Description

ethylergonovine is NOT given to clients with hypertension because of its vasoconstrictive action. Pitocin is given with caution to those with hypertension. • Never give methylergonovine or carboprost to a client while she is in labor or before delivery of the placenta. • Application of Perineal Pads after Delivery o Place two on perineum o Do not touch inside of pad o Do apply from front to back, being careful not to drag pad across the anus. • Full bladder is one of the most common reasons for uterine atony or hemorrhage in the first 24 hours after delivery. If the nurse finds the fundus soft, boggy, and displaced above and to the right of the umbilicus, what action should be taken first? o First perform fundal massage; then have the client empty her bladder. Recheck fundus every 15 minutes for 1 hour, then every 30 minutes for 2 hours. • If narcotic analgesics are given, raise side rails and place call light within reach. Instruct client not to get out of bed or ambulate without assistance. Caution client about drowsiness as a side effect. • A first-degree tear involves only the epidermis. A second-degree tear involves dermis, muscle, and fascia. A third-degree tear extends into the anal sphincter. A fourthdegree tear extends up the rectal mucosa. Tears cause pain and swelling. Avoid rectal manipulations. • Do not wait until a 1-minute Apgar is assigned to begin resuscitation of the compromised neonate. • Apgar scores of 6 or lower at 5 minutes require an additional Apgar assessment at 10 minutes • IV administration of analgesics is preferred to IM administration for a client in labor because the onset and peak occur more quickly and the duration of the drug is shorter. It is important to know the following: o IV administration ▪ Onset: 5 minutes ▪ Peak: 30 minutes ▪ Duration: 1 hour o IM administration ▪ Onset: within 30 minutes ▪ Peak: 1to 3 hours after injection ▪ Duration: 4 to 6 hours • Tranquilizers (ataractics and phenothiazines), such as promethazine and hydroxyzine, are used in labor as analgesic-potentiating drugs to decrease the amount of narcotic needed and to decrease maternal anxiety. • Agonist narcotic drugs (morphine) produce narcosis and have a higher risk for causing maternal and fetal respiratory depression. Antagonist drugs (butorphanol, nalbuphine) have less respiratory depression but must be used with caution in a mother with preexisting narcotic dependency because withdrawal symptoms occur immediately. • Pudendal block and subarachnoid (saddle) block are used only in the second stage of labor. Peridural and epidural blocks may be used during all stages of labor. • The first sign of a block’s effectiveness is usually warmth and tingling in the ball of the foot or the big toe. • Stop continuous infusion at end of stage I or during transition to increase effectiveness of pushing. • Regional Block Anesthesia and Fetal Presentation o Internal rotation is harder to achieve when the pelvic floor is relaxed by the anesthesia; this results in a persistent occiput-posterior position of fetus. o Monitor fetal position. Remember, the mother cannot tell you she has back pain, which is the cardinal sign of persistent posterior fetal position. o Regional blocks, especially epidural and caudal blocks, commonly result in assisted (forceps or vacuum) delivery because of the inability to push effectively during the second stage. Normal Puerperium (Postpartum) • Assessments should be made before notifying the health care provider about any abnormal findings. Assess fundal height and firmness; assess perineal integrity; check for signs and symptoms of thromboembolism; assess pulse, respirations and BP; assess client’s subjective description of symptoms (e.g., burning on urination, pain in leg, excessive tenderness of uterus). • Normal leukocytosis of pregnancy averages 12,000 to 15,000 mm3. During the first 10 to 12 days postbirth, values of 25,000 mm3 are common. Elevated WBC and the normal elevated erythrocyte sedimentation rate (ESR) may confuse interpretation of acute postpartum infections. For example, if a client’s temperature is 38.2 degrees C on the second post-partum day, what assessment should be made? • Client and family teaching is a common subject of NCLEX. Remember that when teaching the first step is to assess the clients’ (parents’) level of knowledge and identify their readiness to learn. Client teaching regarding lochia changes, perineal care, breastfeeding, and sore nipples are subjects that are commonly tested. • After the first postpartum day, the most common cause of uterine atony is retained placental fragments. The nurse must check for the presence of fragments in lochial tissue. • Women can tolerate blood loss, even slightly excessive blood loss, in the postpartal period because of the 40% increase in plasma volume during pregnancy. In the postpartal period, a woman can void up to 3000 mL/day to reduce the volume increase that occurred during pregnancy. • Client should void within 4 hours of delivery. Monitor closely for uterine retention. Suspect retention if voiding is frequent and <100 mL per voiding. • Women often have a syncopal (fainting) spell on the first ambulation after delivery (usually related to vasomotor changes, orthostatic hypotension). The astute nurse will check the client’s Hgb and Hct for anemia and BP, sitting and lying down, to ascertain orthostatic hypotension. • Kegel exercises increase the integrity of the introits and improve urine retention. Teach client to alternate contraction and relaxation of the pubococcygeal muscles. • Remember, RhoGAM is given to an Rh-negative mother who delivers an Rh-positive fetus and has a negative direct Coombs test. If the mother has a positive Coombs test, there is no need to give RhoGAM because the mother is already sensitized. • Because Rh immune globulins suppress the immune system, the client who receives both RhoGAM and the rubella vaccine should be tested for rubella immunity at 3 months. • Assess for thromboembolism: examine legs of postpartum client daily for pain, warmth, and tenderness or a swollen vein that is tender to the touch • “Postpartum blues” are usually normal, especially 5 to 7 days after delivery (unexplained tearfulness, feeling down, and having a decreased appetite). Encourage use of support persons to help with housework for first 2 postpartum weeks. Refer to community resources. The Normal Newborn • Suction the mouth first and then the nose. Stimulating the nares can initiate inspiration, which could cause aspiration of mucus in oral pharynx. • Circumcision has become controversial because there is no real medical indication for the procedure, and it does cause trauma and pain to the newborn. It was once thought to decrease the incidence of penile and cervical cancer, but some researchers say this is unfounded. • Hypothermia (heat loss/extreme cold) leads to depletion of glucose, therefore, to the use of brown fat (special fat deposits fetus develops in last trimester; they are important to thermoregulation) for energy. This results in ketoacidosis and possible shock. Prevent by keeping neonate warm! • A detailed physical assessment is performed by the nurse or physician. Regardless of who performs the physical assessment, the nurse must know normal versus abnormal variations in the newborn. Observations must be recorded and the physician notified regarding abnormalities. • It is difficult to differentiate between caput succedaneum (edema under the scalp) and cephalohematoma (blood under the periosteum). The caput crosses suture lines and is usually present at birth, whereas the cephalohematoma does not cross suture lines and manifests a few hours after birth. The danger of cephalohematoma is increased by hyperbilirubinemia due to excess RBC breakdown. • The umbilical cord should always be checked at birth. It should contain three vessels: one vein which carries oxygenated blood to the fetus, and two arteries, which carry unoxygenated blood back to the placenta. This is the opposite of normal circulation in the adult. Cord abnormalities usually indicate cardiovascular or renal anomalies. • Postnatally, the fetal structures of foramen ovale, ductus arteriosus, and ductus venosus should close. If they do not, cardiac and pulmonary compromise will develop. • These neurologic reflexes are transient and, as such, disappear usually within the first year of life. In the pediatric client, prolonged presence of these reflexes can indicate CNS defects. Anticipate NCLEX-RN questions regarding normal newborn reflexes. Physical assessment questions focus on normal characteristics of the newborn and the differentiation of conditions such as caput succedaneum and cephalohematoma. • Physiologic jaundice occurs at 2 to 3 days of life. If it occurs before 24 hours or persists beyond 7 days, it becomes pathologic. Typically, NCLEX-RN questions ask about the normal problem of physiologic jaundice, which occurs 2 to 3 days after birth due to the immature liver’s normal liability to keep up with RBC destruction and to bind bilirubin. Remember, unconjugated bilirubin is the culprit. • To evaluate exact urine output, weigh dry diaper before applying. Weigh the wet diaper after infant has voided. Calculate and record each gram of added weight as 1 mL urine. • Do NOT feed a newborn when the respiratory rate is OVER 60. Inform the physicial and anticipate gavage feedings in order to prevent further energy utilization and possible aspiration • A 7 lb 8 oz baby would need 50 calories x 7 pounds = 350 calories plus 25 calories (1/2 lb or 8 oz) = 375 calories per day. Most infant formulas contain 20 calories per oz. Dividing 375 by 20 = 18.75 oz of formula needed per day. • Teach parents to take infant’s temperature, both axillary and rectal. Axillary is recommended, but some pediatricians request a rectal (core) temperature. o Axillary: place thermometer under infant’s arm and hold thermometer in place for 5 minutes o Rectal: Use thermometer with BLUNT end. Insert thermometer ¼ to ½ inch and hold in place for 5 minutes. Hold feet and legs firmly. High Risk Disorders • Spontaneous abortion may be the result of intimate partner violence. Intimate partner violence often begins or occurs more frequently during pregnancy. • Clients with prior traumatic delivery, history of D&C, and multiple abortions (spontaneous or induced) and daughters of diethylstilbestrol (DES) mothers may experience miscarriage or preterm labor related to incompetent cervix. The cervix may be surgically repaired before pregnancy or during gestation. A cerclage (a McDonald suture) is placed around the cervix to constrict the internal openings. The cerclage may be removed before labor if labor is planned or left in place if cesarean birth is planned. • Pregnancy may mask the signs and symptoms of choriocarcinoma. If the client’s hCG levels do not diminish, choriocarcinoma may develop. • Suspect ectopic pregnancy in any woman of childbearing age who presents at an emergency room, clinic, or office with unilateral or bilateral abdominal pain. Most are misdiagnosed as appendicitis. • A client who is at 32 weeks’ gestation calls the health care provider because she is experiencing dark-red vaginal bleeding. She is admitted to the emergency department, where the nurse determines the FHR to be 100 bpm. The client’s abdomen is rigid and board like, and she is complaining of severe pain. What action should the nurse take first? First, the nurse must use their knowledge base to differentiate between abruptio placentae (this client) and placenta previa (painless bright-red bleeding occurring in the third trimester). The nurse should immediately notify the health care provider, and no abdominal or vaginal manipulation or examination should be done. Administer O2 by facemask. Monitor for bleeding at IV sites and gums because of the increased risk of DIC. Emergency cesarean section is required because uteroplacental perfusion to the fetus is being compromised by early separation of the placenta from the uterus. • DIC is a syndrome of abnormal clotting that is systemic and pathologic. Large amounts of clotting factors, especially fibrinogen, are depleted, causing widespread external and internal bleeding. DIC is related to fetal demise, infection and sepsis, pregnancy-induced hypertension (preeclampsia), and abruptio placentae. \ • Clients with abruptio placentae or placenta previa (actual or suspected should undergo NO abdominal or vaginal manipulation o No Leopolds maneuvers o No vaginal examination o No rectal exams, enemas or suppositories o No internal monitoring • Female circumcision (aka female genital mutilation) is a deeply entrenched cultural tradition that has no religious significance among some immigrants from Africa and the Middle East. It usually occurs to young girls between infancy and age 15. Often nonmedical personnel perform the procedure under nonsterile conditions that may lead to infections and other problems such as mechanical problems with urination or delivery of an infant. These procedures to the female genitals include pricking, piercing, scraping, cutting and burning of the genital area. • Tetracycline is contraindicated in pregnancy because it darkens the teeth of the newborn. • Podophyllin, which is usually used to treat HPV, is contraindicated in pregnancy because it is associated with fetal death, preterm labor, and cervical carcinoma. Quadrivalent human papillomavirus (types 6,11,16,18) recombinant vaccine (Gardasil) is available to non- pregnant females 9 years and older to prevent HPV. • Toxoplasmosis is usually related to exposure to cats, gardening (where cat feces may be found), or eating raw meat. • Rubella is teratogenic to the fetus during the FIRST trimester, causing congenital heart disease, congenital cataracts, or both. All women should have their titers checked during pregnancy. If a woman’s titers are low, she should receive the vaccine AFTER delivery and be instructed not to get pregnant within 3 months. Breastfeeding mothers may take the vaccine.