instruct the mother on how to burp the infant before changing from one breast to another.16. Show her different positions, such as cradle and football holds and side-lying positions (see Chapter 18).17. Reinforce and praise the mother for her efforts.18. Allow ample time to answer questions and address concerns.19. Refer the mother to support groups and community resources.”