Pediatrics:
❖ Infant: Birth to 1 year:
➢ Erickson Psychosocial~ Trust vs Mistrust
■ Establish trust in caregivers
■ through food, clothing, touch, and comfort
■ If needs not met infant will eventually learn to mistrust others
■ Hold the hospitalized baby often; encourage parents to room-in
● Stranger danger/ separation anxiety
➢ Piaget Cognitive~ Sensorimotor: infants learn thru their senses
■ Primary circular- pleasure in repetition
■ Secondary circular- connecting cause and effect, awareness of
environment
■ Object permanence should be mastered at 8-12 months, other
caregivers may be rejected because the infant may not
understand that parents will return
■ Provide stimuli and comfort; use toys to distract baby during
procedures and assessments
➢ Physically:
■ Will regain birth weight at 10-17 days
■ Birth weight doubles by 6 months
■ 0.5-1 inches in length in first 6 months
■ Triples birth weight by 1 year
■ Average height is 50cm at birth (rapidly grows first 6 months)
■ By 1 year they have increase length by 50%
■ Gradual shift from reflexive moments to intentional actions
➢ Motor ability:
■ Respond to light and sound
■ Palmar grasp to pincer grasp
■ Rolls back to abdomen by 4 months
■ Sits unsupported by 8-9 months
■ Will start crawling by 8-9 months
■ Stands alone by 12 months (walks along furniture)
➢ Communication
■ 1-3: coo and babble
■ 4-7: laughs, vocalizes during play, knows his/her name and
responds to the word “no” and distinguish emotions based on tone
■ 7-10: squeals (pleasure sound), babbles (mamamama) rhythmic
speech
■ 9-12: understands “no”, identifies parents, 2-3 other words,
receptive speech surpasses expressive speech and may say “uhoh”
➢ Toys:
■ 0-1: mobile, B&W, Music, mirrors, patterns
■ 1-4: noisemakers, rattles, bright mobile, singing
■
4-7: different types of music, easy to hold toys (noise), bath toys,
soft dolls or animals
■ 8-12: large blocks, plastic cup/bowl, stacking toys, busy boxes,
balls, dolls, large pictures
➢ Safety and interventions:
■ Crib rails up at all times and mattress is firm (rails 2 3/8 inches)
■ Car seats facing rear until 12 months (weigh 20 pounds)
■ Assess immunizations
■ Keep parents in view, involve in care when appropriate
❖ Toddlers: 1-3 years
➢ Erikson: autonomy vs shame & doubt
■ Increasing independence and says “no” a lot
■ Encourage child to participate in ADL’s
➢ Piaget: ending of sensorimotor, beginning of preoperational stage
■ Increasing curiosity and explorative behavior; improved language
skills
■ Preoperational- Egocentric, Animism, Magical thinking
■ Ensure safe surroundings
■ Name objects and give examples
➢ Physically
■ Anterior fontanelle close by 18 months
➢ Motor ability:
■ Progresses to walking, jumping, climbing, running
■ Can undress self, learning to dress
■ Can walk up and down stairs
➢ Communication:
■ Enjoys talking, asserts independence, knows gender and has
short attention span
■ Likes to have contact with other children (parallel play), temper
tantrums
■ Avoid telling things too soon (no concept of time) provide band
aids, praise, and comfort
➢ Toys: love to experiment, understanding cause and effect
■ Tower of blocks
■ Scribbles at 1-2, draws some from 2-3
■ Push pull toys for 1-2
■ Kicks and throws balls
■ Tricycle and educational TV
■ Simple games
➢ Safety:
■ Gates and child proof locks should be placed
■ Poison control number posted
■
Rear facing car seat until 2 years (at 3 years backseat forward
facing)
❖ Preschooler: 3-6 years
➢ Erikson: Initiative VS guilt:
■ Likes to initiate play activities
■ *GOAL IS TO HAVE SENSE OF PURPOSE
■ Offer medical equipment for play to lessen anxiety
■ Assess concerns expressed through drawings, accept child’s
choices and expression of feelings
➢ Piaget: Preoperational
■ Increasingly verbal: egocentric
■ Child may feel responsible for illness
■ Explain all procedures and treatments
■ Animism and magical thinking
➢ Physically:
■ Gains 4-5 lbs per year
■ Grows: 2.5-3 inches
➢ Motor ability:
■ Uses scissors, draws circles and squares, enjoys art and crafts
■ Learns to tie shoes and button clothes
■ Uses utensils
■ Climbs, bike with trainers, learns letters and numbers
➢ Communication:
■ All parts of speech used (not always correctly)
■ Usually very literal, but will communicate with many people
➢ Toys:
■ Simple games, nursery rhymes
■ Dramatic Play: dolls, playhouse, puppets, dress up
➢ Safety/ interventions
■ Verbalize and explain all procedures, use accurate names for
body functions
■ Allow for questions and choices
❖ School age: 6-12 years
➢ Erikson: Industry vs Inferiority
■ Gain of self-worth through involvement in activities, child wants to
produce a product (crafts, achievements, works hard to be
successful, feels bad if not successful)
■ Need encouragement to work on schoolwork during
hospitalization, may need help to adjust to limitations
➢ Piaget: Concrete operational
■ Capable of mature thought when able to see and touch objects,
capable of logical thinking & reasoning
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Can see things from different points of vies & different
dimensions
■ Give child clear instructions and show them the equipment that
will be used in treatment, can read & has longer periods of
concentration
Physically
■ Gains 4-6 lbs. per year
■ Grows 2-2.5 in a year
■ Increases in height by at least 1ft.
Motor ability
■ Jump rope, 2 wheeled bikes, roller skates
■ Craft projects and board games
■ Ball sports, COLLECTIONS (starting hobbies)
Communication:
■ Mature use of language, ability to converse for lengths of time
■ Spends many hours at school and with friends in sports
Toys:
■ Reading and crafts
■ Musical instruments
■ Board games and video games
■ Cooperative play (team sports)
Safety and interventions:
■ Communicate openly and honestly with child, provide concrete
examples and pics (allow child to select a reward after a
procedure)
■ Clarify misconceptions, and encourage participation in care
■ Use age appropriate therapeutic play, art therapy, journal writing
■ Encourage friends to visit
❖ Adolescent: 12-18 years
➢ Erikson: Identity vs Role confusion
■ Search for self leads to independence from parents and reliance
on peers
■ Health hx and exam without parents present
■ Introduce to other teens with same health problems
➢ Piaget: Formal operational stage
■ Capable of mature abstract thought
■ Offer written, verbal instructions, continue to provide education
about chronic illness (teen has greater understanding)
➢ Physically: reproductive system matures
■ During growth spurt
● Females gain 15-55 lbs., grow 2-8 inches
● Males gain 15-65 lbs., grown 4-12 inches
■ Awkwardness, lack of coordination
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■ Easily fatigued, may require more sleep
Motor ability
■ Muscle development continues, new sports attempted
■ Improving fine motor skills
Communication:
■ Able to handle hypothetical situations
■ Increasing communication and time with peer groups
■ Challenged by doubts of insecurity, may exhibit anger or withdraw
when struggling with loss of control
Toys:
■ Books, video games, computer
■ Music, TV
■ “Hanging out”
Safety/interventions:
■ Involve in plan of care
■ Promote communication between teens and parents
■ Balance firmness, gentleness and choices and respect while
caring for an adolescent
■ Often perceives self as invincible, educate about and discourage
risk taking behavior
❖ Therapeutic Play specific interventions:
➢ Infant: B-1yr
■ Use of external stimuli such as mobiles, music, mirrors that offer
comfort to the newborn or infant
■ Cuddle or rock infant
■ Sing lullabies and talk to the infant
➢ Toddler: 1-3
■ Approach slowly making initial approach in the parent’s presence
■ Play a variation of peek-a-boo or hide and seek to promote
the concept of object permanence to reassure the parents
return
■ Use transitional objects as familiar blankets, stuffed toys etc. to
temporarily substitute for the security of parent’s company
■ Repeatedly read familiar stories to promote sense of familiarity
and stability in an unfamiliar hospital setting
■ Provide toys to play to include medical supplies, but remove the
medical supplies when you must leave child alone
➢ Preschooler: 3-6 years
■ Use simple outlines of the human body
■ Allow the preschooler to play with hospital supplies to work
through feelings of aggression
■ Preschoolers prefer crayons, coloring books, puppets, felt and
magnetic boards, playdough, books, and recorded stories
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■ Use pets as therapy
➢ School age children 6-12:
■ Children tend to regress developmentally during hospitalization as
play begins to lose some importance
■ Use of body outlines (drawings), and anatomically correct dolls to
illustrate the cause and treatment of illnesses and provide an
outlet for expressing fears or anger
■ Use terms that are suitable for older children when discussing
body parts
■ They enjoy collecting things and organizing objects used
during care such as disposables
■ Games, puzzles schoolwork, crafts, tape recordings and
computers provide an outlet for aggression and increase self
esteem
Pediatric gross motor milestones:
➢ Sits without support: 6 months
➢ Rolls- 4 months
➢ Pulls self-up to stand: 10 months
➢ Creeps or crawls: 8-10 months
➢ Walks alone: 12-15 months
➢ Climbs on furniture: 24 months
➢ Walks upstairs, one step at a time: 24 months
Pediatric Fine motor skills
➢ Transfers objects between hands: 5-6 months
➢ Pincer Grasp (Thumb finger grasp): 8 months
➢ Feeds self: 18 months
➢ Scribbles with crayon or pencil: 18 months
➢ Builds two block towers 15 months
➢ Builds four block tower 18 months
Calculation of IV fluid needs
➢ Usual weight maintenance amount
■ Up to 10kg: 100 mg/kg/24 hours
■ 11-20 kg: 1000+ (50 mg/kg for weight above 10 kg)/ 24 hrs
■ >20kg:1500+ (20 mg/kg for weight above 20 kg)/24 hours
■ % of body weight loss x 10 x normal weight= ml/kg/ 24 hours
required
Health risks associated with childhood:
➢ Morbidity: measure of disease, illness or injury within a population
■ Factors that influence morbidity
● Homelessness
● Poverty
● Low birth weight
● Chronic health disorders
● Foreign-born adoptions
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● Daycare attendance
● Barriers to health care
Mortality: # of people who have died over a specific period. Reports as
rates per 100,000 and calculated from sample of death certificates
Can be used to identify a population at risk
Leading causes of death by age group:
■ Infants:
● Congenital anomalies
● Short gestation (preterm)
● Maternal pregnancy complications
● SIDS
■ Early childhood
● Unintentional injury (includes motor vehicle accidents)
● Congenital anomalies
● Homicide
■ Childhood:
● Unintentional injury
● Malignant neoplasms
● Congenital anomalies
■ Later childhood
● Unintentional injury
● Malignant neoplasms
● Suicide
■ Adolescent
● Unintentional injury
● Suicide
● Homicide
Communicable Diseases: Infectious disease
■ Stages:
● Incubation: entrance of pathogen to appearance of
nonspecific symptoms
● Prodromal stage: time of onset of nonspecific symptoms
(fever malaise) to more specific. In this stage they are
capable of transmitting to someone else
● Illness: demonstrates S/S of a specific infection type
● Convalescence: time when acute symptoms of illness
disappear
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Types
● Bacterial
● Viral
● Zoonotic
● Vector-borne
● Parasitic and helminthic
● Sexually transmitted
➢ Skin lesions
■ Macule: flat or flush with skin
■ Papule: elevated from skin surface
■ Vesicle: fluid filled papule
■ Crust: secondary lesion caused by the secretions of the vesicle
drying on the skin
■ Discrete lesion: separated by areas of normal skin
■ Coalesced lesion: lesion that have fused or run together
➢ Methods of prevention
■ Hand washing
■ Immunizations
■ Proper handling and prep of food
■ Judicious antibiotic use
❖ Immunizations:
➢ Active immunity: from person's own immune system which generates
immune response
■ May occur after exposure to natural pathogens or after exposure
to vaccines
➢ Passive immunity: passed from one person to another
■ May be transferred from mother to baby via colostrum or placenta
➢ Natural: immunity permanent at birth, innate or genetic
➢ Naturally acquired active: obtained through having disease
➢ Naturally acquired passive: obtained in placental transmission or by
breast milk
➢ Artificially acquired active: all immunizations
➢ Artificially acquired passive: antibodies injected directly into individual;
immunity increases over time
➢ Vitamin K- for blood clotting, newborns not able to clot without it
❖ Metabolism inborn errors
➢ PKU (phenylketonuria)
■ Genetic disease, absent of enzyme necessary for metabolism
of essential amino acids phenylalanine
■ Increase in blood and urine
■ Dx at newborn screening- Guthrie test
■ Strict diet of low Protein for 6-8 years to keep at safe levels,
needed for growth so can’t be eliminated
■ No grilled cheese!!
■ Can’t be breast fed, different formula!
➢ Galactosemia
■ Disturbance in carb metabolism
■
■
Rare
Absence of liver enzymes that cause galactose to convert to
glucose, causing galactose to accumulate
■ Eliminate all milk and dairy, use Soy as replacement
■ Can’t be breast fed
➢ Vitamin D Deficiency: Rickets
■ Needed for calcium and phosphorus absorption
■ Bone issues
■ Nursing care:
● Fortified Vit D foods
● Sunlight
● Good alignment
● Prevention of infection
● Gentle handling
➢ Vitamin C deficiency: Scurvy
■ Needed for protein synthesis and collagen formation
■ Will see some element of bleeding
■ Nursing care:
● Foods high in Vit C (fresh fruits and veggies)
● Education on cooking foods to preserve vitamins
● Oral hygiene
● Gentle handling
❖ Malnutrition: Overnutrition or Undernutrition
➢ Groups at risk
■ Premature
■ Children with increased energy levels
■ Children with decreased energy levels
■ Dependent feeders
■ Food allergies
■ Those that take meds that interfere with digestive absorption
➢ Vegetarian diets:
■ Needs foods that are nutrient dense, have essential amino acids
■ Macrobiotic Diet- Most severe, main food is brown rice and
cereal
➢ Kwashiorkor: protein deficiency with adequate calories
■ Symptoms: wasted extremities, dry skin, depigmentation,
alopecia, blindness, diarrhea, edema, assess serum protein (low
protein causes fluids to shift)
➢ Marasmus: protein and calorie deficiency (very skeletal/cachectic
looking)
■
Symptoms: gradual wasting, atrophy of tissues, wrinkled flabby
skin, lethargy, prostration (weakness)
➢ Treatment for Kwashiorkor and Marasmus:
■ Protein
■ vitamins/minerals
■ Calories
■ Electrolytes
■ Hygiene care
■ Rest
■ Developmental stimulation
❖ Gastrointestinal Problems:
➢ Acute diarrhea: Gastroenteritis
➢ Rotavirus: Transmitted person to person via fecal oral route
■ VACCINE AVAIALBLE, given orally
■ Greatest risk in childcare settings
■ Causes diarrhea
■ Risk for hypovolemic shock
■ #1 concern is dehydration
➢ Assessments:
■ Assess fontanels of infants
■ # of wet diapers
■ Tears
■ Vitals
■ Weight
■ Bowel sounds
■ Color and appearance of skin, eyes, lips
■ Hydration status: oral mucosa, skin turgor, urine output
■ Significant dehydration is <1 ml/kg/hr
➢ Treatments:
■ Oral replacement therapy- Pedialyte, 0.5-2 ounces q15 mins
■ Use of NS or LR if IV fluids necessary
➢ Intestinal Parasitic Disease:
■ Giardiasis: Contaminated food or water
● Oral fecal route, food, animals
● Watery foul-smelling stool, vomiting, gas
● Can last 4-6 weeks
● Treat with antiparasitic, monitor hydration, assess nutrition
■
Pinworms:
● Anal itching, especially at night
● Clear tape on anal area
● Persist in environment for 2-3 weeks or longer
● Incubation- 1-2 weeks or longer
●
Transmitted by fecal-oral route directly, indirectly, or
inadvertently by contaminated hands or shared toys,
bedding, toilet seats
● Restlessness and teeth grinding
● Weight loss
● Worms in stool (more common after treatment)
● Treatment: (Anti Helminth) Mebendazole
■ GER; Incompetence of lower esophageal sphincter
● Normal in newborns
● Only occurs with feedings
● Can lead to GERD
● Treatment:
◆ Thicken formula/breast milk with rice cereal
◆ Keep upright for 30-45 minutes after feeds
■ COLIC: screaming baby (3/3/3 rule)
● Short lived: 3-4 months
● Typically lasts 3 hours for 3 days
● Treatment:
◆ Soothing music, warm bath, swing, car or stroller
rides, burp frequently
◆ MD may recommend Mylicon drops- gas reducing
◆ Provide support to parents: not due to poor
parenting
■ Lead Poisoning
● Leads to anemia, affects Vit D and Calcium absorption
● Levels >70 emergent treat with chelation therapy,
hospitalization
● Mental development delay
❖ Respiratory Problems:
➢ Tract differences in children
■ Smaller airway
■ Faster RR
■ Irregular breathing (infants)
■ Increase O2 needs
■ Diaphragmatic breathing or abdominal breathing
➢ Hypoxia: S/S
■ Hypotension
■ Bradycardia
■ Dyspnea
■ Cyanosis- peripheral or central
■ Dimness of vision
■ Somnolence
■ Stupor/coma
➢ Respiratory Infections:
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Cold: typically, viral, known as URI (upper respiratory infection)
Croup: typically, viral
● Barky, brassy cough
● Use high humidity
● Prevent dehydration
● Prevent aspiration
● Keep child calm and quiet as possible
Epiglottitis- Bacterial- Hib Vaccine!
● EMERGENT
● S/S
◆ Dysphagia
◆ Drooling
◆ Anxiety
◆ Irritability
◆ Significant resp. distress
● DO NOT USE TONGUE BLADE
RSV-Bronchiolitis- Viral
● Most frequent in winter/early spring
● Spread via direct contact
● Synagis- IM injection (antibody against RSV-given to
high risk infants; qualify)
● Droplet/contact precaution
● Manifestations
◆ Runny nose
◆ Apnea
◆ Listlessness
◆ Fever
◆ Poor eating
◆ Wheezing
◆ Retractions
◆ Rapid breathing
◆ Cough
Pertussis- Bacterial
● Uncontrollable violent coughing
◆ Whooping sound when inhaling to breath
◆ “Whooping Cough”
◆ Caused by Bordetella bacteria; antibiotics given
◆ 7-10 days for results from mucus sample
◆ Symptoms show about a week after exposure
◆ Severe coughing episodes start 10-12 days later
◆ Dtap vaccine; wears off at 5 years old (booster
needed & given at 10 years and up)
● Droplet precaution
● S/S
◆ Runny nose
◆ Slight fever
◆ Coughing fits
➢ Breathing difficult
➢ Results in vomiting
➢ Can cause loss of consciousness
■ Pneumonia- bacterial, viral aspiration etc.
➢ Asthma: airway reacts to invasion of virus, bacteria, allergens, irritant
■ Precipitated by:
● Allergens
● Irritants
● Weather changes
● Infections
● Exercise
● Emotional factors
● Endocrine
● GE reflux
■ Relief of symptoms
● Drug therapy
◆ Beta agonist (bronchodilator)
◆ Epinephrine (emergency situations)
◆ Steroids (anti-inflammatory)
◆ Maintenance meds: Advair, Flovent
● Allergen control
● Exercises that don’t involve endurance (swimming is good)
● Physical therapy
● Hypersensitization: allergy testing and shots
➢ Cystic Fibrosis (CF) increased viscosity of mucous glands, exocrine
gland dysfunction
■ Prominent feature is an impermeability of epithelial cells to
chloride (striking elevation of sweat electrolytes – skin “tastes
salty”)
■ Diagnosis- Sweat Chloride Test
■ **Excessive appetite/poor weight gain
■ Treatment:
 Pulmozyme (inhaled mucus thinning drug)
● TOBI: Tobramycin: aerosolized antibiotic
● Azithromycin: oral antibiotic
■ Nursing care:
● Maintain good nutrition
● Water soluble vitamins
● Prokinetic Agents- pancreatic enzymes for meal and
snack
● Unlimited salt
●
Maintain calories
❖ Child with Problems Related to Psychosocial Function
➢ Congenital anomalies
■ Chromosomal abnormalities (21)
■ Intrauterine environmental factors
➢ Reactions:
■ Crisis of losing perfect child
■ Task of adjusting and accepting child and condition
➢ Stages of adaptation
■ Shock and denial
■ Adjustment (guilt & anger) “chronic sorrow”
● “isn’t that from your side of the family?”
■ Reintegration and acceptance
➢ Parent response
■ Depends on type and severity of defect
● Visibility
● Threat to survival (life-threatening)
● Previous Experience
● Marital harmony (partner harmony)
➢ Child response:
■ Depends on age of onset: earlier the onset, the better to adapt
■ Developmental level and available coping mechanism
● Those with more severe disorders cope better than those
with milder, because milder just struggle to be normal
➢ Sibling response:
■ Most affected in terms of parent child relationship
■ Feel abandoned
■ Keep them involved in the process of dealing
➢ Nursing interventions:
■ Goal: help family remain healthy and functioning at maximum level
thought out child’s life and beyond if child dies
■ Assess coping mechanism and support system
■ Provide support at time of diagnosis
■ Educate family
■ Accept the emotional reaction
■ Help to perceive child as a child first then as an individual with
unique needs
■ Promote normal development
■ Establish realistic future goals
■ Provide support at time of death if child dies
❖ Mental Retardation (Intellectual Disability)
➢ Down syndrome
■ Most common chromosomal abnormality (Trisomy 21)
■ Heart and respiratory problems
■ Usually HYPOTONIA (floppy baby syndrome) at infancy- low
muscle tone
■ Treat as individuals
■ Delays in meeting developmental landmarks
■ Involve child in early stimulation program
■ Help parents identify realistic goals for the child and encourage
family to enroll in special daycare programs and educational
classes
■ Emphasize to parents that child has the same needs of play,
discipline, and social interaction as all children
➢ Autism Spectrum Disorder (can pair with Sensory processing disorder)
■ Cause unknown
■ Genetic vulnerability and environmental triggers
■ Increasing and more prevalent in boys
■ Varying symptoms
● Social issues
● Communication problems
● Developmental delays
■ *Assessments done on all children at 18 and 24 months
■ Asperger's syndrome: mild form, high functioning intellectual
ability, poor social skills
■ Echolalia: repetition of phrases
■ Early intervention and behavioral therapy
■ Encourage child to recognize and respond to own physiological
needs and urges
➢ ADHD- Learning Disability (can pair with autism)
■ Child demonstrates at least 3 of the following:
● Fails to finish what he/she starts
● Often doesn’t seem to listen
● Is easily distracted
● Has difficulty concentrating
● Has difficulty sticking to play activity
● Hyperactivity
● Impulsivity
■ Assist child to recognize when he or she feels angry
● Help child to accept their feelings of anger
■ Redirect bad or violent behavior with physical outlets such as
punching bag or jogging
■ Decrease anxiety in the child and increase self-esteem
● Ritalin may be used
❖ Sensory processing disorders (can pair with autism)
➢ Neurological disorder: Difficulty organizing or integrating sensory input
used in daily living
➢ Hyper/hyposensitivity to sensory input
➢ Results in overreaction to different textures and limits child’s ability to
participate in some aspects of daily life
❖ Tourette syndrome:
➢ Severe tic disorder in which the child has sudden rapid recurrent
stereotypical movements and or sounds over which they appear to have
no control
❖ Oppositional Defiant disorder
➢ Disruptive behavior in which the child exhibits a persistent pattern of
disobedience, argumentativeness, angry outbursts, and low tolerance for
frustration and a tendency to blame others
➢ May have difficulty making new friends, often gets into conflicts with
adults
❖ Conduct disorder:
➢ Child may seriously violate social norms, including aggressive behavior,
destruction of property, cruelty to animals or people
➢ Often lie to achieve short term ends, may be truant from school, may run
away from home
➢ More severe compared to oppositional defiant disorder
❖ Child abuse
➢ Child neglect: family conditions which are assumed to be detrimental to
the child’s health, safety, physical and psychosocial development and that
caregivers have some sort of control over these conditions
➢ Abandonment: lack of supervision, adequate clothing, hygiene,
medical/dental care, education nutrition, shelter
➢ Abuse
■ Sexual: perpetrated by a member of the family group and includes not
only sexual intercourse, but also any act designed to stimulate a child’s
sexuality or to use the child’s for sexual stimulation for either the
perpetrator or another person
■ May include fondling, exposure, genital intercourse, digital penetration,
oral-genital contacts, sexual kissing and exposing the child to explicit
sexual material or acts
○ Abusive Head Trauma (shaken baby syndrome)
 Forcible shaking of infant causing injury to brain: retinal
hemorrhages, subdural hemorrhages, & fractures to cranium.
○ Munchausen syndrome by proxy:
■ Fabrication of symptoms for another, usually a mother inventing and/or
inducing signs and symptoms in relation to her child causing child
innumerable painful and unnecessary physical exams, test, and
treatments
■ Mother’s way of getting attention
■ S/S do not occur in mother’s presence
➢ Nursing care:
○ Multidisciplinary approach
○ Document objectively
○ Protect from further harm: notify authorities even if suspected
○ Promote parental attachment
○ Educate parents
○ Promote self esteem
❖ Mood Disorders
➢ Anxiety Disorder
 Occurs along with depression
 Anxiety becomes a problem when the level of anxiety is excessive
and hinders daily functioning.
 Generalized Anxiety Disorder: unrealistic concerns over
past behavior, future events, and personal competence
 Separation anxiety: developmentally inappropriate fear of
loss of their primary attachment figure (school phobias).
 OCD: repetitive ritualistic behaviors in order to reduce anxiety
about unwanted thoughts.
 Panic attacks: extreme fear or discomfort in the absence of
real danger. May experience physical symptoms such as vital
sign changes, perspiration, difficulty breathing.
 PTSD: anxiety that occurs after child experiences a traumatic
event, repeatedly re-living the event with the accompanying
feelings experienced during the event.
 Bipolar Disorders
 Rapid shifts in moods, going from mania (abnormally and persistently
elevated, expansive, or irritable mood) to hypomania alternating with
depression
 Depressive Disorders (can pair with anxiety)
 Mental state characterized by sadness, loss of interest or pleasure,
feelings of guilt or low self-worth, disturbed sleep or appetite, low
energy and poor concentration.
 When a sad mood interferes with daily life, a depressive disorder may
exist that will benefit from treatment.
 Young children are less likely to spontaneously express feelings
 Untreated is at risk for suicide
❖ Eating Disorders
■ Anorexia nervosa
● Intense fear of being obese
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■
■
● Need for control and perfectionism
● Disturbance of body image
● Increased weight loss with increased physical activity
Bulimia
● Recurrent episodes of binge eating and purging
Pica
● Eating nonnutritive substances for at least 1 month
◆ Paint, plaster, clay, sand, chalk, starch
Interventions:
● Consult with dietitian: determine number of calories
required to provide adequate nutrition and realistic weight
gain
● Weight daily
● Provide support and positive reinforcement and use a nonjudgmental approach
❖ Integumentary system
➢ Inflammatory Skin Conditions
➢ Dermatitis
■ Contact dermatitis
● Hypersensitivity reaction from contact with allergen or
external irritant (soap, detergent, poison ivy)
● For itching: topical corticosteroids
● Severe reaction: oral corticosteroids
● Can lead to secondary bacterial infection from scratching
● Common causes are nickel or cobalt in clothing or dyes
and chemicals found in soaps and detergents.
● Not contagious
■ Diaper dermatitis
● Hypersensitivity reaction of skin in the area covered by a
diaper.
● Can be caused from overgrowth of C. albicans
● Causes shiny, red rash with possible papules
● Prevention is best treatment: change diapers frequently
● Helpful creams that contain vitamins A, D, and E, or
petrolatum
● Apply barrier- Zinc oxide/ Destine
■ Seborrhea dermatitis (cradle cap)
● Inflammatory dermatitis on skin or scalp (more chronic)
● 2 weeks-month to resolve
● Caused by Pityrosporum ovale
● Dandruff in adults
● Apply mineral oil to scalp and massage and then shampoo
in 10-15 mins (avoid fontanels)
● Apply anti-inflammatory cream if prescribed
● Can use selenium sulfide shampoo
■ Atopic dermatitis (atopic eczema)
● Inflamed/itching skin due to allergen
● Relapsing and remitting; often a precursor to developing
allergic rhinitis and/or asthma
● Can lead to secondary bacterial infections
● Apply cream twice daily: Eucerin, Moisturel, Aquaphor
cream
● Keep nails cut short/cotton bedding
➢ Bacterial skin infections
■ Impetigo
● Cause: staph A and/or group A strep
● Occurrence: around face, mouth, hands, neck and
extremities; can also occur on neck, axilla, and groin
● Lesions: starts as papule that turns into a vesicle. The
vesicle rupture, forming a honey colored serous crust
● Topical antibiotic or oral if severe
● Don’t share towels, clean toys and surfaces with
antibacterial wipes
● Can return to school after receiving antibiotics for 24
hours, as long as lesions are not oozing and are getting
smaller or if covered with watertight bandage
➢ Fungal infections
■ Tinea (ringworm)
■ Tinea capitis (ringworm on scalp, eyebrows, eyelashes)
● Oral griseofulvin for 4-6 weeks
● Remain out of school until antifungal is started
● Don’t share hairbrushes or hats and wash sheets and
clothing
■ Tinea corporis (ringworm on arms/legs)
● Topical antifungal twice daily for 4-6 weeks
● Same as tinea capitis
■ Transmission: person to person or from pets (typically cats)
➢ Parasitic infection
■ Scabies- mite burrows under skin and larvae hatch. May be in
linear, threadlike pattern
● Highly contagious and occurs through prolonged
close contact, skin to skin contact, or with sexual
contact
● Diagnosed by skin scraping and observed under
microscope
● Apply scabicide (permethrin or lindane)
● All family members should be treated
●
Bedding washed and toys need to be cleaned or bagged
tightly for 5-7 days
● Child remains out of school until treatment has been
completed
■ Pediculosis capitis (head lice)
● Hair and brushes should be washed with Pediculicide:
Permethium, pyrethrins, lindane, malathion
● Repeat treatment in 7-10 days
● Bedmates should be treated, and all family should be
assessed
● Child can return to school after treatment has started
➢ Acne Vulgaris
■ Avoid oil-based cosmetics
■ Cleanse face twice daily with mild soap
■ OTC with benzoyl peroxide or salicylic acid (takes 4-8 weeks)
■ Can be prescribed antibiotics or Retin-A topical cream (drying)
■ Isotretinoin may be prescribed for severe cystic acne
___________________________________________________
ANTEPARTUM:
First Trimester: conception to 12 weeks
Second Trimester: 12-27 weeks
Third Trimester: 28-41 weeks
Physiological changes
★ Presumptive (subjective) Signs of Pregnancy:
○ Amenorrhea-missed period; could be from stress, pituitary gland
○ Nausea & Vomiting
○ Fatigue
○ Urinary frequency
○ Breast tenderness
○ Quickening (16/18-20 weeks)
○ Hyperpigmentation
○ Breast enlargement
★ Probable (objective) Signs of Pregnancy:
○ Abdominal enlargement (14 weeks)
○ Cervical changes
■ Hegar’s sign-Softening of uterus (6-12 weeks)
■ Goodell’s sign-Significant softening of the cervix (5 weeks)
■ Chadwick’s sign: Cervix has bluish color, sometimes the vagina (6-8
weeks)
○ Ballottement: examiner pushes against the woman’s cervix during exam and
feels rebound from floating fetus (16-28 weeks)
○ Skin changes
○ Braxton Hicks Contractions (16-28 weeks)
○
○
Palpation of the fetal outline
Positive pregnancy test (4-12 weeks)
■ hCG
○ Uterine Souffle
★ Positive signs:
○ Fetal movement felt by the examiner (20 weeks)
○ Auscultation of fetal heart tones via doppler (10-12 weeks)
○ Visualization of the gestational sac via ultrasound: can be as early as 10 days
after implantation, 16 days after ovulation and 2 days after missed period. (4-6
weeks)
Changes in body systems During pregnancy:
★ Uterus: Where the action is.
○ Capacity increases from 10 ml to 5000 ml
○ Weight increases from 2oz to 2.2 lbs
○ Placenta is developed by 11 weeks
○ Pear shape to ovoid shape
○ Ascent into abdomen after 3 months
Growth comes from Both
○ Hyperplasia (new muscle cells) “limited”
■ 1st trimester- estrogen influenced
○ Hypertrophy (stretching of already existing muscles)
■ 2nd-3rd trimesters: fetal growth, displaces intestines as it grows
★ Growth and measurement of pregnant uterus:
○ 12 weeks at symphysis pubis
○ 16 weeks halfway between umbilicus and symphysis pubis
○ 20 weeks at the umbilicus
○ 36 weeks near xiphoid process
○ 1 cm = 1 week
★ Lack of Bowel sounds
○ As baby grows it pushes the other organs around, bowels sounds are heard at
the lateral sides of the abdomen
○ Round ligaments help support the uterus
★ Cervical changes:
○ Responds to estrogen influence
○ Chadwick’s Sign: bluish color, softens with increased vascularity
○ Leukorrhea: Excessive white discharge, promote the mucous plug that keeps
bacteria from entering the uterus
■ Warning signs: Fishy odor, burning or itching could mean infection
★ Vaginal Changes:
○ Increased blood supply (estrogen), vaginal walls begin to thicken, could have
bluish color (increased glycogen)
○ Vaginal vault lengthening
○
○
○
★
★
★
★
★
pH decreases to prevent infection (becomes more acidic)
Rugae becomes prominent (pleated skirt effect)
Time to teach kegel exercises, No douching, wear cotton panties or panty liners
and S/S of infection.
Ovaries:
○ Corpus luteum produces E&P (estrogen and progesterone??) for the 1st 12
weeks, after that the placenta takes over production.
○ Enlargement until 12-14th weeks of gestation
Breasts:
○ Get larger and become tender (estrogen and progesterone)
○ Very vascular- veins are prominent
○ Areolar area begins to get darker
○ Growth of ductal tissue (estrogen)
○ Growth of lobes, lobules, and alveoli (progesterone)
○ Nipples become larger and more erect
○ Tubercles of Montgomery (sebaceous glands) more notable, keep nipples
lubricated
○ Colostrum present (can be expressed after the 12th week)---conversion to
mature milk after delivery
GI system:
○ Tissue of mouth more vascular and prone to bleeding
■ Good oral care necessary
○ Ptyalism: excessive saliva production
■ Chew gum, suck on hard candy to help
■ Saliva becomes more acidic
○ Nausea and vomiting:
■ Due to increased HCG, Estrogen and progesterone (1st Trimester)
■ Small frequent meals, increased carb diet
○ Progesterone relaxes all smooth muscles
○ 2nd and 3rd trimester
■ Decreased tone and motility in the GI tract leads to constipation (due to
compression of intestines)
■ Also relaxes the cardiac sphincter: heartburn (pyrosis)
■ High fiber diet, stool softeners, low acidic foods, don’t eat late at night
○ Progesterone delays the emptying of the gallbladder, prone to gallstones
Pica: offers no nutrient values cravings that are unusual
○ Clay
○ Dirt
○ Starch
○ Concern is iron-deficiency anemia!!
Urinary system:
○ Pressure from the uterus causes increased frequency after lightening occurs
○ Bladder capacity almost doubles in response to progesterone
○
Dilation of the renal pelvis and ureters (progesterone and pressure) leads to
stasis and possible infection
○ Asymptomatic bacteria in urine and UTI are risks for preterm labor
○ Glomerular filtration rate up as much as 50%
○ Renal threshold for glucose decreases (spilling over of glucose that can’t be
replaced)
○ Increase in kidney activity when lying supine, later in pregnancy its greater when
side lying
○ Kidney size can take up to 3 months postpartum to return to normal
★ Integumentary system:
○ Increased circulation to the skin
○ Warmer: Basal metabolic rate (BMR) is higher
○ Hyperpigmentation- produced by melanocyte stimulating hormone (MSH)
○ Linea Nigra- Dark line that runs from pubic symphysis to the xiphoid process
○ Chloasma/melasma- “mask of pregnancy” brown discoloration of the face
■ Caused by MSH (Melanocyte Stimulating Hormone)
■ Worse in dark hair women
■ Aggravated by sunlight and exposure
■ More common in subsequent pregnancies
○ Vascular spiders- small blood vessels that can appear on neck, thorax, face,
and arms (tiny red branching elevations; capillaries that burst on the skin)
○ Varicosities- “varicose veins” result of distension, instability and poor circulation
○ Striae gravidarum- “stretch marks” tears in the underlying connective tissue
caused by rapid growth. On stomach, breasts, back and butt (most prominent by
6-7 months, some predispositions to it)
○ Palmar erythema- well delineated pinkish area on palmar surface of hands
○ Decline in hair growth
○ Nails grow fast and thin
★ Musculoskeletal system:
○ Relaxin: “waddling hormone” loosening of the pelvic joints
○ Softening of the pelvic ligaments (by 10-12th week, purpose of increasing size of
pelvic cavity)
○ Increased swayback/lumbosacral curve (lordosis)
○ Common discomforts:
■ Leg cramps
■ Carpal tunnel syndrome
■ backaches/sciatica:exaggeration of the lumbosacral curve (lordosis)
● Exercises may help
★ Endocrine:
○ Insulin needs decreased for the first ½ of pregnancy but increase later (29
weeks)
○ Insulin resistance- inability of insulin to increase glucose uptake and utilization
(leads to Gestational Diabetes)-due to HPL and other hormones in 2nd half of
pregnancy
○
○
○
○
○
Thyroid slightly enlarged
Pituitary gland enlargement
BMR increases by 20-25%
Increase in cortisol and aldosterone
Hormone: Human Placental Lactogen (HPL) responsible for insulin resistance
■ Increase HPL production starts at 24 weeks
★ Immune system:
○ Pregnancy is an immunosuppressed state
○ Immunizations are OK but no LIVE viruses (Rubella or Varicella)
○ Flu and Tdap recommended
○ WBC can be elevated during pregnancy but especially during labor, stress can
increase it (can be up to 16,000)
○ Vaccines contraindicated during pregnancy
■ Influenza (Live, attenuated vaccine) nasal spray
■ Measles
■ Rubella
■ Mumps
■ Varicella
■ BCG (Tuberculosis)
■ Meningococcal
■ Typhoid
★ Weight Gain:
○ Philosophy varies, but 25-35 lbs is usually thought to be optimal.
■ 3-5 lbs in 1st trimester
■ 10-12 in 2nd trimester
■ 10-12 in 3rd trimester
○ Underweight (BMI less than 18.5)
■ 28-40lbs
○ Normal (BMI 18.5-24)
■ 25-35 lbs
○ Overweight (BMI 25-29)
■ 15-25 lbs
○ Obese (BMI greater than 30)
■ 11-20 lbs
★ Cardiovascular system
○ Slight cardiac enlargement and shift up and to left due to increased workloadreverses later
○ Blood volume increases by as much as 50% above nonpregnancy levels
(1,500ml)- (1,000 plasma and 450-500 RBC)
■ Need a lot of iron to carry O2 all over the body
○ Causes pseudoanemia
■ Hemodilution “physiologic anemia”
○ Hemoglobin: non pregnant: 12-14
■ 1st trimester: at at least 11
■ 2nd trimester: at 10.5 or above
■ 3rd trimester: at 11
○ Cardiac output increases
■ CO= HR x Stroke Volume
○ BP remains about the same; decreases slightly (by 5-10 mmHG) during 2nd
trimester (especially diastolic)
○ Gestational hypertension: 140+/90+ after 20 weeks
○ Blood flow to kidney increases (30%), skin, and uterus
○ Edema in the legs and feet can occur, abnormal if in the face and hands
○ Vena cava syndrome: Blood return to the heart is decreased by the pressure of
the gravid uterus on the vena cava, this increases femoral pressure, decreases
cardiac output and uteroplacental blood flow.
○ Supine Hypotensive syndrome: compression on vena cava, decreased blood
flow causes hypotension (occurs when laying on back, resolves when turned
onto side)
■ Pregnant women should never lay flat.
○ RBC increased by as much as ⅓ due to need for more hemoglobin to carry
oxygen to tissues and fetus.
■ 28-32 weeks: the body is producing more RBC
■ 500cc/min flows through the placenta to the baby at 3rd trimester
■ Iron and Vit. C very important
○ WBC increase to a normal of 12,000-16,000 (from 5,000-10,000)
○ Fibrin, plasma fibrinogen and other clotting factors are increased leading to
hypercoagulable state, making pregnant women more prone to DVT’s
○ Varicosities:
■ Associated with increased venous stasis caused by pressure from the
gravid uterus on the pelvic vessels
■ Vasodilation resulting from effects of progesterone
■ Obesity, genetics, inactivity, poor muscle tone contribute as well
■ Treatment includes elevate legs when resting, support hose/pregnancy
girdles, low heel shoes, avoid crossing legs/ no knee hi, elevate legs
above heart BID, avoid prolonged sitting/standing, ice packs for vulvar
varicosities
○ Hemorrhoids: varicosities of rectum/anus
■ Can be internal/external
■ Prevent constipation: stool softeners
■ Avoid prolonged sitting/standing
■ Topical anesthetics/ topical steroids
■ Sitz baths, witch hazel compresses, cold compresses
★ Respiratory system:
○ Tidal volume increases 30-40%
○ Diaphragm is elevated 4cms
○ Breathing becomes more diaphragmatic (can also be faster and deeper)
★
★
★
★
★
★
○ Circumference of the chest increases about 6cms
○ Increase in nasal stuffiness and epistaxis- from estrogen (nose bleeds)
○ Lightening allows them to breathe easier
Psychological changes in pregnancy:
○ First trimester: Disbelief and Ambivalence (mixed feelings-common)
○ Second trimester: Quickening allows mother to view fetus as separate from self
○ Third trimester: Anxiety about labor and birth; nesting (burst of energy-happens
weeks before due date) occurs
Rubins 4 tasks: these task help the woman develop her self-concept as a mom.
○ Task #1: Seeking acceptance of this child by others
○ Task #2: Seeking commitment and acceptance of herself as a mother to the
infant (binding in)
○ Task #3: Learning to give of oneself on behalf of one’s child
○ Task #4: Ensuring safe passage through pregnancy , labor and birth
Father/Partner’s emotional and psychological changes
○ Couvade Syndrome: sympathetic response to partner’s pregnancy that can lead
to physical changes
○ First trimester:
■ May feel left out
■ Disbelief
■ May be confused by partners mood changes
■ Might resent the attention she receives
○ Second trimester:
■ Begins to decide which behaviors of own father he wants to imitate or
discard
○ Third Trimester:
■ Anxiety about labor and birth
Siblings:
○ May view baby as a threat to security of their relationship with parents
○ Reaction depends on age
○ Preparation for birth is essential
Grandparents:
○ Usually supportive
○ Excited about the birth
○ May be unsure about how deeply to become involved
Cultural Factors: May influence a family’s response to pregnancy
○ CULTURAL ASSESSMENT: helps explore woman’s (family’s) expectations of
healthcare system; allows the nurse to provide care that is appropriate and
responsive to family needs.
■ Main beliefs
■ Wishes
■ Traditions
■ Values
■ Behaviors about pregnancy and childbearing
■ Religious preferences
■ Language
■ Communication style
■ Etiquette
■ Ethnic backgrounds
■ Amount of affiliation with ethnic groups
★ Estimating Due date: EDC or EDD
○ Naegle’s rule:
■ Subtract 3 months and add 7 days to the date of LMP (first day of last
menstrual period)
○ Ultrasound can be used if date of LMP is unknown
■ Ultrasound is typically the most accurate method of dating a pregnancy
★ Taking OB History:
○ Para:
■ (G)ravida: total # of pregnancies (including current)
■ (P)ara: # of pregnancies delivered PAST 20 weeks (no matter if alive or
dead)
■ (A)bortus: # of pregnancies delivered BEFORE 20 weeks (may be
spontaneous or elective)
○ Expanded Para:
■ (T)erm: # of pregnancies delivered at 37 weeks or more
■ (P)reterm: # of pregnancies delivered BEFORE 37 weeks (but after 20)
■ (A)bortus: # of pregnancies ending prior to 20 weeks (will be the same #
as the (A) in the para
■ (L)iving: # of children currently living
○ Example: Mrs. B is pregnant and in the first trimester. She has a 3 yr old son and
a 2 yr old daughter, both born at term, she gave birth to a baby who was stillborn
at 21 weeks.
■ G=4
■ P=3
■ A=0
■ OR….G4P(2102)
High Risk management
★ Iron-deficiency anemia
○ Clinical consequences include preterm delivery, perinatal mortality, and
postpartum depression
○ The risk of hemorrhage and infection during and after birth are also increased
○ Clinical symptoms include fatigue, diminished quality of life, impaired cognitive
function, increased risk for thromboembolic events, headache, restless legs
syndrome, and pica
○ Therapeutic management
■ Goal= eliminate symptoms, correct the deficiency, and replenish iron
stores
■
○
○
Routine iron supplementation for all pregnant woman starting at a low
dose of 30 mg/day beginning at the first prenatal visit
Nursing assessment
■ Assess dietary intake
■ Assess for symptoms of iron deficiency
■ Obtain vitals and report any tachycardia
■ Prepare the woman for la testing.
● Lab tests usually reveal low Hgb (<11 g/dL), low Hct (<35%), low
serum iron (<30 mcg/dL), microcytic and hypochromic cells, and
low serum ferritin (<100 mg/dL)
Nursing management
■ Stress importance of taking prenatal vitamins and iron supplement
consistently. Encourage the woman to take the iron supplement with
Vitamin C-containing fluids (orange juice) which will promote absorption
■ Recommend foods high in iron, such as: dried fruit, whole grains, green
leafy vegetables, meats, peanut butter, and iron-fortified cereals
★ Group B Strep (GBS)
○ GBS is rarely serious in adults, but can be life threatening to newborns
○ Most common cause of sepsis and meningitis in the newborn
○ Therapeutic management
■ Antibiotic therapy
■ All women should be screened for GBS at 35-37 weeks and treated
■ Both pregnant women and women during labor who have positive
cultures are treated with a penicillin-based anti-infective agent
■ Penicillin G is the treatment of choice
● ASK ABOUT ALLERGIES TO ANY CILLIN DRUGS
● Usually administered IV at least 4 hours before birth
○ Nursing assessment
■ Determine if ROM and time of ROM
● Monitor vitals, reporting any maternal fever greater than 100.4° F
(38° C)
■ Assess for any UTI
○ Nursing management
■ Nurses play major roles as educators and advocates for all women and
newborns to reduce the incidence of GBS infection
■ Ensure women are screened between 35-37 weeks for GBS during
prenatal visit
■ During labor administer IV antibiotics to all women GBS+
★ Pregnant Adolescent
○ Teens are least likely of all maternal age to get early and regular prenatal care
○ Nurses need to examine their own beliefs about teen sexuality to identify
personal assumptions ---> Put them aside!
○ Nursing assessment
■
Assessment is the same as that for any pregnant woman. However, when
dealing with teens, the nurse also needs to ask:
● How much does she know about child development
● What financial resources are available to her?
● Does she work? Does she go to school?
● What emotional support is available to her?
● What does she know about nutrition and health for herself and her
child?
■ Having an honest regard for adolescents requires getting to know them
and being able to appreciate the important aspects of their life. Doing so
forms a basis for the nurse’s clinical judgement and promotes care that
takes into account the concerns and practical circumstances of the teen
and her family
■ Skillful practice includes knowing how and when to advise a teen and
when to listen and refrain from giving advice
■ Assess for STIs
○ Nursing management
■ Nurses must support adolescents during the transition from childhood into
adulthood, which is complicated by their emergence into motherhood
■ Assist in identifying family and friends who want to be involved and
provide support throughout the pregnancy
● THIS CAN’T BE YOU. YOU HAVE TO KEEP A PATIENT NURSE
RELATIONSHIP
■ Help the adolescent identify the options they have such as abortion, selfparenting, temporary foster care, or adoption
■ Monitor weight gain, sleep and rest patterns, and nutritional status
● Adolescents are most likely to not eat right
■ Stress the importance of attending prenatal classes
★ The pregnant woman over 35
○ Women in this age group may already have chronic health conditions that can
put the pregnancy at risk
○ Increased risk for infertility and spontaneous abortions, gestational diabetes,
chronic hypertension, postpartum hemorrhage, preeclampsia, preterm labor and
birth, multiple pregnancy, genetic disorders and chromosomal abnormalities,
placenta previa, fetal growth restrictions, low APGAR scores, and surgical births
○ Nursing assessment
■ A preconception visit is important to identify chronic health problems that
might affect the pregnancy
■ The risk of having a baby with Down syndrome increases with age so
Amniocentesis is routinely offered to all older women to allow the early
detection of numerous chromosomal abnormalities
○ Nursing management
■ Assess women's knowledge about risk factors and measures to reduce
them
■ Encourage regular prenatal care
■ Prenatal vitamins- 400 mcg of folic acid
★ The obese pregnant woman
○ Defined as BMI of 30 or more
○ Tend to gain excessive weight in pregnancy
○ Increased risks included: gestational diabetes, hypertension, thromboembolism,
preeclampsia, preterm labor and birth, congenital anomalies, childhood obesity,
fetal macrosomia (birth weight >4,000 grams), difficulty fighting postpartum
infections, depression, prolonged pregnancy, increased risk of stillbirth, higher
rate of c/s, postpartum hemorrhage
○ Nursing management
■ Preconception assessment and counseling are needed for obese women,
which should include specific information about maternal and fetal risks of
obesity in pregnancy, as well as encouragement to undertake a weightreduction program, including diet, exercise, and behavior modification, to
achieve a healthy weight prior to conception
■ Extra time may be needed to promote healthful practices, which should
include dealing with issues of weight, diet, and exercise.
■ Specialist dietary interventions and evidence-based guidelines for
working with childbearing women must be seen as a public health priority
by all nurses. This care must be done with honesty and respect for all of
the woman’s needs
■ Negative or judgmental attitudes toward overweight or obese individuals
can be encountered within the health care community and its providers,
including nurses. Nurses can find it difficult to discuss weight issues
during prenatal visits with obese women
Prenatal Care (chapter 12 PPT)
First Trimester (conception-13 weeks)
★ Blood tests: usually done at 1st prenatal visit for prenatal profile.
○ Blood type: A, B, O or AB
○ Rh Factor: Positive or Negative
○ Antibody screen: Positive or Negative (want to be negative)
○ Rubella titer: Positive (immune) negative (nonimmune)
○ VDRL or RPR (syphilis screen): reactive or nonreactive
○ HIV: Positive or negative
○ HBsAg: (hepatitis B surface antigen) Positive or negative (if positive, give HBig)
○ CBC: (complete blood count)
■ WBC-white blood cells
■ HGB-hemoglobin
■ HCT-hematocrit
■ PLT- platelets
○ Genetic blood tests:
■
Sickle cells screen: (sometimes called sickledex, or sickle prep); Hgb
electrophoresis also determines sickle status
■ Cystic Fibrosis Screen
■ Mother and Father must be a carrier of gene for baby to get it
■ **Possible early 1 hr glucola screen for high risk groups (otherwise done
between 24-28 weeks)
● Previous large for gestational age baby
● Strong family history of diabetes
● Obesity
● Chronic hypertension
★ Other non-blood tests:
○ PAP
○ Gonorrhea/chlamydia cultures
○ U/A: Urinalysis
○ Urine C & S (culture and sensitivity)
○ Organogenesis- development of organs
First trimester Office Visits: (Every 4 weeks)
★ What to expect: Thorough assessment through history:
○ Age of patient/ developmental age
○ Gynecological history & LNMP (Last normal menstrual period)
○ Medical/Surgical history
○ Obstetrics history (include complications)
○ Social history
■ Drink?
■ Smoke? # of packs per day
■ Drugs?
○ Occupational history
○ Pets (cats?- concern for toxoplasmosis)
○ Culture
○ Father of baby/ social support/ educational level/ economic status
★ Physical Exam with Pelvic: (Baseline data is obtained)
○ Provider (MD,CNM,PA) assesses Vital signs, weight, thyroid, heart, lungs,
breasts/nipples, abdomen, extremities
○ Provider will assess pelvic structure
■ Size/shape
● Gynecoid → best shape for a vaginal delivery
● Android
● Anthropoid
● Platypelloid
■ Uterine size vs gestational age
■ Cervical length/closure
★ Fetal heart rate auscultated with Doppler (10-12 weeks’ gestation)
★ Possible ultrasound (transvaginal or abdominal) to determine presence of gestational
sac in uterus or tube and fetal pole. U/S good for dating pregnancy if LMP questionable
(dates good within 7 days)
★ Nuchal Translucency Testing (NTT): (done at 11-13 wks gestation “optional”)
○ Measures the thickness of the folds in the neck of fetus
○ Early screen for chromosomal defects (Trisomy 13, 18, 21)
■ Detects 70-80% of all Down’s fetuses, but can have a false positive result
■ More accurate if serum blood test is done with it (PAPP-A and B-hcg)91% identification rate)
■ If screening is abnormal, Further testing offered (amniocentesis for
diagnosis)
★ Chorionic Villus Sampling:
○ Invasive procedure in which a small sample of villi taken from developing
placenta at 10-12 wks gestation in order to diagnose genetic, metabolic and DNA
disorders
■ Only done on high risk persons for these disorders
■ Does NOT diagnose neural tube defects
First Trimester Teaching:
★ Teratogens
★ Normal changes (physical and emotional)
★ Ambivalence
★ Who to call for problems
★ Warning signs
○ Vaginal bleeding
○ Abdominal pain/severe cramping
○ Severe nausea/vomiting (hyperemesis gravidarum)
○ Urinary burning/urgency
○ Fever >100°F (37.7°C) (infection)
○ Lower abdominal pain with dizziness and accompanied by shoulder pain
(ruptured ectopic pregnancy)
★ Foods to avoid
○ Large fish
■ Swordfish= high in mercury ←- not good
○ Soft cheeses
○ Uncooked deli meats
2nd Trimester: (14-26 weeks) Visits every 4 weeks
★ Office Visit:
○ Urine dip
○ Weight
○ BP
○ Fundal height (1 cm =1 week)
○ FHT
○ Protein 1+ (pre-eclampsia?)
★ Labs:
○
AFP: alpha-fetoprotein “Quad Screen”: offer amniocentesis if abnormal (elevated
AFP= increased risk for neural tube defects, decreased AFP= increased risk for
Downs/Trisomy 18), “optional” only done between 15-20 weeks
○ 24-28 weeks: 1hour glucola- screen for GDM (if above 135 a 3 hour glucose test
needed), repeat H/H (10.5/29) Pseudoanemia
★ Ultrasound:
○ 18-20 weeks: anomaly screen “gender ultrasound”
★ Teaching:
○ Quickening: 16-20 weeks- multigravida; 18-20 weeks primigravida
○ Nutrition: increase calcium, iron, protein, fluids/ fetal GHD
○ Exercise: pulse >140 risk for injury (relaxin and progesterone)
○ Sexuality: +/○ Danger signs of pregnancy (during 2nd trimester)
■ Regular uterine contractions (preterm labor); pain in calf- often increased
with foot flexion (DVT); sudden gush or leakage of fluid from vagina
(premature ROM); and absence of fetal movement for more than 12
hours (possible fetal distress or demise)
3rd Trimester: (27-40 weeks) visit every 2-3 weeks; (36+ weekly until delivery)
★ Office visit:
○ Urine dip
○ Weight
○ BP
○ Fundal height
○ FHT
○ EFW- Estimated fetal weight
○ Leopold’s exam
★ Labs
○ Antibody screen for all Rh-negative mothers-Rhogam given at 28 weeks and
stays in system for 12 weeks (second dose within 72 hours after birth if fetus
Rh+)
○ GBS (group beta strep- 35-37 weeks)- if + will treat during labor with PCN G
○ 36 weeks VDRL repeated (Gonorrhea/Chlamydia)
○ H&H repeated at 36 weeks (11/33)
★ Teaching
○ Preterm labor signs and symptoms
■ Heavy bleeding
■ Contractions
■ Fluid leakage
■ Lack of fetal movement
■ Fever >101
■ Periorbital or facial edema
○ Kick counts
○ Danger signs
INTRAPARTUM:
True contractions vs False
★ Timing:
○ True: Regular, closer together, 4-6 mins apart, lasting 30-60 seconds
○ False: Irregular, not close together
★ Strength:
○ True: Stronger over time, vaginal pressure felt
○ False: Frequently weak, not getting stronger with time or alternating (strong then
weak)
★ Discomfort:
○ True: Starting in the back then radiates to the front of abdomen
○ False: Felt only in the front/ top of abdomen
★ Activity changes:
○ True: Contractions continue no matter what position
○ False: May stop or slow with walking or position change
★ Stay or go:
○ True: Stay home until 5 mins apart, last 45-60 seconds, can’t walk or talk through
them
○ False: Drink fluids, and walk around to see if any changes to the intensity of
contractions
-Ideal for contraction frequency to be 2-3 minutes with 1-minute resting time in between
-Contractions include increment, acme, and decrement
Premonitory signs of Labor:
★ Cervical Changes:
○ Can occur 1 month to 1 hour before actual labor begins
○ Softening, dilation (1 finger= 1 cm), ripening
○ Lightening: occurs when the fetal presenting part begins to descend into the
true pelvis
■ Moves to a more anterior position
■ Can occur 2 weeks or more before labor begins
● Multiparas may or may not occur before labor begins
★ Increased energy levels: referred to as “nesting”
○ Normally 24-48hrs before the onset of labor
★ Bloody show: mucous plug that fills the cervical canal during pregnancy is expelled as
a result of softening and increased pressure.
★ Braxton hicks: May be stronger and more frequent, usually felt as a tightening or pulling
at the top of uterus
○ Irregular
○ Can be decreased by movement, voiding, eating, fluid increase, change in
position
★ Rupture of membranes
○ Sudden gush or steady leakage
○
○
○
Even if membranes rupture continual supply is produced until birth
Barrier is gone, infection can occur
Always advise to notify provider due to possibility of complications
Stages of Labor:
★ Stage One: Onset of contractions to 10 cm dilated
○ Latent phase: 0-3 cm, 0-40% effaced, frequency of contractions: 5-10 mins
apart, mild to moderate upon palpation; last 30-45 seconds
■ Maintain hydration, rest to conserve energy, use distraction methods,
time contractions, use slow paced breathing (cleansing breath), ambulate
as desired
○ Active phase: 4-7 cm, 40-80% effaced, frequency: 2-5 mins, Duration: 45-60
seconds, Intensity: moderate upon palpation
■ Steady cervical change, provide continuous support, assess FHTs, use
moderate paced breathing (avoid hyperventilation), effleurage, VS
q30mins for low risk patients
■ Primipara at least 1.2cm/hr and Multipara at least 1.5cm/hr (but not
always the case
○ Transition phase: 8-10 cm, 80-100% effaced, frequency 1-2 mins apart, duration:
60-90 seconds, Intensity: strong by palpation
■ Several short breaths followed by a longer exhale, continuous monitoring
of FHT/VS/contractions, rapid progress
■ Can experience Nausea/vomiting, trembling extremities, backache,
increased apprehension and irritability, restless movement, increased
bloody show, inability to relax, diaphoresis, feeling loss of control and
being overwhelmed. ex. “I can’t take it anymore”
★ Stage Two: 10 cm dilated to birth “rim of fire”
○ Pelvic Phase: Period of fetal descent
○ Perineal Phase: Active pushing. Contractions every 2-3 mins, lasting 60-90
seconds, strong by palpation; strong urge to push, rectal pressure. (spontaneous
vs directed pushing).
■ Crowning is when the head no longer regresses between contractions,
occurs during the later perineal phase.
-Want to avoid Valsalva (holding breath while pushing)
★ Stage Three: Delivery of baby to delivery of placenta (5-30 minutes)
○ Placental Separation: Detach from uterine wall
○ Placental expulsion: Coming out of the vaginal opening
★ Stage Four: Delivery of placenta to postpartum several hours later
○ Time of maternal physiological adjustment and stabilization
○ Assess vital signs every 15 mins during the first 2 hours after birth, 30 mins for
the next hour if needed; asses fundal height, position and firmness every 15 mins
during first 2 hours after birth; assess perineum including the episiotomy; assess
woman’s comfort level frequently and assess vaginal discharge (lochia)
○
Bladder can become hypotonic (no urge to void); full bladder can lead to
hemorrhage
★ Cardinal Movements of Fetus
○ Descent ->Flexion ->Internal Rotation ->Extension ->External Rotation ->
Expulsion
Amniotic Fluid: Water, water everywhere!!
★ Purpose of:
○ Cushions embryo (protection against mechanical injury to woman’s abdomen)
○ Float umbilical cord to prevent compression
○ Permits growth and development of embryo
○ Keeps uterus distended away to allow freedom of movement, aiding in
musculoskeletal development
○ Acts as a wedge during labor
○ Able to be used for analysis to determine fetal health and maturity
★ Quantity:
○ Oligohydramnios: too little fluid surrounding fetus (can cause cord accidents)
○ Polyhydramnios/Hydramnios: Too much amniotic fluid surrounding fetus (can
cause swallow defects and possible preterm labor)
○ Both conditions are high risk pregnancies
★ Rupture of membranes: Can be a trickle or a gush of fluids
○ Spontaneous (SROM)
○ Artificial (AROM): amniotomy with use of amnihook
★ Methods of Fluid evaluation
○ Nitrazine test:
■ Tests pH of fluid: yellow- negative; Dark blue Positive
● Amniotic fluid is ALWAYS ALKALINE
■ Performed by RN or MD/CNM
■ Strip placed on fluid-soaked pad or in vagina
■ False positives possible
○ Fern test:
■ Amniotic fluid is obtained from the vagina (sterile speculum exam),
smeared on slide, allowed to air dry. Crystallizes and creates fern leaf-like
pattern under microscope
■ Performed by MD or CNM
■ Conclusive test for ROM
○ Amnisure test:
■ Commercially available test (rapid and noninvasive)
■ Can be performed during assessment by RN (with Order)
■ Swab sample and place in test tube x 1min
■ Positive= 2 lines; negative= 1 line
★ Role of Nurse after ROM
○ Check FHT FIRST!!
■ Prolapse of cord can occur: Fetal heart rate drops
○
○
○
○
○
○
○
● Immediate Cesarean section
Test to evaluate fluid: if necessary
Note time ruptured, color/consistency, odor
■ Yellow: old meconium; Green, brown, black: new meconium
Assess temp every 2 hours if ROM; 4 hrs if no ROM
■ Temp of 100.4 is considered fever
Limit vaginal exams: can cause bacteria to be pushed into genital tract infecting
the membranes, fetus can become infected (Chorioamnionitis)
Keep clean/dry
■ Change chux pads and peripads
Know station/ presentation
■ How low in the pelvis is the presenting part?
■ -3 to -1 (not engaged), 0 to +3 (well engaged)
Document appropriately
★ Cord Prolapse
○ Can occur with ROM is presenting fetal part is not well engaged in the pelvis
○ Leaves room for the cord to slip down in front of the presenting part (weight of
baby compresses cord and caused FHR to decrease and severe fetal distress to
occur)
○ Not always visual, might have to palpate
○ Decreased O2 supply to baby can cause release of meconium while still in uterus
(can cause meconium aspiration syndrome)
○ Emergency C/S required
★ Leopold’s Maneuver
○ Method of determining the position, presentation and lie of the fetus through
inspection and palpation (four maneuvers)
○ Maneuvers:
■ Maneuver 1: determines which fetal part is located in the fundus
● Facing the woman, palpate upper abdomen w/ both hands noting
shape, consistency and mobility of the palpated part (head is
round, firm and moves independently, buttocks feels softer and
moves with trunk)
■ Maneuver 2: determines on which maternal side the fetal back is located
● Move hands on the pelvis and palpate the abdomen w/ gentle
pressure (fetal back on one side of the abdomen feels smooth and
fetal extremities on the other side feels knobby)
■ Maneuver 3: determines what is the presenting part
● Place hand just above the symphysis pubis noting whether the
palpated part feels like the fetal head or the breech and whether
its engaged
■ Maneuver 4: determines if the fetal head is flexed and engaged in the
pelvis
●
Facing the woman, place both hands on the lower abdomen and
move hands gently down the sides of the uterus toward the pubis
noting the cephalic prominence or brow
Analgesia and Anesthesia:
★ Why?
○ Pain & stress causes increase in maternal RR and O2 consumption, resulting in
decrease O2 available to fetus
○ Can lead to metabolic acidosis and release of catecholamines (cause
vasoconstriction) results in less O2 and nutrients to fetus
★ Causes of pain in labor:
○ 1st stage:
■ Dilation of cervix
■ Stretching of lower uterine segment
■ Pressure on adjacent structures: bladder, ovaries
■ Hypoxia of uterine muscle cells during contractions
○ 2nd stage:
■ Hypoxia of contracting uterine muscle cells
■ Distention of vagina and perineum
● Little nerve endings in the perineum
■ Pressure of adjacent structures
○ 3rd stage:
■ Uterine contractions
■ Cervical dilation as placenta is expelled
● Not as intense
★ Analgesia:
○ Offer as needed:
■ IV pain meds: opioid narcotics: nubain, stadol, dilaudid
■ Ataractics: analgesia potentiators used to enhance effects of narcotics
used to enhance effect of narcotics (Phenergan, Largon)
■ **Nubain and Phenergan often given together IV every 2-3 hours PRN in
active labor**
○ Assessment
■ VS
■ FHR
■ Contraction pattern
■ Pain level
■ Allergies prior to administering
○ Meds cross placenta and can sedate mom/baby
○ Will decrease FHR variability
○ Don’t give too close to delivery (7-8 cm)
○ Don’t give too early
■ If in latent phase it may prolong labor
○ Instruct to stay in bed
○ Keep call bell within reach
○
Maintain quiet to facilitate rest
■ Narcotics and ataractics will make her drowsy
★ Labor Anesthesia
○ Offer as needed, most common:
■ Epidural anesthesia: injection of anesthetic agent into epidural space to
provide pain relief in labor (regional)
● Performed by anesthesiologist, CRNA, or OB
● Occasionally narcotics are added to add extra effect
● Need informed consent, IV fluid bolus (500-1,000ml) prior to
placement to prevent hypotension, frequent VS assessment,
continuous FHR monitoring, and position laterally to displace
uterus
● Will not feel pain from top of fundus to tips of toes, but will/should
still feel pressure
■ Pudendal anesthesia: provides perineal anesthesia immediately before
and during birth
● Doesn’t relieve contractions
● May decrease urge to push
● No hypotension or FHR effects
○ Advantages
■ Awake and part of birth process
■ Less fetal sedation than IV meds
■ Allows for rest/regain strength
○ Disadvantages
■ Hypotension common
■ 2nd stage pushing may be hindered
■ Bladder anesthetized- can’t feel need to void
■ Temporary low back pain/ soreness
■ Can’t ambulate/ hinders self-movement
★ Operative Anesthesia
○ Spinal block: local anesthesia injected directly into spinal fluid in spinal canal
(anesthetizes from nipple line down)
■ Often used in C/S
○ Epidural block: same procedure, side effects and precautions as epidural
anesthesia
■ Can also be used for C/S but dosage is slightly different
○ General anesthesia: “induced unconsciousness”
■ Last resort for C/S
■ Risk of vomit/aspiration
■ Risk of fetal depression r/t meds given to mother (baby must be delivered
quickly)
■ Need to know last oral intake, preoxygenate 3-4 mins on 100% O2
★ Local Anesthesia
○ Can be used at the time of birth
○ Used in preparation for episiotomy and/or perineal laceration repair
○ Lidocaine is commonly used
○ No common adverse effects
The 4 P’s of Labor
★ Passenger: The Baby
○ Lie: Relationship of the longitudinal axis of the baby to the longitudinal axis of the
mother
■ Longitudinal: Up and down
■ Transverse: across
● Can’t come out that way
● Risk of cord prolapse if woman had ROM
○ Station: Relationship of the presenting part to the ischial spine
■ Engagement: from zero station or below (up to +3, crowning)
■ Minus stations: Above the spines
■ Positive stations: below the spines
○ Presentation: Part of the baby that enters the pelvis first
■ Vertex: 95%
■ Breech: 4%
● Risks: Prolapse cord, CPD, Asphyxia, C/S
■ Brow, face, shoulder: 1% (more difficult to fit through pelvis)
○ Position: Three letters denoting the relationship of the landmark on the baby to
the mother’s pelvis
■ Landmarks: Occiput/Vertex; Sacrum/ Breech
■ Ex. LOA=Left occiput anterior
● The occiput of the baby is pointing toward the left front of the
mother’s pelvis
○ Mechanisms of Labor: movements of the baby through the pelvis during
labor/birth. Each is essential to an easy, safe passage.
■ Engagement/descent
■ Flexion
■ Internal rotation
■ Extension
■ External rotation/restitution
★ Power
○ Power during labor comes from strong contraction of the upper uterine segment
■ 2nd stage adds power of the abdominal muscles (pushing)
○ Use of drugs to augment (“to add to”) or induce (“to begin”) labor, or ripen
(“soften and efface) the cervix
○ Action: stimulate the uterine contractions
○ Prostaglandins:
■ Prepidil gel
■ Cervidil vaginal insert
■ Cervidil vaginal tablet
○ Oxytocin
■ Always goes on a pump
■ Always label your line and closest to your port
○ Cervical ripening agents
■ Prostaglandins
■ Evening primrose oil
■ Mechanical dilation using balloon cath
■ “Stripping” the membrane
■ Castor oil
■ Sexual Intercourse
○ Most common reasons for inductions:
■ Going over 40 weeks
■ Medical reasons
■ Elective (not before 39 weeks)
○ Who is not a candidate for induction?
■ Scar on uterus
■ NST nonreactive
■ Vaginal bleeding
■ Less than 39 weeks
■ Breech or transverse
■ Active genital herpes
■ Placenta previa (low lying placenta)
○ Safe use of Oxytocin
■ Start slowly and evaluate before advancing
■ Watch patient, VS, and fetal monitor
■ Know the side effects
○ Risks of Oxytocin
■ Hyperstimulation
■ Fetal distress
■ Uterine rupture
■ Hypertension
■ Water intoxication: too much fluid
★ Passageway
○ 4 types:
■ Gynecoid: best for birth; inlet is round a roomy
■ Android- funnel shaped
■ Anthropoid: pelvic inlet is oval, and sacrum is long
■ Platypelloid: cavity is shallow and difficult for decent
○ Pelvic measurements:
■ Diagonal Conjugate: usually about 12.5 cm measured vaginally from the
symphysis to the sacral promontory
■ True conjugate: measurement from the top of the symphysis to the sacral
promontory, estimated by subtracting 1.5 cm from the diagonal conjugate
○ Lacerations
■ 1st degree- tearing of the perineal skin ← (will heal on its own (no sutures)
■ 2nd degree- skin & perineal muscle ←- (needs sutures)
■ 3rd degree- skin, muscle & anal sphincter
■ 4th degree- skin, muscle, sphincter, & rectal mucosa ←- (Long time to recover)
○ Life after lacerations
■ They heal quickly and well facilitated by:
● Stool softeners
● High fiber diet
● Peri Bottle
● Ice pack
● Keeping cleaned and changing pads frequently
○ Possible indications for C/S
■ Cephalopelvic disproportion
■ Active genital herpes
■ No reassuring FHR patterns
■ Prolapsed cord
■ Breech/ transverse lie
■ Certain prior uterine surgeries (classical incision)
■ Certain medical diseases where labor is not advisable
○ Nursing care preparing for C/S
■ Pre-op teaching (if possible) ←- sometimes c/s is last minute
■ Touch, eye contact, info to decrease anxiety
■ Needs IV line, foley, shave prep (lower abd)
■ NPO
■ Notifies pediatrician-- prepare baby items
■ Positioning on OR table (roll a towel or IV bag under hip to prevent
supine hypotension)
■ Monitor FHR until procedure-check one more time prior to surgery
○ VBAC
■ Candidates for VBAC (ACOG):
● Prior low-transverse c/s (no prior classical incision)
● Clinically adequate pelvis
● MD immediately available to perform emergency c/s
■ Risks
● Uterine rupture
● fetal/maternal death
● Hysterectomy
■ Nursing interventions
● Continuous fetal monitoring (fetal distress can be a sign of uterine
rupture)
● Do not use prostaglandins for cervical ripening
● Oxytocin use very carefully
● Document well
● Have OR and OR staff available
Fetal Monitoring:
★ What is being monitored:
○ Contractions
■ Frequency: time from beginning of one contraction to the beginning of the
next
■ Duration: how long the contraction lasts
■ Intensity: strength of the contraction
● External monitoring: feel at the top of uterus
○ Fetal heart rate:
■ FHR baseline: normal 110-160 bpm
● >160- tachycardia for 10 mins
● <110 bradycardia for 10 mins
■ Variability: (push and pull)- sympathetic and parasympathetic effect on
the baby. Single best indicator for fetal oxygenation
■ Accelerations: Always good when HR goes up 15 beats for at least 15
seconds
■ Decelerations:
● Early Decelerations (head compression)- pressure of the
contraction on the head of the baby, vagal nerve gets pressed on
● Variable decelerations (cord compression)- Sharp V shape from
cord compression
○ Reposition mother to relieve pressure
○ Can inject fluid though catheter, amnio infusion
● Late decelerations- ALWAYS BAD!! Uteroplacental insufficiency,
not getting enough O2, nutrients
○ Increase O2 to the baby- reposition mother on her side
and give O2 via face mask
○ Increase fluids
○ If this doesn’t work, C/S
● Prolonged Decelerations: below the FHR baseline lasting longer
than 2 mins
○ D/C any pitocin infusion
○ Change mothers’ position
○ Vaginal exam to look for cord prolapse or fetal decent
○ Amnioinfusion
○ O2
○ Notify provider, and prepare for CS if no improvement
■ Things that lower Variability:
● Normal:
○ Baby sleeping
○ Narcotic medication
○ Premature
● Abnormal
○ Drugs
○ Cord prolapse
■ Categories:
● Category 1 strip: everything is reassuring
● Category 2 strip: in the middle, not a lot of variability
● Category 3 strip: Not reassuring, late decelerations
★ Methods of fetal monitoring:
○ Auscultation/palpation
■ fetoscope/ hand-held doppler to auscultate FHR
■ Palpation of uterine contractions
○ External electronic fetal monitoring
■ Ultrasound transducer to monitor FHR
■ Tocotransducer to monitor uterine activity
○ Internal electronic fetal monitoring
■ Fetal scalp electrodes (FSE) to monitor FHR
■ Intrauterine pressure catheter (IUPC) to monitor uterine activity
★ Test for fetal well-being:
○ Non-stress test: to assure well-being of fetus, accelerations should be concurrent
with fetal movement
■ 15 beats above baseline for at least 15 seconds
■ Need 2 accelerations within 20 mins interval
■ Usually not reliable before 28 weeks
■ Interpreted as either reactive/ nonreactive
● Reasons for nonreactive:
○ Hypoxia
○ Sleeping from medication or normal sleep cycle
○ Less than 28 weeks
○ Fetal neurological insult/complications
○ Contraction stress testing: to measure the response of the FHR to the stress of
contractions
■ Induce 3 contractions in 40 secs within 10 min period
■ Contractions are induced by either nipple stimulation by patient of IV
oxytocin infusion
■ Test is interpreted as negative (no decels) or positive (late decels seen)
■ Positive CST is immediate delivery by Cesarean section
○ Biophysical profile: combination of non-stress test and ultrasound results used to
detect hypoxia early enough to intervene before any permanent fetal damage or
stillbirth can occur. If abnormal, then an expedited delivery (CS or induction) will
be considered
■ 0-2 points given for each of the 5 parameters
● Parameters:
○ NST: reactive: 2 points, non reactive: 0 points
○ Ultrasound: 2 points for each observed normal by specific
measurements
■ Fetal movement
■
■
■
Fetal muscle tone
Fetal breathing movements
Amniotic fluid intake
●
BP results
○ Overall score of >8/10 reassuring that baby will be well
oxygenated in-utero. Pregnancy will continue
○ Scores of < 6/10 suspicious, possibly indicating
oxygenation compromised fetus. Provider will consider
expedited delivery of fetus by C/S or induction.
Transition to extrauterine life
★ The mechanics of birth require a change in the newborn to survive outside the uterus
★ Newborn experiences complex changes in major organ systems
★ Transitions take place with the first 6-10 hours. Many adaptations take weeks to
attain full maturity
★ Respiratory Adaptations:
○ At birth, the newborn must adjust from a fluid filled intrauterine environment to a
gaseous extrauterine environment
○ Passage through the birth canal allows intermittent compression of the thorax,
which helps eliminate the fluid in the lungs
○ Pulmonary capillaries and the lymphatics remove the remaining fluid
○ Surfactant: is a surface tension-reducing lipoprotein that prevents alveolar
collapse
■ Provides lung stability needed for gas exchange
■ Alveoli of lungs lined by surfactant (phospholipid) which lowers surface
tension of alveoli during extrauterine exhalation
■ By decreasing surface tension of alveoli, surfactant stabilizes alveoli,
causing certain amount of air to remain in alveoli during expiration
○ Mechanical events:
■ Compression of the thorax as baby passes through birth canal
■ Secretion of lung fluid decreases 48 hrs before onset of labor
■ The remaining fluid is “squeezed out” so air exchange can occur
■ Decreased thoracic squeezing during birth or diminished respiratory effort
can lead to transient tachypnea of the newborn (RR>60)
● Example: C section delivery, sedation in newborns and severe
asphyxia
○ Chemical Stimuli:
■ Transitory asphyxia
■ When you cut the cord PC02 increases and PO2 decreases
■ Cutting the cord stimulates the aortic and carotid chemoreceptors, triggering
respiratory center in the medulla → TAKE A BREATH!
■ Some asphyxia is a respiratory stimulant
■ Prolonged asphyxia is a CNS depressant
○ Thermal Stimuli
■
Decrease temperature after delivery helps initiate breathing (98.6 for
mom to 70-75-degree room temp)
■ Nerve endings in skin send messages to respiratory center in medulla
■ Newborn responds with respiration
■ Excessive cooling can be a respiratory depressant
○ Sensory Stimuli:
■ Gentle physical contact
■ Tactile, auditory, visual stimuli of birth
■ Thorough drying, rubbing procedure provide stimulation (& helps
decrease heat loss)
○ Newborn Respirations
■ Shallow and irregular
■ Range from 30-60 breaths per minute with short periods of apnea
■ Chest movements should be symmetric
■ Periodic breathing may occur-cessation of breathing that lasts 5-15
seconds without changes in color or heart rate
■ Obligatory nose breather (obstruction causes distress-keep clean, OG
tubes vs NG)
■ Concern if respirations are below 30 or above 60 when infant is at rest
■ Apnea should not occur-cessation of breathing that lasts longer than 15
seconds with cyanosis and changes in heart rate
○ Signs/Symptoms of Respiratory Distress Syndrome (RDS)
■ Tachypnea
■ Grunting
■ Nasal flaring
■ Retractions
■ Circumoral (central) cyanosis
★ Cardiovascular System Adaptations
○ Umbilical vein carries oxygenated blood from placenta to fetus
○ Fetus depends on the placenta to provide oxygen and nutrients and to remove
waste products
○ Fetal heart structures allows bypassing of pulmonary circulation
○ At birth, circulation switches from placental to pulmonary gas exchange
○ Before birth, the foramen ovale allowed oxygenated blood from the right atrium to
pass into the left atrium of the heart
○ With the first breath, the pressure in the left atrium becomes higher than in the
right atrium
○ The pressure change forces the foramen ovale to close, allowing blood in the
right ventricle to flow entirely to the lungs, it closes due to the decrease in the
right sided heart pressures
○ The ductus arteriosus is located between the aorta and the pulmonary artery
○ During fetal life, the ductus arteriosus shunts blood into the descending aorta
bypassing pulmonary circulation
■ Closes within a few hours after birth
■
★
★
★
★
Closure depends on the high oxygen content of the aortic blood which
results from aeration of the lungs at birth
○ Heart Rate:
■ For the first few minutes after birth, HR is 120-180. After birth the average
HR is 120-160
■ B/P highest immediately after birth
■ Murmurs: turbulence in blood flow-transient- associated with persistent
fetal circulation (incomplete closure of the dictus arteriosus/foramen
ovale)
Blood Components
○ Fetal red blood cells are large, but few in number. Life span is 80-100 days,
compared to 120 days in adults
○ Physiologic anemia of infancy- hemoglobin initially declines as a result of
decrease in neonatal red cell mass
○ Leukocytosis (elevated WBC) trauma of birth stimulates neutrophils
Temperature Regulation:
○ Thermoregulation- process of maintaining the balance between heat loss and
heat production
○ Newborns tolerate a narrower range of environmental temperatures
○ Newborns are extremely vulnerable to both overheating and under heating
○ Newborns lose about 4x as much heat as an adult
○ Newborns require higher temps than adults to maintain temp because of:
■ Decreased subcutaneous fat for insulation
■ Large body surface area relative
■ Thin epidermis (blood vessels close to skin)
■ Lack of shivering to produce heat
○ Should be placed in a thermal neutral zone TNZ- where they can maintain a
stable body temperature without an increase in oxygen consumption or metabolic
rate
○ Normal axillary temp= 97.7-99.5 degrees Fahrenheit (36.5-37.5 Celsius)
Hyperthermia
○ Prone to overheating
○ Control of body temp is regulated by hypothalamus and CNS
○ Immature CNS makes it difficult to control temp
○ Overheating increases fluid loss, respiratory rate and metabolic rate
○ Severe hyperthermia can cause brain damage/death
Cold Stress:
○ If infants experience heat loss, this can result in cold stress
○ Excessive heat loss that requires a newborn to used compensatory mechanisms
to maintain core body temperature.
○ Preterm newborns are at greatest risk because of less fat stores and immature
responses
○ If not addressed, cold stress can lead to:
■ Increased metabolism
■ Increased O2 consumption
■ Increased glucose consumption (hypoglycemia)
■ Depleted brown fat stores
■ Metabolic acidosis, jaundice, hypoxia
★ Heat Loss to Environment
○ Occurs if skin temp is less than core temp (core tries to heat skin)
○ Skin temp/ core temp can be decreased in four ways:
■ Convection- Heat loss from warm body surface to cooler air currents
● AC in rooms
● O2 masks
● Drafts
● Removal from isolette for procedures, without overhead warmer
■ Radiation- Heat loss from warm body surface to cooler surfaces and
object not in direct contact with body
● Bassinet near cold window panes
● Walls of room or isolette not heated
■ Evaporation- Heat loss when water converted to vapor
● Immediately after birth when wet with amniotic fluid (drying quickly
after birth)
● After bath
■ Conduction: Heat loss to a cooler surface by direct skin contact
● Cold hands
● Cold scales
● Exam tables
● Stethoscopes
★ Heat Production
○ Non-shivering Thermogenesis- uses newborn stores of brown adipose tissue/
brown fat
○ Primary source of heat in cold-stressed newborn
○ 1st appears @26-30 weeks and continues to increase 2-5 weeks after birth
(unless depleted by cold-stress)
○ Brown Fat:
■ Deposited in mid-scapula, around neck and axilla, around trachea,
esophagus, abdominal aorta, kidneys, & adrenal glands
■ Designed to produce heat faster than white fat
■ Metabolized within several weeks after birth
■ Dark color due to increased blood supply
★ Gastrointestinal System Adaptations:
○ Full term newborn has the capacity to swallow, digest, metabolize, and absorb
food soon after birth
○ Gut is sterile but changes rapidly
○ Bowel sounds are heard but may be hypoactive at first
○ Must develop mucosal barrier
○ Colonization of gut is required for production of Vitamin K
○
○
○
There is a rapid gain in the stomach capacity during the first 4 days
Immature cardiac sphincter-regurgitation
Stomach Capacity:
■ Day 1: 5-7 mls
■ Day 3: 0.75-1oz
■ Day 7: 1.5-2 oz
○ Initial weight loss of 5-10% of birth (related to fluid loss, insufficient calories)
○ Caloric intake: usually not sufficient for weight gain for 5-10 days.
○ Newborn Bowel Elimination:
■ Frequency, consistency and type of stool vary
■ Meconium-newborns first stool, sterile
■ Meconium passed within 12-24 hrs. After birth (thick, tarry, dark green)
■ Transitional stool- thin brown/ green
■ Yellow normal infant stool (breast-fed: more liquid and gold; bottle-fed:
pale yellow)
○ How much is normal:
■ Can be as few as 1 stool every 2-3 days, up to 10 per day
■ Teach parents that baby not constipated as long as stool remains soft
★ Urinary Adaptation:
○ The newborn’s kidneys can produce urine
○ Newborns have limited ability to concentrate urine (until 3 months of age)
○ Majority of term newborns void immediately after birth
○ Newborns void 6-8 times daily (2-6 per day after first 24 hours)
■ One diaper per days old approx
○ Indication of adequate fluid intake: soft smooth skin
○ At least one urine output in 24 hours
○ IN the diapers you could see
■ urate crystals (brick red spots): inability to concentrate urine
■ Pseudo-menstruation (from withdrawal of maternal hormones)
■ Blood from circumcision
○ Circumcision:
■ Surgical removal of all or part of the foreskin (prepuce) of the penis
■ Three commonly used methods: the Gomco clamp, Plastibell device, and
the Mogen clamp
■ Benefits:
● decreased UTI
● Decreased STI, including HIV
● Lower penile cancer
■ Risks:
● Hemorrhage
● Infection
● Skin dehiscence
● Adhesions
● Urethral fistula
● Pain
■ Contraindications:
● Compromised newborn
● Preemie
● GU defect
● Bleeding problems
■ Care of circumcision:
● Assess for bleeding every 30 mins for at least 2 hours
● Document the first voiding to evaluate for urinary obstruction or
edema
● Squeeze soapy water over area daily and rinse with warm water,
pat dry.
● Avoid positioning baby on his stomach
● Check for any foul-smelling drainage or bleeding at least once a
day, light, sticky, yellow drainage is part of the healing process
○ Uncircumcised:
■ Clean penis with water during diaper changes and with bath
■ Do not force foreskin back over penis
★ Immune system adaptations:
○ Newborn gets some passive acquired immunity from mother in 3rd trimester
(antibodies passed from mother to baby)
○ Immune system isn’t fully activated until after birth- newborn has poor
hypothalamic response to pyrogens
○ Fever not reliable indicator of infection- in newborn period, hypothermia is
more reliable indicator of infections
○ Mottled skin or grey skin, decreased muscle tone, could be signs of infection
★ Liver adaptations:
○ Liver assumes the role of the placenta after delivery
○ Roles of the liver
■ Iron storage
● As RBC are destroyed after birth, iron is stored by the liver until it
is needed for new RBC production
● If good maternal Fe intake during pregnancy, baby should have
good Fe stores for 6 months
■ CHO metabolism
● When the placenta is lost at birth, maternal glucose supply is cut
off
● Glucose is main source of energy for the first several hours after
birth
● Pre and post term babies, small or large for gestational age
● Due to the newborn increased energy needs, the liver releases
glucose from glycogen stores for the first 24 hours
● Feedings will help stabilize glucose levels
■
Conjugation of bilirubin: conversion of yellow lipid-soluble pigment into
water soluble pigment
● Total bilirubin at birth is usually less than 3 mg/ dL unless
abnormal hemolytic process present
● After birth, infant must conjugate bilirubin in liver, producing rise in
serum bilirubin in 1st days of life
● Unconjugated bilirubin (lipid soluble) is a breakdown product from
hemoglobin which is released from lysed RBCs and heme
pigments
● Unconjugated is not an excretable form: potential toxin: Brain
damage
■ Coagulation:
● Fetus does NOT conjugate bilirubin
● In utero, elimination of bilirubin is handled by the placenta and the
mother’s liver
● After birth, infant must conjugate bilirubin in liver, producing rise in
serum bilirubin in 1st days of life
★ Jaundice: Yellowish-coloration of the skin and sclera of the eyes that develops from
deposits of bilirubin in fat- containing tissues
○ Why:
○ Physiologic Jaundice:
■ Caused by rapid lysis of RBCs and impaired conjugation of bilirubin
■ Not pathologic- a normal biological response to unique physiology of
newborn
■ Bilirubin levels peak in the first 3-5 days
■ 50% of term newborns and 80% of preterm newborns have physiologic
jaundice in the 2nd or 3rd day of life
○ Pathologic Jaundice:
■ Abnormal- usually due to hemolytic process in utero
■ Present at birth or during 1st 24 hours of life
■ Will begin to test bilirubin levels when see jaundice in newborn
○ Bilirubin Levels:
■ All babies tested at 24 hours of life (transcutaneous)- if high, will check
serum
■ Bilirubin level at about 8%mg/dl when looks jaundiced
■ Hyperbilirubinemia is a total serum bilirubin level above 5 mg/dL
■ Phototherapy (“bili”-lights) converts unconjugated bilirubin. Used when
bilirubin reaches 12 or 13 mg/dL
● Fluorescent lights placed over infant
● Light absorbed through skin and helps to convert bilirubin to water
soluble pigment for excretion in urine
● Sunlight does the same thing (placing crib by window)
● Fiberoptic blanket- mom can still hold baby, used for home
phototherapy also
●
Kernicterus:
○ Mental retardation caused by deposits of bilirubin pigment
in the brain
○ Concern if bilirubin levels stay at 18 or 20 mg/ dL
● Nursing care with Phototherapy
○ Encourage feedings, monitor I’s and O’s, wt, Hydration!
○ Monitor stools for eliminated bilirubin (green, loose)
○ Eye patches (remove during feedings)
○ Temperature assessment (q3-4hrs)
○ Skin care and inspection
○ Encourage parent-infant interaction
○ Emotional/ financial support for infants extended hospital
stay
● Breast milk jaundice:
○ Rare (1-5% of newborns)
○ Prolonged Jaundice
○ Theory that some breast milk contains several times the
normal concentration of certain free fatty acids- which
inhibit conjugation of bilirubin
○ Appears 3-4 days after milk comes in
○ Breastfeeding D/C’d until levels decrease
■ Coagulation
● Liver produces clotting factors II, VII, IX, and X
● Clotting factors are Vitamin K dependent
● No vitamin K synthesis @ birth (sterile intestinal tract- absence of
normal flora)
● Vitamin K injection after birth (aqua-MEPHYTON) provides
protection until newborn produces his own clotting factors
★ Neurologic System Adaptations
○ Neurologic development follows cephalocaudal (head to toe) and proximal- distal
(center to outside) patterns
○ Newborn has an acute sense of hearing, smell and taste
○ Hearing- well developed at birth, response to noise
○ Taste- can taste sweet and sour by 72 hours old
○ Smell- knows mothers breast milk vs breast milk from others
○ Touch- sensitive to pain, responds to tactile stimuli
○ Vision- incomplete at birth. Maturation is dependent on nutrition and visual
stimulation. Newborns can focus on close objects (8-10 inches away) with a
visual acuity of 20/140
○ The central nervous system plays a major role in successful adaptations of many
other systems
○ A reflex is an involuntary muscular response to a sensory stimulus
○ Congenital reflexes are the hallmarks of maturity of the CNS
○
The presence and strength of a reflex is an important indication of neurologic
development and function
★ Newborn Reflexes:
○ Major reflexes of the newborn: gag, babinski, moro, galant
○ Minor reflexes: Finger grasp, toe grasp, rooting, sucking, head righting, stepping,
and tonic neck
○ Many neonatal reflexes disappear with maturation, although some remain
through adulthood
○ Damage to the nervous system (birth trauma, perinatal hypoxia) during the
birthing process can cause delays in the normal growth, development and
functioning of the newborn
○ Early intervention is key to prevent long term complications
○ Newborn reflexes that are absent or abnormal, persistence past the age it is
normally lost, redevelopment of an infantile reflex may indicate neurologic
pathology
Newborn Physical Assessment:
★ Nurse includes prenatal, labor, and birthing data with assessment findings as well as
gestational, behavioral, and physical assessments of newborn
○ Done within the first 1 to 4 hours after birth
★ Assessment and Findings:
○ Evaluate for respiratory distress
○ Evaluate for cold stress- notify physician of elevation or drop in temperature
○ BP is done in case of distress, premature birth, and anomaly
○ Assess HR and for Capillary refill (over sternum)
○ Identify sleep-wake state and correlate with respiration
★ Weight:
○ Plot weight and gestational age on growth chart
○ Ascertain body build of parents
○ Feed infant early post birth
○ Calculate fluid intake and losses
★ Posture, Skin and Hair
○ Record spontaneity of motor activity and symmetry of movements
○ Evaluate skin texture, turgor, pigmentation, variations and birthmarks
○ Assess location and type of rash- examine for petechiae
○ Examine the texture and distribution of hair
○ Record size and shape of birthmarks
★ Skin:
○ Color
○ Cyanosis
○ Acrocyanosis
○ Mottling
○ Jaundice
○ Milia- tiny white bumps that appear on baby’s face
○ Erythema toxicum: common rash- appears 2-5 days after birth
○
○
Stork bite: common birthmark, most often temporary aka: nevus simplex or
salmon patch
Mongolian Spots and lanugo: common in dark skinned babies, flat grey-blue in
color, looks like bruise.
★ Head:
○ Head circumference should be 2 cm greater than the chest
○ Assess fontanelles and sutures- observe for signs of hydrocephalus and evaluate
neurologic status
★ Face, mouth, eyes, and ears:
○ Assess and record symmetry
○ Hearing screening
○ Assess for signs of Down syndrome
○ Low set ears
○ Check for presence of gag, swallowing reflexes, coordinated with sucking reflex
○ Check for clefts in either hard or soft palates
○ Check for excessive drooling
○ Check tongue for deviation, white cheesy coating
★ Eyes:
○ Assess PERLA
○ Assess cornea and blink reflex
○ Note true eye color does not occur before 6 months
○ May have blocked tear ducts
★ Neck, Chest, Heart and Lungs:
○ Neck:
■ Tone, clavicle
○ Lungs/Chest
■ Assess airway, rate and any signs of distress
■ Breath sounds--color
■ Examine appearance and size of chest
■ Note if there is funnel chest, barrel chest, unequal chest expansion
■ Breasts are flat with symmetric nipples-- note lack of breast tissue or
discharge
○ Heart:
■ Assess heart rate, rhythm--evaluate murmur: location, timing, and
duration
■ Peripheral pulses
■ BP-- Not usually done routinely on healthy newborns
■ Check pulses in extremities
○ Abdomen:
■ Abdomen appears large in relation to pelvis
● Auscultate bowel sounds
■ Umbilical cord
● Note any discharge or oozing from cord
● Note appearance and amount of vessels
○
○
● Record any umbilical hernia
■ Genitals:
● Girl:
○ Examine labia majora, labia minora, and clitoris
■ Note size of each for gestational age assessment
○ Observe for pseudo-menstruation
● Boy:
○ Position of urinary orifice
○ Palpate testes separately-- warm hands first
■ Scrotum covered in rugae
○ Assess for hydrocele
○ Note discoloration and edema (common in breech births)
■ Anus:
● Inspect anal area to verify that it is patent and has no fissure
● Digital exam by physician or nurse practitioner if needed-- some
hospitals do initial rectal temperature
● Note passage of meconium-- usually within first 24 hours
Extremities:
■ Examine for gross deformities
● Note position and condition of extremities and trunk--term babies’
flexion
● Examine more closely when infant is reluctant to move an
extremity-- note if there is brachial palsy or Erb-Duchenne
paralysis
■ Check for developmental dysplasia of the hip-- perform Ortolani’s
maneuver or Barlow’s maneuver
■ Examine the back for associations with any neural tube defects
● Sacral dimple
● Tuft of hair
■ Clubfoot
● Nurse examines feet for evidence of talipes deformity (clubfoot)
● Intrauterine positions can cause feed to appear to turn inward-“positional” clubfoot
● To determine presence of clubfoot, nurse moves foot to midline-- if
resists, it is true clubfoot
Neurological Status
■ Assessment begins with period of observation
● Observe behaviors-- note:
○ State of alertness
○ Resting Posture
○ Cry
○ Quality of muscle tone
○ Motor activity
○ Jitteriness
●
○ Differentiate causative factors
Reflexes
○ Immature central nervous system CNS of newborn is
characterized by variety of reflexes
○ Some reflexes are protective, some aid in feeding, other
stimulate interaction
■ Protective reflexes are blinking, yawning, coughing,
sneezing, drawing back from pain
■ Rooting and sucking reflexes assist with feeding
■ Grasping stimulates interaction
○ Additional reflexes include
■ rooting/suck
■ palmar/plantar grasp
■ Babinski
■ REPORT THE ABSENCE OF THESE