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NU313 Exam 2 With Complete
Solution
How long is max suctioning for a newborn with bulb? - ANSWER 5-10 sec Normal Newborn RR - ANSWER 30-60 breaths/min Normal Newborn Temp - ANSWER - 97.7 - 99.5 F (Axillary)
- Take 30 mins after birth Normal Newborn HR - ANSWER - 120 - 160 bpm (Apical) at rest
- 160 - 180 bpm when crying
- 100 bpm at rest/sleeping Upon assessing the lungs of a newborn 1 hour after their c-section, you hear moist sounds bilaterally. What further actions should you take? - ANSWER Nothing, sounds of moisture for the first two hours of life is common, more so with C/sections Signs of Respiratory Distress in Newborn - ANSWER - RR > 60 bpm
- Retractions
- Cyanosis
- Grunting
- Nasal flaring
- Choanal Atresia (narrowing or blockage of nasal passages)
- Asymmetric chest rise
- Mewing Periodic Breathing - ANSWER - Pauses in breathing
- Lasts 5-10 seconds without other physiologic changes occurring
- Followed by rapid respirations lasting 10-15 seconds
- Normal finding Apnea - ANSWER - A pause in breathing lasting 20 seconds or more
- Accompanied by cyanosis, bradycardia
- Abnormal finding While assessing a newborn you note their Cap refill is >4 seconds, what further actions should you take? - ANSWER Follow up with provider, normal Cap refill is 3-4 seconds Where is a newborn's apical HR best assessed? - ANSWER 3rd-4th intercostal space lateral midclavicular line S/S of Cardiopulmonary Distress - ANSWER - Absent or weak cry despite stimulation
- Floppy
- Labored breathing
- Bradypnea or tachypnea
- Bradycardia or tachycardia
edema at base
- Dries, turns brownish/black after 2-3 days, falls off within 10-14 days Opthalmia Neonatorum Prophylaxis - ANSWER - Prevents conjunctivitis acquired during birth (gonorrhea & to a lesser degree, chlamydia)
- Prophylaxis within 2 hrs of birth required by MA law
- Erythromycin ophthalmic ointment 0.5% Shots Immediately After Birth - ANSWER - Vitamin K within 1-2hrs of birth
- Hep B within 2 hrs of birth
- Use vastus lateralis site
- Max volume 0.5 mL
- 25 gauge, 5/8 in needle
- Wash thigh before cleansing with alcohol Hep B & Mom - ANSWER - Hep B negative mother: admin 0.5 mL vaccine IM before discharge, 2nd & 3rd doses in 1-2 & 6-18 months by pediatrician
- Hep B positive mother: admin 0.5 mL of vaccine & 0.5mL Hepatitis B Immune Globulin (HBIG) IM into separate sites within 12 hrs of birth Newborn Weight Normal Range - ANSWER - Normal range-2500g-4000g ( lbs 8oz - 8 lbs 13oz)
- Weighed daily at the same time
- 10% lose of birthweight in first week of life is normal
Newborn Length Normal Range - ANSWER - Top of head to heel, leg must be outstretched
- Normal range 19-21 inches Erythema toxicum - ANSWER Red blotchy areas AKA- "newborn rash" Mongolian spots - ANSWER - Bluish grey looks like bruising
- More common in Arab or Mediterranean babies Newborn Head Circumference Normal Range - ANSWER 32 - 38 cm (13 - 15 inches) Anterior Fontanel - ANSWER - Diamond shape, where parietal and frontal bones meet
- About 4-6 cm bone to bone
- Closes by 18 months Posterior Fontanel - ANSWER - Triangular-shape where occipital & parietal bones meet
- About 0.5 cm size
- Closes by 2months Fontanel Assessment - ANSWER - Should be soft and flat
- Depressed may indicate dehydration
- Bulging may indicate increased intracranial pressure Caput Succedaneum - ANSWER - Area of localized edema over vertex of the
- LGA: Large for Gestational age infant
- SGA: Small for Gestational age infant Newborn S/S of Hypoglycemia - ANSWER - Jitteriness/tremors
- Decrease in muscle tone
- Grunting
- Poor sucking reflexes
- Low temperature
- Lethargy, listlessness
- Irritability
- Tachypnea/Tachycardia
- Seizure activity Newborn Bilirubin - ANSWER Assess for jaundice every 8 hours Newborn GU Assessment - ANSWER - Urine: voids within 12-24 hours
- Stool: Meconium within 12-48 hours
- Anus: patent, no rectal temps if not needed Hip Dysplasia S/S & Risk Factors - ANSWER - Problem with ball of hip joint or socket of hip joint or both
- Reduced motion in hip, limited abduction, limp leg
- Hereditary, position while in utero, First born, females
Ortolani's & Barlow's Maneuvers - ANSWER - Barlow: "Clunk" of exit as femur is dislocated
- Ortolani: "Clunk" of entry as dislocated femur renters socket Premonitory Signs of Labor - ANSWER - Lightening 2-3 weeks before labor
- Uterus moves down
- Nesting 24-
- Weight loss 1-3 lbs
- Fluid loss & electrolytes due to hormones
- Backache
- Diarrhea, indigestion, N/V False Labor - ANSWER - Contractions are irregular & intervals & duration don't change
- Discomfort doesn't radiate
- No cervical dilation
- Rest & warm baths lessen contractions Effacement - ANSWER - Thinning & shortening of cervix caused by pressure from the fetal head
- Documented as percentage
- 100% is fully effaced & shortened PROM - ANSWER Premature Rupture of membrane, membranes rupture prior to the onset of labor
Normal Fetal Attitude - ANSWER - Relation of fetal body parts to one another
- Head flexed towards the chest, arms & legs flexed toward thorax, back is curved in a C-Shape Fetal Station - ANSWER - Where top of baby's head is in relation to Ischial spine
- 0 station is when baby's head is in line with Ischial spine, anything above that is in negatives, anything below that is in positives
- Don't want to rupture membranes if baby is in negative station, could lead to cord prolapse Cardinal Movements - ANSWER - Head movements baby makes while delivering
- Want baby to have face facing down toward anus while delivering (occiput anterior) 4 Stages of Labor - ANSWER - Stage 1: Onset of true labor, complete dilation & effacement
- Stage 2: Delivery of Baby
- Stage 3: Delivery of Placenta
- Stage 4: First 1-4 hrs post delivery Stage 1 of Labor - ANSWER - Latent Phase: 0-3 cm
- Active Phase: 4-7 cm
- Transition Phase: 8-10 cm
Latent Phase of Labor - ANSWER - 0-3 cm
- Begins with onset of regular contractions
- Good to labor at home if possible
- Fluids to maintain hydration
- If at home, position changes, REST
- No tub if ROM
- Bloody show due to cervical dilation
Active Phase of Labor - ANSWER - 4-7 cm
- Increased frequency, duration of contractions
- Fetus descends
- Anxiety, decreased ability to cope
- Flushed cheeks & fatigue
Transition Phase of Labor - ANSWER - Dilated 8-10 cm
- Shaking, nausea, vomiting
- Irritability
- Dilation slows
- Fear of loss of control-reassurance needed, HELP FOCUS
- Contractions every 5 minutes, 60-90 seconds
- Fundus at umbilicus
- Time of high risk of maternal hemorrhage-frequent assessment of vaginal flown
- Hypotonic bladder, encourage void
Effleurage - ANSWER A light circular stroke of the lower abdomen, done in rhythm to control breathing, to aid in relaxation of abdominal muscles
Counter-pressure - ANSWER - Sacral pressure may help with back pain/pressure
- Palm of fist, tennis ball
Nubain (Nalbuphine) - ANSWER - Route of admin varies according to stage of labor & HCP preference
- Given IM or IV
- Crosses the placenta
- Have narcan available
- Assess hx of narcotic dependency
- Opioid agonist & antagonist
Narcan (Naloxone) - ANSWER - Crosses the placenta
- Route, IM, SC, IV. May be given more than once
- Recommended dose of naloxone is 0.1 mg/kg for infants
Adverse Effects of Epidural - ANSWER - Maternal Hypotension
- Bladder distention
- Prolonged second stage of labor
- Migration of epidural catheter-creating a "window"
- Maternal Fever
- Increases chance of c-section
- N/V
- Pruritus
Spinal Anesthesia - ANSWER - Local Anesthetic is injected through the 3rd, 4th or 5th lumbar space into the subarachnoid space
- Onset of action: 1-2 mins
- Duration: 1-3 hrs
Spinal Anesthesia Adverse Effects - ANSWER - Drug reaction
- HYPOTENSION
- Respiratory paralysis
- Indicates cord compression, reposition mom
Early Decelerations - ANSWER - FHR starts to go down before peak of contraction, comes back up as contraction ends
- Good! Indicates fetal head compression
- Precipitates birth so check cervical dilation
Accelerations - ANSWER - FHR increases >15 beats from baseline for > seconds
Late Decelerations - ANSWER - FHR starts to go down at end of contraction, doesn't immediately go back up
- Indicates placental insufficiency
- Give mom O2, change positioning, stop Pitocin
Induction - ANSWER - Associated with higher risk for Cesarean birth
- More likely to be success with a term pregnancy
Possible Maternal Reasons for Induction - ANSWER - Pregnancy Induced Hypertension
- Maternal Gestational Diabetes
- Premature Rupture of Membranes (PROM)
- Chorioamnionitis
- Post Term Pregnancy
- Anticipated difficult birth
- Fetal demise
Possible Fetal Reasons for Induction - ANSWER - Distress, un-reassuring FHR tracing
- Suspected Intra Uterine Growth Retardation (IUGR)
- Post Term fetus
- Anticipated large baby or difficult birth
- Oligohydramnios/Polyhydramnios
Augmentation - ANSWER - Labor has begun spontaneously but progress has slowed or stopped
- Inadequate contractions to produce dilation & effacement
- Can be due to maternal exhaustion or being post date
Prostaglandin - ANSWER - Method of cervical ripening
Desired Contraction Rate - ANSWER Every 2-3 minutes, lasting 40-90 seconds with intensity of 40-90mm Hg and resting tone of less than 20mm Hg
Pitocin Nursing Considerations - ANSWER - Given IV
- Standard supply Pitocin: 10-20 units/mL
- Mixed in 1000LR to obtain a concentration that allows for small incremental increases in dose
- Standard dose: 0.5 milliunits/min or 2 milliunits/min
- Increased every 20 minutes
Pitocin Administration - ANSWER - Leave rate when: Mother achieves adequate labor pattern or cervical changes are occurring
- Turn off when: Tetanic contractions, decreased resting tone, or FHR shows intolerance to uterine stimulation
C-Section Nursing Process - ANSWER - Informed Consent from Provider
- Insertion of large bore IV
- Hydration w/isotonic IV solution
- Antibiotic administration
- Antacid prior to surgery
- Assist w/positioning for spinal anesthesia
- Assist w/positioning on OR table after anesthesia taken effect
- Assist w/ cleaning/prepping skin
- Apply electrocautery pad to ground
- Apply compression boots
Low Transverse Incision - ANSWER - Incision parallels muscle sheaths
- Incision of choice
- Allows for VBAC
Low Vertical Incision - ANSWER Used with low transverse to delivery a very large baby
Vertical/Classical Midline Incision - ANSWER - Emergencies, big baby
- Requires repeat C/S-due to scarring, resulting in thin, unstable uterine wall
Nursing Care of the Mother with a Surgical Birth - ANSWER - Vital signs, POX, Lung, Bowel Sounds, flatus
- Ambulate within 8-12 hours
