HARRISON, ARKANSAS
Maternal-Neonatal Nursing
Nursing 1124
Syllabus
Spring 2014
2013 Calendar for NURS 1124 Monday 3/10 Unit I: Overview Ch. 1,2 Unit 2: Pre‐
clinical Skills 3/17 Clinical Tuesday 3/11 Unit 2: Pre‐clinical Skills Lab Ch. 9 and more 3/18 Clinical Wednesday Thursday 3/12 3/13 Test #1 Unit 3: Antepartum Nursing Care Ch. 3 & 4 Physiological Aspects of Pregnancy Unit 4: Psycho‐Social‐Cultural Aspects of Pregnancy Ch. 5 Friday 3/14 3/19 3/20 Unit 5: Pregnancy at Risk Antepartum Testing Ch. 6 High‐Risk Antepartum Ch. 7 3/24 3/25 3/26 3/27 3/28 4/4 S P R I N G B R E A K 3/31 Clinical 4/1 Clinical 4/8 Clinical 4/2 4/15 Clinical 4/16 4/21 Clinical 4/22 Clinical 4/23 4/28 Clinical 4/29 Clinical 4/30 5/1 Test #4 Review for Final Due: ATI Practice Exams 5/2 5/5 Lab Simulation On‐Campus 5/6 Lab Simulation On‐Campus 5/7 5/8 ATI Proctored Exam will count as the Final Exam 5/9 4/7 Clinical 4/14 Clinical Calendar is subject to change. 4/9 4/3 Test #2 Unit 6: Intrapartum Nursing Care Ch. 8 4/10 Unit 6: Intraparum Nursing Care Ch. 10, 11 Breast Disorders Iggy Ch. 73 4/17 Test #3 Unit 7: Postpartum Nursing Care Ch. 12, 13, 14, 18, 19 Gynecologic Problems Iggy Ch. 74 4/24 Unit 8: Newborn Nursing Care Ch. 15, 16, 17 4/11 4/18 4/25 TABLE OF CONTENTS
General Information ....................................................................................................... 1
Course Description ........................................................................................................ 1
Credit and Time Allotment ............................................................................................. 1
Placement ..................................................................................................................... 1
Prerequisites ................................................................................................................. 1
Course Outcomes ......................................................................................................... 2
Required Texts .............................................................................................................. 3
Major Teaching-Learning Activities ............................................................................... 3
Course Content ............................................................................................................. 3
Course Evaluation and Grade ....................................................................................... 4
Clinical Evaluation ......................................................................................................... 5
General Policies ............................................................................................................ 5
Attendance .................................................................................................................... 5
Academic Dishonesty .................................................................................................... 6
Student Responsibilities ................................................................................................ 6
Accommodations for Students with Special Needs ....................................................... 7
Unit 1 ............................................................................................................................ 8
Unit 2 ............................................................................................................................. 9
Unit 3 ............................................................................................................................. 11
Unit 4 ............................................................................................................................ 13
Unit 5 ............................................................................................................................. 18
Unit 6 ............................................................................................................................. 21
Unit 7 ............................................................................................................................. 21
Unit 8 ............................................................................................................................. 23
Unit 9 ............................................................................................................................. 25
Appendix A .................................................................................................................... 26
Assignment #1 - Concept Map .............................................................................. 27
Creating a Concept Map ....................................................................................... 28
Concept Map Example - COPD ............................................................................ 29
Concept Map Example - Sodium Balance ............................................................ 30
Grading Rubric ...................................................................................................... 31
NCLEX Review Assignment #2 ............................................................................. 32
Case Study Chapter 7 ........................................................................................... 33
Gestational Diabetes ............................................................................................. 35
Pregnancy Induced Hypertension ......................................................................... 36
Case Study Chapter 8 ........................................................................................... 37
Case Study Chapter 15-17.................................................................................... 40
i
Appendix B .................................................................................................................... 45
Milestones in Fetal Development .......................................................................... 46
Fetal Circulation .................................................................................................... 48
Diagnostic Assessment of Fetal Status ................................................................. 49
Stages of Labor Chart — A Guide for Supporting Mothers in Labor ..................... 51
8-Point Postpartum Assessment ........................................................................... 55
Circulatory Changes After Birth ............................................................................. 57
Newborn Transition ............................................................................................... 58
Thermal Regulation ............................................................................................... 62
Guidelines for the Physical Examination of the Newborn Infant ........................... 65
Gestational Age Assessment ................................................................................ 70
Classification of Newborn ...................................................................................... 71
Predictable Problems Based on Gestational Age ................................................. 72
Hypoglycemia........................................................................................................ 73
Physiologic Status of the Premature Infant ........................................................... 75
Appendix C .................................................................................................................... 78
Clinical Competencies ........................................................................................... 79
Clinical Guidelines ................................................................................................. 80
Clinical Objectives ................................................................................................. 81
Assessment of Client in Labor .............................................................................. 83
Assessment of Postpartal Client ........................................................................... 85
Newborn Assessment ........................................................................................... 87
Public Health Clinic Written Assignment ............................................................... 92
APN Clinical Written Assignment .......................................................................... 93
Post-Conference Suggestions .............................................................................. 94
ii
SYLLABUS ACKNOWLEDGEMENT
Course:
___Maternal-Neonatal Nursing NURS 1124__________
Semester:
___Spring 2014_________________________________
I acknowledge by signing below that I have received the syllabus for the course indicated
above. I have reviewed the syllabus and understand the objectives of this course. Further,
I understand how my performance will be evaluated and how my final grade will be
determined. I am aware of my instructor’s office hours, and I know how to contact him or
her for help with and/or clarification of course contents or procedures.
_______________________________________________
(Student Signature)
_______________________________________________
(Date)
Department of Nursing
Course Title:
Maternal-Neonatal Nursing
Course Number:
NURS 1124
Course Credit &
Time Allotment:
Course
Instructor:
Office:
Phone:
E-Mail:
Office Hours:
Course
Description:
Rationale:
Audience for
the Course:
4 semester credit hours
Thursday
8:30-12:30 8 Weeks
12 hours of clinical each week
Carla Jacobs, MSN, RN
M 172
391-3535
cjacobs@northark.edu
Wednesday 9-11:30 a.m.; 1-3 p.m.
Thursday
1-3 p.m.
Friday
by appointment
Maternal Neonatal Nursing is an 8 week course focusing on nursing
care of the child-bearing family. The Student Learning Outcomes serve
as the basis for course outcomes and are incorporated into
experiences in theory and clinical. Emphasis is placed on the role and
practice of the nurse in assisting the patient and family during the
antepartal, intrapartal, postpartal, and neonatal periods. Pre-requisite:
NURS 1107 and 1114.
In the clinical component of Nursing 1124, students develop and
expand skills and behaviors needed to assist clients and their families
in various phases of the health-illness continuum. The students utilize
all steps of the nursing process and apply principles, concepts and
nursing skills learned in this and in prerequisite courses to the care of
clients and families during the childbearing cycle. The settings for
clinical experience include: newborn nursery, labor and delivery,
postpartal unit, and prenatal clinic
First Level, 2nd semester Traditional RN students.
Student Learning Outcomes:
Human Flourishing
Nursing Judgment
Spirit of Inquiry
Professional Identity
Course
Outcomes:
Core Competencies
Communication
Patient-Centered Care
Cultural Diversity
Safety/Quality Improvement
Evidence-Based Practice
Managing Care
Collaboration/Teamwork
Clinical Decision-Making
Clinical Reasoning
Professional Behavior
Legal/Ethical
Teaching/Learning
Informatics
Upon successful completion of this course, the student will be able to:
Human Flourishing
1.
Provide patient-centered care incorporating effective communication and respect
for cultural diversity. Measured by clinical practice and exam.
Nursing Judgment
2.
Incorporate evidence-based practice to provide competent care based on client
responses to physiological and psychological adaptations during antepartum,
postpartum and newborn periods. Measured by clinical practice, exam and written
assignments.
3.
Identify safety measures employed in maternal-neonatal health care settings.
Measured by exam and clinical practice.
4.
Discuss the nurse’s role in promoting quality improvement in maternal-neonatal
health care settings. Measured by discussion.
5.
Collaborate with the health care team in managing the care of maternal-neonatal
patients. Measured by written exam and clinical discussion.
Spirit of Inquiry
6.
Demonstrate clinical decision-making to plan and prioritize for a family-centered
approach in meeting the needs of childbearing clients. Measured by clinical written
assignment.
7.
Apply clinical reasoning based on the nursing process to the care of patients in
maternal-neonatal health care settings. Measured by exam and Portfolio
assignment: Develop a Concept Map related to an actual or potential health
problem that might occur during the childbearing cycle.
2
Professional Identity
8.
Model professional behaviors including teaching/learning and use of informatics
in the provision of nursing care. Measured in clinical practice and discussion.
9.
Examine legal and ethical aspects of maternal-neonatal nursing. Measured by
written exam and clinical discussion.
Course Text:
Chapman, L. & Durham, R. (2014). Maternal-newborn nursing: The
critical components of nursing care (2nd ed.). Philadelphia, PA: F.A.
Davis.
Ignatavicius, D. D., & Workman, M. L. (2013). Medical surgical nursing:
Patient-centered collaborative care (7th ed.). St. Louis. Elsevier
Saunders.
Syllabus for Nursing 1124 — Maternal-Neonatal Nursing
ATI RN Maternal-Newborn Nursing, 8th Ed.
ATI Maternal-Newborn Practice Tests
Current nursing journals and textbooks other than required for this course
are available in the library or on-line via Portal.
Course
Resources:
Methods to
Facilitate
Learning:
Course Content:
Northark, Campus Libraries
Videos
The instructor will utilize a variety of teaching strategies to actively engage
the student to enhance learning and critical thinking including Lecture,
Class Discussion, PowerPoint Presentations, Case Studies, Audiovisual
presentations, Demonstrations, Nursing Skill Laboratory Practice, Critical
Thinking Exercises, Games, Student response systems (clickers),
muddiest point, one minute papers, think-pair-share, etc.
Unit 1:
Unit 2:
Unit 3:
Unit 4:
Unit 5:
Unit 6:
Trends and Issues in Maternity Care
Ethics and Standards of Practice Issues
Maternal-Neonatal Nursing Skills
Preconception Health Care
Genetics
Conception
Fetal Development
Infertility
Assessment of the Reproductive System
Pre-natal care
Antepartal Testing
Pregnancy at risk
Processes of Labor and Birth
Promoting Comfort During Labor and Delivery
Labor Related Complications
3
Unit 7:
Unit 8:
Unit 9:
Course
Evaluation:
A.
Postpartal Adaptations
Postpartum at Risk
Adaptation to Extrauterine Life
Nursing Assessment of the Neonate
Nursing Intervention
Nutritional Needs and Feeding
Newborn Care
Legal/Ethical Care
Newborns at Risk
Newborn Birth Related Stressors
Perinatal Loss
Unit Examinations
Test I: Chapters 1, 2 &9 Chapman
Test II: Chapters 3-7 Chapman
Test III: Chapters 8-11 Chapmen
Test IV: Chapters 12-19 Chapman
Test V: ATI Comprehensive Final Exam
B.
Course Grade:
Completion of Miscellaneous Homework and Assignments (pop
quizzes, individual and group reports, study guide assignments,
etc.)
Unit Examinations
Homework Assignments
Comprehensive Final
Clinical Component
70%
10%
20%
Pass
Students must be passing with a 79% on unit tests and the final, or the
student will not progress. Credit for Homework Assignments will not be
added unless the student is passing with a 79%.
Clinical
Evaluation A clinical evaluation by the clinical instructor will be given a
"satisfactory/unsatisfactory" rating. Formative evaluations will be given by the
clinical instructor each week. A summative evaluation is completed at the
end of the semester. Upon request by an instructor, the director and the
faculty may require a student to be evaluated by another instructor. Students
must pass the clinical component of the course in order to progress in the
program. If the student fails the clinical component, the theory grade drops to
a "D" and the student cannot progress. Clinical component is Pass/Fail.
4
Clinical
Evaluation
S = Satisfactory
Students meet minimum requirements for the program outcomes.
N = Needs Improvement
Students did not meet minimum requirements for 1 or more core
competency for that program outcome. If an N is received then the
student and instructor are expected to:
1. Discuss the issue during the clinical rotation.
2. The instructor will document the discussion on the clinical
formative evaluation tool.
3. The instructor will fill out the clinical warning form.
4. The student will formulate a simple remediation plan to be
presented to the clinical instructor and course coordinator. (if
applicable)
5. If after remediation, the student receives another N, the process
will be repeated once more.
6. If the student receives 3 N’s in the same program outcome
category, such as Human Flourishing, on separate occasions
during a course clinical rotation then they will receive a U for that
clinical rotation and will be dismissed from the program.
U= Unsatisfactory (3 N’s)
Student did not demonstrate essential skills for patient safety,
professional behavior etc., as stated on page 37 in the RN Handbook.
If the student participates in any of the reasons for dismissal as listed
under “Unsafe Clinical Practice” in the RN Handbook they will receive
a U on the clinical formative evaluation tool.
General Policies: Refer to the Registered Nursing Program Handbook for policies
concerning daily assignments, clinical policies and evaluation,
tardiness, make-up work, dress code, academic integrity, student
responsibilities and ADA Statement.
Attendance:
Students are expected to attend all class meetings. Tardiness will not
be tolerated. A pattern of tardiness will result in disciplinary action at
the discretion of the instructor. Student’s that miss excessively will be
counseled with regard to likelihood of program failure. Excessive
absences are defined as 15% or more of class time (see Northark
catalog).
Students are responsible for the content in class when absent. Lecture
content missed will not be repeated. Check the Portal for course
materials.
Students will be automatically terminated from the program if more
than 12 hours of clinical are missed per 16 weeks.
5
Academic
Dishonesty:
North Arkansas College's commitment to academic achievement is
supported by a strict but fair policy to protect academic integrity. This
policy regards academic fraud and dishonesty as disciplinary offenses
requiring disciplinary actions. Any student who engages in such
offenses (as here defined), will be subject to one or more courses of
action as determined by the instructor, and in some cases the Division
Chairperson or Program Director, the Vice President of Instruction, and
Institutional Standards and Appeals Committee as well.
Academic fraud and dishonesty are defined as follows:
Cheating:
Test
Tampering:
Plagiarism:
Facilitating
Academic
Dishonesty:
Intentionally using or attempting to use unauthorized materials,
information, or study aids in any academic exercise.
Intentionally gaining access to restricted test booklets, banks,
questions, or answers before a test is given; or tampering with
questions or answers after a test is taken.
Intentionally or knowingly representing the words and ideas of another
as one's own in any academic exercise.
Intentionally or knowingly helping or attempting to help another commit
an act of academic dishonesty.
Student
Responsibilities: A. Read the college catalog and all materials you receive during
registration. These materials tell you what the college expects
from you.
B. Read the syllabus for each class. The syllabus tells you what the
instructor expects from you.
C. Attend all class meetings. Something important to learning
happens during every class period. If you must miss a class
meeting, talk to the instructor in advance about what you should
do.
D. Be on time. If you come in after class has started, you disrupt the
entire class.
E. Never interrupt another class to talk to the instructor or a student in
that class.
F. Be prepared for class. Complete reading assignments and other
homework before class so that you can understand the lecture and
participate in discussion. Always have pen/pencil, paper, and
other specific tools for class.
G. Learn to take good notes. Write down ideas rather than word-forword statements by the instructor.
6
H. Allow time to use all the resources available to you at the college.
Visit your instructor during office hours for help with material or
assignments you do not understand; use the library; tapes,
computers, and other resources in Learning Commons.
I. Treat others with respect. Part of the college experience is being
exposed to people with ideas, values, and backgrounds different
from yours. Listen to others and evaluate ideas on their own merit.
J. If at midterm your examination grade point average is below 79%,
schedule an appointment to meet with your instructor.
K. Cell phones are not permitted in the classroom or clinical area. No
text messaging in class/clinical.
L. No food/drink in classroom.
M. Must use simple calculator. Do not share with friends.
N. Please review the Nursing Program inclement weather policy (870)
743-7669 (SNOW), Information, Policies, and Standards Manual.
ADA
Statement:
Final Note:
North Arkansas College complies with Section 504 of the
Rehabilitation Act of 1973 and the Americans with Disabilities Act of
1990. Students with disabilities who need special accommodations
should make their requests in the following way: (1) talk to the
instructor after class or during office hours about their disability or
special need related to classroom work; and/or (2) contact Special
Services in Room M149 and ask to speak to Kim Brecklein.
The stated schedule, assignments, and procedures in this course are
subject to change in the event of extenuating circumstances. Students
will be notified verbally or in writing of changes by the instructor.
7
Unit 1: Maternal‐Neonatal Overview Course Objectives: 1, 2, 6 & 8 Unit Outcomes 1. Identify key Internet sites/resources that provide statistical information regarding maternal‐newborn health‐care issues. 2. Discuss current trends in management of pregnancy, labor and birth. 3. Review current maternal‐newborn health outcomes and the implications of these trends for expectant couples, parents, and health‐care providers. 4. Collaborate with the primary provider and health‐care team to promote positive outcomes for the childbearing family. 5. Discuss ethical dilemmas that may be encountered in the care of mothers and neonates. 6. Describe the standards of practice related to the care of families during the antepartum, intrapartum, and postpartum periods. 7. Discuss potential legal issues confronting maternal‐newborn nurses. 8 I.
Content Trends and Issues A. Definitions of key terms B. Factors affecting maternal‐
newborn outcomes C. Health disparities D. Maternal and Infant health goals E. Role of the nurse in perinatal care II.
Ethics and Standards of Practice Issues A. Ethical issues in maternal‐
newborn care. B. Standards of practice for maternal‐newborn nursing C. Legal issues D. Evidence‐based practice Learner Activities Read Chapman Ch. 1 & 2 Spirit of Inquiry: Theory: Research these issues and trends using nursing informatics: o Teenage pregnancy trends and birth rates o Tobacco use during pregnancy o Substance abuse during pregnancy o Health disparities in perinatal outcomes o Labor induction rates o Cesarean birth rates and trends o Prematurity rates and trends Raab, C. (2011) The perinatal safety nurse. MCN, 36 (5). 280‐289. Professional Identity: Perform an internet search for articles related to ethical/ legal issues in Maternal‐Newborn nursing. Nursing Judgment: Schneider, M. (2012). Nurse‐physician collaboration. Nursing 2012, 42(7). 50‐53 McKeon, L. & Cardell, B. (2011). Preventing never events: What frontline nurses need to know. Nursing Made Incredibly Easy, 9(1). 44‐53. Unit 2: Pre-Clinical Skills Lab
Course Outcomes:
2, 3, 4, 5, 7 & 8
Unit Outcomes
Content
I.
1.
2.
Maternal-Neonatal Nursing Skills
A. Calculation of due date
Chapman p. 53
Box 8-3, p. 208
B. Leopold’s maneuver’s
3.
Apply the electronic fetal monitor
(EFM) to assess fetal heart rate.
C. Fetal heart rate assessment
1.
Ultrasound transducer
2.
Tocotransducer
3.
Interpretation of fetal heart rate pattern
4.
Nursing interventions
Ch. 9
4.
Compare and contrast non-stress
test and contraction stress test to
assess fetal status.
Discuss the components of fetal
heart rate patterns essential to
interpretation of monitor strips.
Identify correct nursing actions
based on interpretation of EFM
strips.
Analyze contraction duration,
frequency, and intensity.
D. Non-stress test
5.
Purpose
6.
Procedure
7.
Interpretation
8.
Actions
p. 95-96
Monitor intravenous pitocin
infusions for induction or
augmentation of labor.
F. Pitocin induction/augmentation
1. Dosage
2. Effects
3. Risks
5.
6.
7.
8.
9
Calculate the estimated date of
delivery.
Use Leopold’s maneuver’s to
determine fetal position.
Learner Activities
E. Contraction stress test
1. Purpose
2. Procedure
3. Interpretation
4. Actions
Clinical Decision-Making:
Practice interpreting EFM strips
and planning interventions.
p. 126, 275
Unit 2: Pre-Clinical Skills Lab
Course Outcomes:
2, 3, 4, 5, 7 & 8
G. Postpartum fundal massage
p. 360
10. Explain Apgar scores.
H. Newborn apgar scores
p. 216
11. Assess newborn vital signs.
I.
Table 15-3 p. 384
12. Plan nursing interventions to
maintain newborn temperature.
J. Thermoregulation in the newborn
9.
10
Safely perform uterine fundal
massage during postpartum.
Newborn vital signs
p.432
p. 378
Unit 3: Antepartum Nursing Care—Preconception Issues; Conception Course Outcomes: 1, 2, 3, 4, 5, 6, 7 & 8 Unit Outcomes Content 1. Write a plan for preconception health
care.
2. Define key inheritance patterns.
3. Explain the relevance of genetics in
providing care to childbearing families.
Preconception Health Care
A. Promoting health before pregnancy
B. Anticipatory guidance/education
II. Genetics
A. Inheritance patterns
B.
Relevance to the Nursing role
4. Discuss the process of conception.
III. Conception
5. List milestones of fetal development.
IV. Fetal Development
A. Milestones
B. Placental function
C. Amniotic fluid function
D. Risks to normal development
6. Identify factors posing a risk to normal
development of the fetus.
7. State common causes of infertility.
8. Explain various diagnostic tests related
to infertility.
9. Compare assisted fertility technologies.
10. Advocate for the patient desiring
assisted reproduction.
11. Discuss the emotional/social aspects of
infertility.
11 I.
V. Infertility
A. Common causes
B. Testing
C. Assisted fertility technology
Learner Activities Read Chapman Ch. 3
Discussion groups:
a. Discuss how our increasing knowledge and
understanding of genetics affects the care
of women during pregnancy.
b. Discuss the stages of embryonic and fetal
development and the effects of teratogens
on the developing human.
Unit 3: Antepartum Nursing Care—Preconception Issues; Conception Course Outcomes: 1, 2, 3, 4, 5, 6, 7 & 8 Unit Outcome
12. Perform a focused physical
assessment of the patient with a
female reproductive system problem.
13. Develop a teaching plan for
recommended reproductive screening
tests.
12 Content
VI. Assessment Methods
A. Patient History
B. Physical Assessment
C. Psychosocial Assessment
D. Diagnostic Assessment
Learner Activities
Read Iggy, Chapter 72.
View Echo Capture.
Unit 4: Antepartal Nursing Care—Physiological and Psych‐Social‐Cultural Aspects of Pregnancy Course Outcomes: 1, 2, 3, 4, 5, 6, 7 & 8 UNIT OUTCOMES 1. List subjective and objective signs and symptoms of pregnancy. 2. Discuss methods of diagnosing pregnancy. 3. Calculate the estimated date of delivery. 4. Use appropriate terminology in describing a woman’s obstetrical status. 5. Link anatomical and physiologic changes of pregnancy to the signs and symptoms and common discomforts of pregnancy. 6. Educate the patient for each trimester. 7. Describe expected emotional changes of pregnancy. 8. Identify major developmental tasks of pregnancy as they relate to maternal, paternal, and family adaptation. 9. Apply ethnic and cultural considerations to the nursing care of the childbearing family. 13 CONTENT I.
Pregnancy A. Diagnosis 1. Signs and symptoms 2. Pregnancy tests 3. Estimated date of delivery LEARNER ACTIVITIES Read Chapman Ch. 4 & 5 B. Assessment terminology C. Physiologic changes 1. Anatomical changes 2. Discomforts of pregnancy a. Nursing interventions b. Patient/family education Human Flourishing: Cultural Diversity In‐Class Discussion: D. Psycho‐Social‐Cultural Aspects Independent Research: Examine cultural 1. Maternal tasks meanings of childbirth as reflected in the 2. Variables affecting adaptations population of this geographical area (Rural 3. Paternal tasks Caucasians and Hispanics). 4. Family tasks Areas to consider: terminology related to customs and beliefs; behaviors expected 5. Interventions during pregnancy; restrictive behaviors; what 6. Cultural considerations is taboo. Arbour, M., et. al. (2012). Racial differences in the health of childbearing‐aged women. MCN 37(4). 262‐268. Unit 4: Antepartal Nursing Care—Physiological and Psych‐Social‐Cultural Aspects of Pregnancy Course Outcomes: 1, 2, 3, 4, 5, 6, 7 & 8 10. Analyze factors which influence plans/preparations for birth. 11. Participate in providing childbirth education. 14 E.
Planning for birth 1. Provider 2. Place 3. Plan 4. Education NURSING 1124
UNIT 5 -- Pregnancy at Risk
Course Outcomes: 1, 2, 3, 4, 5, 6, 7 & 8
OUTCOMES
1.
Compare and contrast various antepartal tests
and the information provided by each.
2.Describe nursing responsibilities related to key
antepartal tests.
3.
Write a teaching plan to explain diagnostic
techniques and implications of findings to
clients and their families.
4.
Differentiate between reassuring and
nonreassuring fetal heart rate patterns.
5.
Examine factors that contribute to changes in
fetal heart rate patterns.
6.
Identify appropriate nursing interventions for
various fetal heart rate patterns.
7.
Identify risk factors for preterm labor and birth.
8.
Implement nursing interventions for clients at
risk for preterm labor and birth.
9.
Collaborate with the heath care team to
manage the client with premature rupture of
membranes.
10. Discuss risks to the client and the fetus related
to a gestational complication.
15
11. Teach the client concerning in-hospital
management of hyperemesis gravidarum and
follow-up care at home.
CONTENT
LEARNER ACTIVITIES
I. Antepartal testing
A. Biophysical assessment
1.Ultrasound
2. Doppler studies
3. Magnetic resonance imaging
B. Biochemical assessment
1.Amniocentesis
2. Chorionic villus sampling
3. Percutaneous umbilical blood sampling
C. Maternal assays
1. Maternal serum - alpha-fetoprotein
2. Multiple marker screen
D. Fetal status assessment
1. Daily fetal movement counts
2. Non-stress tests
3. Vibroacoustic stimulation
4. Contraction stress test
5. Amniotic fluid index
6. Biophysical profile
Chapman: Chapter 6.
II. Pregnancy at risk
A. Gestational complications
1. Pre-term labor and birth
a.
Risk factors
b.
Medical management
c.
Nursing interventions
2. Premature rupture of membranes
a.
Risk factors
b.
Medical Management
c.
Nursing interventions
3.
Incompetent cervix
4.
Multiple gestation
Chapman: Chapter 7.
5.
Hyperemesis gravidarum
OUTCOMES
12. Explain the risks or complications associated
with diabetes during pregnancy.
13. Compare insulin requirements during
pregnancy, postpartum, and with lactation.
CONTENT
LEARNER ACTIVITIES
B.Diabetes
1.
Pregestational
2.
Gestational
14. Plan care for pregnant clients with a preexisting
disorder, physiologic condition that complicates
the pregnancy.
15. Compare and contrast nursing management of
the client with mild preeclampsia from that of
the client with severe preeclampsia.
16. Evaluate the client's response to medications
and interventions implemented to manage
pregnancy induced hypertension,
preeclampsia, or eclampsia.
C. Pregnancy-induced hypertension
1. Classifications
2.
Diagnostics
3.
Medical management
4.
Nursing interventions
17. Define HELLP syndrome and associated risks.
18. Discuss the diagnoses and management of
disseminated intravascular coagulation.
19. Plan nursing interventions appropriate to
the safety and care of clients experiencing a
bleeding disorder of pregnancy.
20. Compare and contrast the signs and symptoms,
risks, and management of placenta previa and
abruptio placenta.
21. Teach about the effects of sexually transmitted
diseases on pregnancy and the fetus.
22. Identify priorities in assessing and managing
the pregnant client experiencing surgery or
trauma. (Nursing Judgment: Managing Care)
D. Bleeding disorders
1.
Placenta previa
2.
Abruptio placenta
3.
Placenta accreta
4.
Spontaneous abortion
5.
Ectopic pregnancy
6.
Hydatidiform mole
E.Infections
F. Trauma and abuse emergencies
DiGiulio, M., Wieclaseck, S. & Monchek, R. (2012).
Understanding hydatidform mole. MCN, 37(1). 3034.
16
OUTCOMES
23. Identify the maternal and fetal risks related to
various pregestational disorders.
CONTENT
G. Pregestational complications
1.
Cardiac disorders
2.
Anemia
3.
Pulmonary disorders
4.
Gastrointestinal disorders
H. Substance abuse
LEARNER ACTIVITIES
17
NURSING 1124
UNIT 6 -- Intrapartum Nursing Care
Course Outcomes: 1, 2, 3, 4, 5, 6, 7 & 8
OUTCOMES
CONTENT
1.
Identify normal measurements of the diameters
of the pelvic inlet, cavity and outlet.
2.
Assess fetal lie, attitude, presentation, station,
and engagement.
3.
Explain the cardinal movements as part of the
mechanisms of labor.
4.
Define involuntary and voluntary powers.
5.
Explain how the position of the fetus affects
labor.
4.Position
6.
Analyze the psychological response to labor.
7.
Identify prodromal signs of labor.
5. Psychological response
B. Process of Labor
1. Signs of labor
8.
Differentiate between true and false labor.
9.
Describe the stages of labor.
2. Stages of labor
10. Explain effacement and dilatation.
3. Mechanism of labor
11. Discuss nursing assessment and care of the
mother and fetus in each stage of labor.
C. Intrapartal Nursing Assessment
1.Fetal
2.Maternal
12. Describe the physiologic basis for pain in labor
and delivery.
II. Promoting Comfort During Labor and Delivery
A. Nursing process overview for pain relief
during childbirth
B. Factors affecting the experience of pain/
discomfort during labor and delivery
C. Management of discomfort/pain
1.Nonpharmacologic
2.Pharmacologic
13. Compare and contrast the action of local,
regional, and general anesthesia as used in
labor and delivery.
I. Processes of Labor and Birth
A. Factors affecting labor, 5 P's
1. Passageway
2.Passenger
LEARNER ACTIVITIES
Chapman: Chapter 8.
3. Powers
Sawhney, M. (2012). Epidural anesthesia: What
nurses need to know. Nursing 2012, 42(8). 36-42.
18
OUTCOMES
CONTENT
LEARNER ACTIVITIES
14. Assess the degree and type of pain a woman
in labor is experiencing and her ability to cope
effectively.
15. List common measures used for pain relief in
labor and delivery, including relaxation methods
and pharmacologic management.
16. Analyze ways to maintain family-centered care
when analgesia and anesthesia is used in
childbirth.
17. Discuss how the nurse can promote the mother/
newborn/family relationship after delivery.
C. Immediate care at delivery
1.Safety
18. Describe the nursing care of the mother
immediately after delivery.
19. Cite factors that increase the client's risk for
dysfunctional labor.
2. Fourth stage
III. Labor-Related Complications
A. Dysfunctional labor
20. Explain interventions to manage dysfunctional
labor.
21. Educate the client scheduled for induction of
labor.
22. Evaluate the effectiveness of and risks
of pitocin administration for induction/
augmentation of labor.
23. Educate the client and family preparing for
a cesarean birth. (Professional Identity: Teaching/Learning)
24. Collaborate with the health care team to safely
manage the client and family experiencing an
obstetric emergency. (Human Flourishing: Patient-Centered Care)
B. Birth-Related Procedures
1.
Version
2.
Labor induction
3.
Labor augmentation
4.
Assisted birth
5.
Cesarean birth
a.
Intrapartum care
b.
Postpartum care
C. Obstetric emergencies
1.
Shoulder dystocia
2. Prolapsed umbilical cord
3.
Uterine rupture
4. Amniotic fluid embolism
Chapman: Chapter 10.
Simpson, K., Newman, G. & Chirins, O. (2010) Patient education to reduce elective
induction of labor. MCN, 35(4). 188-195.
Chapman: Chapter 11.
19
OUTCOMES
CONTENT
25. Describe the three-pronged approach to early
detection of breast masses.
IV.
Breast Assessment
A. Self-Breast Exam
B.Mammography
C. Clinical Breast Exam
26. Discuss the psychosocial aspects of breast
cancer and treatment.
V. Plan of Care
A. Coping Sstrategies
27. Develop a post-operative plan of care for a
patient with breast cancer.
B. Pre- and Post-Operative care
C. Community Resources
LEARNER ACTIVITIES
Iggy: Chapter 73.
20
NURSING 1124
UNIT 7 -- Postpartum Nursing Care
Course Outcomes: 1 2, 3, 4, 5, 6, 7 & 8
OUTCOMES
1.
Describe physiologic adaptations during the
perperium.
2. Identify changes that occur in the uterus,
cervix, perineum after delivery, and state
rationale.
3. Assess and plan nursing care of the puerperal
patient.
4. Document rationales for the use of oxytocic
drugs during the postpartal period.
5. List ways to facilitate infant-parent interaction
and bonding.
6. Identify causal factors and appropriate
comfort measures for minor stressors in the
puerperium: chills, disphoresis, afterbirth
pains, episistomy, hemorrhoids, and
engorgement.
7. Collaborate with client and family for self-care.
8.
Explain behaviors of the three phases of
maternal adjustment.
9.
Contrast the symptoms and prognosis of
postpartum blues, postpartum depression, and
psychosis.
21
10. Plan teaching to prepare new parents to care
for the infant at home. (Human Flourishing;
Professional Identity)
CONTENT
I. Postpartal Adaptations
A.Physiological
1.
Involution
2.
Lochia
3.
Cervix
4.
Perineum
5.
Clinical changes
LEARNER ACTIVITIES
Chapman: Chapters 12 & 13.
Syllabus - Appendix B
•"8-point Postpartal Check"
Review the critical components identified in the text.
B.Psychological
1. Bonding and attachment
2. Maternal/paternal role behavior
C. Postpartal nursing care
1. Assessment of physiologic status
2. Identification of risk factors
3. Intervention to support adaptation
4. Management of discomfort
D. Discharge/self-care instructions
1.
Health promotion
2.
Contraception
E. Home care/community follow-up for the
postpartal family
F. Psychologic adjustment
1. Taking-in
2. Taking-hold
3.
Letting-go
4.
Postpartum "blues"
5.
Depression
6.
Psychosis
G. Anticipatory guidance
Critical Thinking Exercise:
•Postpartum Depression
Logsdon, C., et al. (2012). Identification of mothers
at risk for postpartum depression by hospital-based
perinatal nurses. MCN, 37(4). 218-227.
OUTCOMES
11. Discuss medical and nursing management of
postpartum hemorrhage.
CONTENT
II. Postpartum at Risk
A. Postpartum hemorrhage
12. Summarize care of the client with a postpartum
infection.
B. Postpartum infections
13. Describe sequelae of childbirth trauma.
C. Childbirth trauma
14. Analyze the role of the nurse in the home care
setting in managing the care of the client with
postpartum psychological complications.
D. Psychological complications
15. Describe evidence-based health promotion and
maintenance to prevent or detect gynecologic
concerns.
III.
Gynecologic Concerns
A.Assessment
B. Reducing Metastasis
C. Psychosocial Issues
D. Community-Based Care
16. Develop a plan of care for a patient undergoing
a hysterectomy.
LEARNER ACTIVITIES
Iggy: Chapter 74.
Chapman: Chapters 18 & 19.
22
NURSING 1124
UNIT 8 -- Nursing Care of the Newborn
Course Outcomes: 1, 2, 3, 4, 5, 6, 7 & 8
OUTCOMES
1. Discuss neonatal physiologic adaptations to
extrauterine life.
2. State the normal range of neonate's vital signs.
3. Collaborate with parents to maintain thermoregulation in the newborn.
4. Teach the effects of cold stress on the neonate.
5. Describe the physical examination of the neonate and state the norms.
6. Estimate the gestational age of a newborn.
7. Review the components of the Apgar score.
8. Apply safety and security measures in the
maternal-neonatal unit. (Nursing Judgment)
9. Discuss common drugs administered in the
neonatal period and their nursing implications.
CONTENT
I. Adaptation to Extrauterine Life
A. Immediate adjustments
1. Initiation of respirations
2.
Circulatory changes
B. Physiological adaptation
1.
Respiratory
2.
Circulatory
3.
Thermoregulation
4.
Renal system
5. Gastrointestinal system
6.
Neurological system
7.
Sensory functions
8.
Immunologic system
9.
Hemopoitic system
10.
Reproductive system
11.
Hepatic system
12.
Integumentary system
II.
Nursing Assessment of the Neonate
A. Physical
B. Gestational
C.Neurological
D.Behavior
III. Nursing Intervention
A. Immediate needs
1. Patent airway
2.
Thermoregulation
3. Protection from infection and injury
4.
Nutrition
5. Parent-infant interaction
6.
Security measures
LEARNER ACTIVITIES
Chapman: Chapter 15.
Syllabus - Appendix B
•Circulatory Changes After Birth
•Newborn Transition
•Thermal Regulation
•Guidelines for Physical Exam of the Newborn
•Gestational Age Assessmsent Form
Audiovisual:
•Gestational Age Assessment
•Normal Newborn Assessment
23
OUTCOMES
10. Discuss the nursing care of the newborn during
the transition to extrauterine life.
11. Write a teaching plan for new parents, include
post circumcision care.
12. Explain the rationale and method for screening
infants for phenylketonuria (PKU) and hypothyroidism.
13. Compare breast and bottle feeding, including
advantages and disadvantages.
14. Identify community resources for nutritional
concerns.
CONTENT
B.Observations
1.
Vital signs
2. Signs of distress
3.
Elimination
4.
Circumcision
C. Metabolic screening
1. PKU
2.
Hypothyroidism
IV. Nutritional Needs and Feeding
A. Nutrient Needs
B. Types of Feeding
C.Lactation
1. Benefits of
2. Physiology of
3.
Instructing mother
4.
Community resources
15. Provide newborn care information to parents
incorporating safety and cultural values.
V.
Newborn Care
A.Safety
B. Parental education
C. Cultural values
16. Communicate legal, ethical concerns in caring
for newborns. (Professional Identity)
VI. Legal/Ethical Issues
LEARNER ACTIVITIES
Morrow, C., Hidinger, A. & Wilkinson-Faulk, D. (2010) Reducing neonatal pain during routine heellance procedures. MCN 35(6). 345-355.
Chapman: Chapter 16.
Morrison, B. & Ludington-Hoe, S. (2012) Interruptions to breastfeeding dyads in a LDRP unit. MCN
37(1). 36-41.
Smith, P., Moore, K. & Peters, L. (2012). Implementing baby-friendly practices: Strategies for success. MCN 37(4). 228-235.
24
NURSING 1124
UNIT 9 -- The Newborn at Risk
Course Outcomes: 1, 2, 3, 4, 5, 6, 7 & 8
OUTCOMES
1.
Differentiate characteristics of preterm, term,
postterm, and postmature neonates.
2.
Write a plan of care for a neonate with a highrisk disorder such as meconium aspiration,
hypoglycemia, SGA, or IUGR.
3.
Discuss methods of oxygen therapy for highrisk neonates.
4.
Plan nutritonal support for high-risk neonates.
5.
Collaborate for transport of the high-risk
neonate.
6.
Incorporate cultural and spiritual values of the
family into the care of the neonate with an
acquired or congenital problem.
7.
Summarize assessment and care of the
neonate with an acquired or congenital
problem.
8.
Communicate to the parents the plan of care
for the neonate with an acquired or congenital
problem.
9.
Identify specific nursing interventions to meet
the special needs of the parents and family
experiencing perinatal loss.
25
10. Differentiate therapeutic and non-therapeutic
responses in caring for the parents and family
experiencing perinatal loss.
CONTENT
I. Newborns at Risk
A. Classification of high-risk infants
B. Specific disorders
1. Gestational age variations
2. Infant of diabetic mother
3.
Congenital anomalies
4.
Substance abuse
C. Care management
1.
Oxygen therapy
LEARNER ACTIVITIES
Chapman: Chapter 17.
2.
Nutrition
3.
Parenteral support
4.
Cultural issues
5.
Spiritual issues
D.Transport
II.
Newborn Birth-Related Stressors
A. Birth injuries
B. Respiratory distress
C. Cold stress
D.Hypoglycemia
E. Hemolytic disorders
III. Perinatal Loss
Whitaker, C. Kavanaugh, K. & Klima, C. (2010) Perinatal
grief in Latino parents. MCN 35(6). 341-345.
APPENDIX A
GUIDELINES FOR
WRITTEN ASSIGNMENTS
26
NURS 1124: Maternal-Neonatal Nursing
ASSIGNMENT #1
Concept Map
Objective:
Prepare a concept map on a selected maternalneonatal topic from the list below.
Points possible:
50 (see the grading rubric on the following page).
Topics
Date due
1.
Infertility ................................................................. 3/13
2.
Oral contraceptives ............................................... 3/13
3.
Cardiovascular/Hematologic Adaptations.............. 3/13
4.
Respirations Adaptations ...................................... 3/13
5.
Integumentary Adaptations ................................... 3/13
6.
Premature Labor ................................................... 3/20
7.
Placenta Previa ..................................................... 3/20
8.
Abruptio Placenta .................................................. 3/20
9.
Ectopic Pregnancy ................................................ 3/20
10.
Hydatiform Mole .................................................... 3/20
11.
Epidural Anesthesia .............................................. 4/3
12.
Labor Induction...................................................... 4/10
13.
Shoulder Dystocia ................................................. 4/10
14.
Amniotic Fluid Embolism ....................................... 4/10
15.
Mastitis .................................................................. 4/17
16.
Rh Isoimmunization ............................................... 4/24
17.
Thermoregulation in the Newborn ......................... 4/24
18.
Hypoglycemia in the Newborn ............................... 4/24
19.
Cold Stress in the Newborn ................................... 4/24
20.
Group B Streptococcus ......................................... 4/24
27
CREATING A CONCEPT MAP
1.
Select the topic, reading, or client for whom you wish to develop a
map.
2.
Identify the most general concepts first and place them at the top (or
middle) of the map.
3.
Identify the more specific concepts that are related in some way to
the general concepts.
4.
Tie the general and specific concepts together with linking words in
some fashion that make sense or have meaning to you.
5.
Look for cross-linkages between the more general and more specific
concepts.
6.
Discuss, share, think about, and revise the map.
28
29
30
Grading Rubric for Concept Map Assignment
Student Name(s) _______________________________________________________
Topic ________________________________________________________________
If you score poor on more than two categories, then you will receive a failing
grade for this assignment.
Topic
Organization of
Content
(10 points)
Eye Appeal
(10 points)
Excellent
Content
demonstrated
clear organization
of content – able
to follow
relationships
easily between
concepts
Very eyecatching – used
color and shape
to enhance
concepts
Established
Relationships
between
Concepts
Clear and
appropriate
demonstration of
relationships
between
(10 points)
concepts
Professionalism Presentation was
presented
(10 points)
professionally –
both in
appearance and
speech
Critical
Reasoning
(CR)
(10 points)
Presentation
demonstrated
clear CR and
stimulated class
discussion
Points_________________
Good
Content
demonstrated fair
organization of
content – able to
follow
relationships with
moderate ease
between
concepts
Moderately eyecatching – used
some color and
shape to
enhance
concepts
Fair
demonstration of
relationships
between
concepts
Poor
Content
demonstrated
poor organization
of content – not
able to easily
follow
relationships
between concepts
Presentation
could have been
more
professional –
contained some
aspects of
professionalism
Presentation
demonstrated
some CR and
class discussion
Presentation was
poorly presented
– lacked
preparedness and
quality
Comments
Poor eye appeal –
lacked color and
shapes to
enhance concepts
Poor
demonstration of
relationships
between concepts
Lacked CR and
did not stimulate
class discussion
Date_______________________
Instructor’s Signature ____________________________________________________
31
NCLEX REVIEW
Due Date:
5/1/14
Objective:
Complete the ATI Practice Exams for MaternalNewborn Nursing
Points possible:
50
Credit:
The student will receive full credit for the assignment
if a score of 90% or greater is achieved on each of
two practice exams by the due date. Late
assignments receive 0 points.
The instructor will access practice exam results on the ATI
web-site.
32
Case Study
Chapter 7
P.T. is a married 30-year-old gravida 4 para 1203 at 28 weeks gestation. She
arrives in the labor and delivery unit complaining of low back pain and frequency
of urination. She states that she feels occasional uterine cramping and believes
that her membranes have not ruptured.
You are the nurse and admit P.T. Based on the information you have identify 2
most likely diagnosis.
You need additional information from P.T. to determine what you will do next.
What important questions do you need to ask to differentiate what is going on?
List risk factors for preterm labor
What nursing interventions would you do before calling the physician?
The criteria for diagnosis of preterm labor is what?
What other problems/diagnosis might be considered?
P.T.’s history reveals that she had one preterm delivery 4 years ago at 31 weeks
gestation. The infant girl was in the neonatal intensive care unit for 3 weeks and
discharged without problems. The second preterm infant, a boy, was delivered 2
years ago at 35 weeks and spent 4 days in the hospital before discharge. She
has no other risk factors for preterm labor. Vital signs are normal. Her vaginal
exam was essentially within normal limits; cervix long, closed and thick:
membrane intact. Abdominal exam revealed that abd was nontender with fundal
height at 29cm, fetus vertex.
While you are waiting for laboratory results, what therapeutic measures do you
consider?
33
When caring for a woman with symptoms of preterm labor, it is important to
question the woman about whether she has symptoms when she is engaged in
certain activities that might require lifestyle modifications. What activities should
you assess for?
You consider that if P.T. is in preterm labor she would receive glucocorticoids.
What is the rationale?
How long does it take for the drugs to be effective?
Which of these situations are considered contraindications to antenatal
glucocorticoids?
a. Cord prolapse b. Chorioamnionitis c. Presence of twins d. Cervical dilation of 2.5cm e. Abruption placenta Two hours later the lab results indicate a UTI. The contraction monitor indicates
infrequent, mild contractions. Her physician discharges her to home on an
antibiotic.
What discharge instructions would you provide the patient with?
Suppose the patient was in preterm labor, what medications might you give?
Nursing considerations for the medication?
Suppose the patient did have preterm premature rupture of membranes, list
nursing considerations.
What condition might warrant a cerclage?
34
Gestational Diabetes
Lisa is 24 weeks pregnant and has had no complications. Her 1 hour GTT was
positive and she is scheduled for a 3hour GTT. Her grandmother takes metformin
for her diabetes and Lisa asks if she will be prescribed it.
What is the purpose of the glucose tolerance test?
What instructions would you provide her with before the test?
Interpret the lab test results
Fasting
109mg/dl
1hr
213mg/dl
2 hr
162mg/dl
How would you respond to Lisa’s question about the metformin?
Lisa is diagnosed with gestational diabetes and is says, “Great, now I will have to
take medication for life.” How would you respond?
Lisa asks “Exactly what is gestational diabetes”?
What will you tell Lisa concerning how to monitor her blood sugar at home?
Describe the usual diet used in treating gestational diabetes.
The physician orders Humulin and Regular insulin. Explain to Lisa why she is on
2 different insulins. What do you need to teach Lisa concerning insulin
administration?
Explain possible complications the baby may have and pathophysiology.
Explain possible complications for Lisa during and after delivery and the
pathophysiology.
35
Pregnancy-Induced Hypertension
J.F is an 18 year old woman, gravida 1 para 0 at 38 weeks gestation. She felt fine 2
days ago, when she noticed swelling in her hands, feet and face. She complains of a
frontal headache which started yesterday and has not been relieved with
acetaminophen or coffee. She says she feels irritable and doesn’t want the “overhead
lights on.” Her physician is inducing her labor. Assessment is follows:
152/84, 98.8-88-16
289lbs, ht 64inches
2+edema of feet and ankles, also edema of hands and feet
Deep tendon reflexes 2+, no clonus
Urine dipstick 3+proteinuria
Based on the assessment data you have now, what do you think is happening?
What other assessment questions should you ask her at this time?
What information should you obtain from her obstetric record?
What laboratory tests should be considered at this time?
List 3 possible maternal complications with this diagnosis
List 3 possible fetal complications.
Underline the risk factors above.
List 8 nursing interventions.
The physician orders magnesium sulfate infusion. 4 gram bolus followed by 2 grams an
hour. Pharmacy sends 80 grams magnesium in 1000cc. How do you set the pump for
the bolus?
Continuous infusion?
As you monitor J.F., you observe for what signs of toxicity?
Four hours later, a serum magnesium level is drawn and results show 7.8 mEql. How do
you interpret the result? What are your nursing interventions?
What is the antidote for magnesium sulfate?
36
Chapter 8
Suzanne is an excited 24-yr-old primagravida, kindergarten teacher, married to Jeff, a computer
analyst. She is admitted to labor and delivery with signs of bloody show and contractions every
16 minutes and lasting 20-30 seconds. Jeff reports that she is doing really well with her breathing
and that they are excited about having a natural childbirth. Suzanne has a normal H & P, BP
128/64, P 90, R 24, FHT 140, membranes are intact. A vaginal check reveals Suzanne to be 2cm
dilated and 50% effaced, vertex and at O station.
1. What stage and phase of labor is Suzanne in?
2. What comfort or pain measure could be used in this stage?
3. What else would you need to assess?
4. What data, if seen, would prompt you to call the physician (warning signs)?
5. List 2 nursing diagnosis & interventions appropriate for this stage of labor.
Suzanne now is having contractions every 4 minutes, lasting 45-60 sec and are of moderate
intensity. Vaginal check reveals 6cm, 100% effaced, +2 station, ROA. Suzanne is more serious,
focused, apprehensive, feels helpless, and “wants to get this over with”. She asks, “Can I have
something to take the edge off this pain?” Jeff is supportive and attentive. She has been walking
in the hallway but not wants to lie down. As she gets into bed her membranes spontaneously
rupture and you note green tinged color. There is also increasing bloody show.
6. What stage and phase of labor is she in now?
7. What comfort or pain measure could be used in this stage?
8. List one nursing diagnosis and interventions that are appropriate now.
9. What potential problems should you anticipate?
37
Suzanne’s contractions are 2-3 minutes apart, lasting 70-80 seconds and are very strong. She
shows frustration, loss of control, has nausea and vomits a small amount. She yells at her
husband, “get away and do not touch me!” As you enter the room she says she needs to use the
restroom to have a bowel movement.
10. What stage and phase of labor is she in now?
11. What nursing interventions are appropriate for this stage and phase of labor?
A vaginal exam reveals Suzanne is 9cm. +3 station and 100% effaced.
12. Suzanne insists on pushing, what should you do and why?
13. Suzanne now complains of stiff fingers and numbness around her mouth. What should
you do?
14. What if she were 10cm dilated?
15. What would be important items to document at this time?
Suzanne is completely dilated, +3, vertex well flexed and now starts pushing.
16. What stage and phase of labor is she in now? At what point does this stage begin and
when does it end?
17. List nursing interventions for immediately before and after delivery.
Suzanne delivers a 9lb baby girl. The baby is doing well and the physician is waiting for delivery
of the placenta.
18. What stage of labor is Suzanne in now and how long should it last?
19. What complications might you expect if the stage 3 lasts longer that it should?
20. Why is pulling on the cord contraindicated?
21. While waiting for delivery of the placenta the physician repairs Suzanne’s episiotomy.
What are the two types of episiotomies? List nursing interventions.
22. How much bleeding is to be expected for a vaginal delivery? A C-Section?
38
23. What signs might you see indicating separation of the placenta has occurred and may
deliver soon?
24. What things does the nurse look for when inspecting the placenta? Why?
Suzanne delivered 45 min ago. Nursing assessment reveals fundus at +3, deviated to the
right. Lochia is large amount rubra with small clots. BP 90/50, P 120, R 24. She complains of
feeling cold and is shivering. Her perineum is swollen, especially on the right side
25. What could be happening to Suzanne? Why?
26. What interventions should be done immediately and why?
The following chart shows a typical status report often used in intrapartum units. Interpret the
data about each woman’s labor by answering the questions below
Name
Amy
Becky
Cathy
Deanna
Gravida
2
4
1
3
Para
0
3
0
1
Gest
36
42
40
39
Dil
1-2
6
3-4
C
Eff
50%
80%
90%
100%
Station
-2
-1
0
+2
FHR
160
115
144
132
Which patients are full term gestation?
Which fetuses are engaged?
Who is likely to deliver soonest? Why?
Which FHT are you concerned about? What other information would you assess?
39
Chapters 15, 16 & 17
Today you are the nurse in charge of 3 mother baby couplets
Baby A is a male, born at 37 weeks gestation to a diabetic mother. He weighed 4730
grams and was a spontaneous vaginal birth. He is now 1 hour old, has a large caput,
facial bruising, positive moro reflex and Apgars of 6 & 8. Mom plans to bottle-feed. VS
are 98-130-48
Baby B is 3 hours old. Your assessment shows a SGA female infant of 42 weeks who
weighs 2280 grams, has small eye openings and a flat upper lip. Mom has a known
history of alcohol and cocaine addiction. She also has a history of having hepatitis B.
She is a chronic carrier. You note there are only 2 vessels on the umbilical cord. VS
96.8-120-62. The baby is jittery and has a poor suck reflex. Apgars were 5 & 7.
Baby C is 40 weeks, 3410 grams, 40 weeks gestation from a spontaneous vaginal
delivery. He is scheduled for circumcision tomorrow morning. VS 98.2-130-40. Mother
plans to breastfeed. Apgars were 8 & 10.
1. There are several routine procedures, lab tests, and treatments necessary for all newborns from birth to discharge. Discuss this generic plan of care, giving rational for all procedures and treatments. 2. What additional things would be indicated for Baby A based on history? 3. What additional things would be indicated for Baby B based on history? 4. What additional things would be indicated for Baby C based on history? 40
5. Baby A is doing well. His blood sugar is 80 and he fed well at his first feeding, taking 1oz, of formula. The mother states, “I hope he does not have diabetes like me.” How would you respond? 6. Baby B’s mother refuses to feed or look at her daughter. “I will have plenty of time to take care of her at home, let me rest.” List interventions to enhance bonding. 7. Baby C is returned to his mother after the circumcision and has petroleum jelly gauze wrapped around his penis and a small spot of bright red blood in the diaper. What teaching instructions are needed? 8. Baby’s C’s mother says “I’m about ready to give up on breastfeeding. He does not seem to be very interested and does not latch on. What am I to do?” What help will you give her? 9. A nurse’s aide is assigned to work with you today. What tasks could you delegate? 10. Which infant would you have seen first after receiving report and why? 41
APPENDIX B
Study Supplements
45
MILESTONES IN FETAL DEVELOPMENT
AGE
Conception
LENGTH
WEIGHT
Single Cell to 2 layers of cells
DESCRIPTION
3-4 days in fallopian tube -- mulberry cluster of cells.
2-3 days in uterus before in uterus before implanting -- 2 layers of cells.
Outer cells eat out nest in thick, succulent endometrium.
Finger-like projections are surrounded by pools of mother's blood.
Substances diffuse through membrane.
Has a tail. Head 1/3 of length.
Surrounded by fluid-filled space -- amniotic fluid.
Tube formed for heart, pulsating--blood.
Rudiments of digestive tract.
Beginnings of eyes, ears, extremities visible.
1 lunar month
Embryo
4 weeks
1/4"
2 months
8 weeks
Embryo
1"
1/30 oz.
3 months
Fetus
12 weeks
3"
1 oz.
Sex can be distinguished. Fetal heart tones can be heard with doppler or ultrasound.
Fingers and toes separate, covered by fine membrane--nails, tooth buds form and bones begin to
ossify. Rudimentary kidney secretes urine. Weak movements may occur but are not felt.
4 months
16 weeks
6 1/2"
4 oz.
Bag of waters is size of large orange--fills uterus.
Fine, downy hair--lanugo--on body. Meconium in intestine; sucking motions; swallows amniotic
fluid. May hear heart beat with stethoscope.
Faint movements may be felt, "quickening".
5 months
20 weeks
10"
8 oz.
Has nails and hair.
Hear fetal heart tones with stethoscope.
Muscles well-developed and fetus active; fetal movement felt by mother.
Fetus has grasp reflex. Brown fat begins to form.
20-24 weeks is considered age of viability.
6 months
24 weeks
12"
1 1/2#
Has face, arms with elbow, fingers; legs with knee, toes.
Brain develops more rapidly, head prominent.
External genitalia appear but cannot tell sex.
Development of heart complete.
Red, wrinkled skin.
Begins to develop covering--vernix caseosa or "chessy varnish", fatty cheesy, 1/8" thick at times.
Eye lids separate.
46
AGE
LENGTH
WEIGHT
DESCRIPTION
7 months
28 weeks
15"
2 1/2#
8 months
32 weeks
16 1/2"
4#
50-50 to 2/3 chance of survival if born.
Bones firmer. Most reflexes present. Cry stronger.
Gains 1/2# a week in last 2 months.
9 months
36 weeks
19"
6#
Body and extremities are filling out.
Good chance of survival if born at this time but still would need special care.
Descent of testes into upper scrotal sac.
10 months
40 weeks
20"
7 to 7 1/2#
Alveoli present in lungs and beginning to produce surfactant.
Eyes open.
Lanugo--most gone. Skin smooth and pink.
Vernix present in skin folds.
Fingernails firm. Creases cover sole.
Breasts firm due to mother's hormones.
47
FETAL CIRCULATION
Single umbilical vein carries oxygen enriched blood from the placenta
It divides at the edge of the fetal liver allowing 1/2 the oxygenated blood
a small quantity of
oxgenated blood from
inferior vena cava
remains in the R. atrium
and mixes with deoxygenated
blood from the superior
vena cava
inferior vena cava
right atrium
left atrium
pumped through the foramen
ovale
mixes with small amounts of
deoxygenated blood
returning from the lungs.
left ventricle
exits through the ascending aorta
superior vena cava
right ventricle
pulmonary artery
mixes with deoxyenated
blood from the fetal lower
extremities, abdomen and
pelvis.
aorta
vessels leading to heart,
head, neck and upper limbs
receive well oxygenated
blood.
ductus arteriosus
small amount nonfunctional lungs
The paired umbilical arteries return most of the blood from the descending aorta to the pacenta through the chorionic villi. There the fetal blood simultaneously gives up CO2 and waste products and takes on O2 and nutrients.
The remaining blood circulates through the lower part of the fetal body and ultimately enters the inferior vena
cava.
48
DIAGNOSTIC ASSESSMENT OF FETAL STATUS
The severity of maternal disease is reflected in the growth and devleopment of the fetus. Any condition that
places a mother at risk affects her fetus — who is the most vulnerable of the two.
A. Physical Examination
1. Fundal Height (symphysis pubis to upper rim of fundus) gives an estimate of fetal growth.
2. Abdominal palpation — to determine uterine contour (anatomic abn = breech or transverse), fetal
presentation and position (unusual presentations suggest fetal anomalie or low placenta).
3. Fetal movement — sudden change should be investigated — especially if it ↓ or stops.
4. FHR — initial asculation is corroborative evidence of gestational age; periodic counting establishes a
baseline. Bradycardia — congenital heart disease; tachycardia — maternal disease or fetal hypoxia.
B. Amniocentesis
1. Introduction of a needle through the abdominal and uterine walls into the amniotic cavity in order to
remove some fluid for examination.
2. Ultrasound usually done first — identify placenta and fetal parts.
3. Good pre-procedure explanation and support.
4. If third trimester, watch for vena cava syndrome.
5. Check FHR before and after for 1-2 hours.
6. Clinical application of amniotic fluid analysis:
a.
Genetic diagnosis
1. usualy done as early as is practical — 14-16 weeks gestation.
Chromosone analysis, detection of enzymatic defects and DNA isolation
procedures can be done following adequate cell growth.
2. AFP — alpha-fetoprotein levels — elevated in open neural tube defects
b. Evaluation of Rh — sensitized pregnancies
1. If an Rh — sensitized mother produces an Rh+ fetus, antibodies cross the placenta and cause hemolytic anemia in the fetus. Bilirubin from destroyed RBC’s can be
detected in amniotic fluid by spectrophotometry.
2. By plotting the concentration (optical density) of bilirubin on Liley curve, the medical team can determine the degree fetus is affected & need for intervention or intrauterine transfusion.
c. Identification of meconium staining
1. When fetus is in uterus, hypoxia → peristalsis, relaxing anal sphincter and passage of
meconium. Stains amniotic fluid green.
2. Amnioscopy
d.
Maturity Studies
1.
L/S ratio (lecithin/spingomyelin)
Lecithin — major constituant of sufactant (alveolar produced substance that ↓ surface tension
of alveoli)
Rising L/S ratio = sufactant production (p- 35-36 gest. wk) and 2:1 ratio is believed necessary
for fetal lung maturity.
“Shake” or “Foam” test — lacks precision of L/S ratio; simple and rapid test for presence of
surfactant in amniotic fluids.
2. Bilirubin level in amniotic fluid — a marked ↓ in concentration of bilirubin in amniotic fluid occurs
toward term and disappears 37-38 weeks gestation.
3. Amniotic fluid creatinine — amniotic creatinine ↑ as pregnancy advances due to excretion of
fetal urine reflecting fetal kidney function or muscle mass. Values of 2 mg/100 ml indicate fetal
maturity.
4. Osmolality
Amniotic fluid in early pregnancy isotonic -c maternal plasma, as
pregnancy progresses fluid becomes more hypotonic (↑ amts fetal urine)
49
250 mOsm/L/kg or less = fetal maturity.
5. Cytologic study of fetal cells
Fat cells ­as fetus matures and % of these cells in amniotic fluid gives an indication of gestational
age. Nile blue sulfate staining 15-20% indicates 36 weeks gestation or more.
C. Laboratory Studies of Placental Function
Placental insufficiency is a significant factor in intrauterine growth retardation and in fetal death. O2 and
nutrients are supplied by well functioning placenta.
1. Estriol Excretion studies
a. Estriol is excreted in ↑ amounts throughout pregnancy and depend upon a healthy fetus c
functioning adrenals, a normally functioning placenta and healthy maternal liver and kidneys.
b. Serial values are more meaningful than single values withconsistently rising values over time more
indicative of fetal well being regardless of absolute numbers. A 40-50% drop from previous value
indicates fetal jeopardy.
c. Drugs and conditions that influence estriol values: Ampicillin, Mandelamine, laxatives containing
phenophthalein, corticosteriods, Rh isoimmunization, eclampsia.
2. HPL (Human placental lactogen) or HCS (Human chroriomic somatomamamotropin)
a. HPL is produced by the placenta (syncytiotrophoblastic cells) ­in amounts throughout pregnancy
and has potential of servingas an index of placental function and fetal well beign — particularly in
post datism and eclampsia.
b. However normal values are so variable that interpretation is difficult at present and other tests
should be considered together c- HPL.
D. Electronic Assessment Methods
1.Ultrasound
a. Ultrasonic echo sounds (sonar) utilizes sound waves of high frequency which are projected through
a transducer applied to the abdomen and are reflected off tissue then displayed on an oscilloscope
or TV screen.
b. Ultrasound is noninvasive and painless and at this time believed to be harmless to mother and
fetus.
c.
Clinical applications
Early identification pregnancy; identification of multiple fetus, anomalies, placental abnormalities
and position; estimation fetal age (BPD) or IUGR; fetal respiratory movements.
d. procedure — good explanations and support; discomfort: full bladder; mineral oil over abd; having
to lie on back 20-30 minutes.
2. OCT (Ocytocin Challenge Test) or CST (Contraction Stress Test)
a. CST (OCT) involves administration of IV oxytocin to stimulate uterine contractions while
simultaneously monitoring uterine activity and FHR with an external monitor. Well known that
uterine contractions interfere with uteroplacental circulation. In pregancies where fetal-placental
reserve ↓ the fetus will become hypoxic during a contraction and FHR will drop (late deceleration)
b. Negative test — no late deceleration — suggests can tolerate labor unless there is a change in
maternal status — high risk mothers (toxemia, diabetes, etc.) may have weekly CST p- 32-34
weeks.
c. Positive test — late deceleration occur — associated -c high frequency of poor outcome. When
positive OCT and mature L/S ratio — labor usually induced. If late decelerations continue or signs
of fetal acidosis then a C/S is done.
3. Non stress test
a. Requires continuous monitoring of FHR. The client indicates when fetal movement occurs and the
FHR is observed at this time. A brief period of FHR acceleration occurs in association c activity in
situations where there is good fetal reserve. Non-reactive test indicates need for further tests such
as OCT and estriol studies.
50
STAGES OF LABOR CHART -- A GUIDE FOR SUPPORTING MOTHERS IN LABOR
STAGE ONE -- THE DILATION STAGE: This period begins with the onset of true labor contractions and ends with complete dilation
of the cervix.
DURATION
Total time of first stage: varies from
a few to 12 or more hours.
CHARACTERISTICS
HOW SHE MAY FEEL
WHAT SHE MAY DO
Early (latent) Phase: cervix dilates 1
cm to 4 cm
Uterine contractions, which may
follow a regular pattern and may be
accompanied by:
abdominal cramps
backache
rupture of membranes
show (blood-tinged mucoid vaginal discharge)
(In early phase)
Excited. She may also feel:
*A sense of anticipation
*A sense of relief
*Happy
*Some apprehension
(In early phase)
* Carry on with normal activities if
possible, or keep diverted with
other activities of interest.
* Try pelvic rocking if back aches.
* Try abdominal breathing if
contractions are strong and painful.
* Time duration and frequency of
contractions.
* Ask doctor when to go to hospital.
Mid-(Active) Phase: cervix dilates 4
cm to 8 cm
Uterine contractions become stronger,
longer (40-50 seconds), more
frequent, and may be accompanied by
pain.
(In mid-phase)
Apprehensive. She may also feel:
*A growing seriousness
*Ill-defined doubts and fears
* Desire for companionship
*Uncertain if she can cope with
contractions
(In mid-phase)
* Assume most comfortable position.
* Try abdominal breathing with
contractions and breathe normally
between contractions. Try pelvic
rocking and have back rubbed if it
aches.
* Ask for medication if unable to
relax.
* When doctor does a rectal
examination, relax pelvic floor.
51
DURATION
Transition phase: usually lasts
through 20-30 contractions.
CHARACTERISTICS
Transition Phase: cervix dilates 8
cm to 10 cm. Uterine contractions
may become stronger, longer (50-60
seconds), and may be accompanied
by:
* Amnesia between contractions
* Cramp in legs
* Generalized discomfort
* Hiccuping
* Irritable abdomen
* Marked restlessness
* Nausea and possible vomiting
*Pain
* Perspiration on upper lip and
forehead
* Profuse, dark, heavy show
* Pulling or stretching sensation
deep in pelvis
* Rupture of membranes
* Severe low backache
* Shaking of legs
HOW SHE MAY FEEL
Increasingly apprehensive.
She may also feel:
* bewildered by intensity of
contractions
* irritable and unwilling to be
touched
* frustrated and unable to cope
with contractions if left alone
* eager to be "put to sleep"
WHAT SHE MAY DO
* Relax as much as possible.
* Slow deep chest breathing with
contractions--abdominal breathing
usually becomes impossible at this
time.
* If nauseated, prevent vomiting by
taking and holding a deep breath.
* Have pressure applied to small of
back if this area aches.
* Ask for medication to ease
sharpness of contractions.
* Keep in mind that contractions
have now reached maximum
strength and that relief will soon
come with pushing.
52
STAGES OF LABOR CHART -- A GUIDE FOR SUPPORTING MOTHERS IN LABOR
STAGE TWO -- THE EXPULSIVE STAGE: This period begins with the complete dilation of the cervix and ends with birth of the baby.
DURATION
CHARACTERISTICS
HOW SHE MAY FEEL
Total time of second stage: anywhere from 2 to 60 or more minutes.
Full dilation of the cervix accompanied
by:
* Contractions which may be 1
to 2 minutes apart, becoming
increasingly expulsive in nature.
* Increased show.
* Expulsive grunt when exhaling.
* Rectal bulging with flattening of
perineum.
* Increased amnesia between
contractions.
* Gradual appearance of presenting
part at vaginal opening.
Increasingly involved in birth process.
She may also feel:
* Relief because second stage has
begun.
* Desire to bear down or push.
* Tremendous satisfaction with each
push, or conversely, acute pain
with each push.
* Desire to move bowels.
* Complete exhaustion after each
expulsive contraction.
* Unable to follow directions readily.
* Desire to participate fully in total
birth process, or conversely, to be
"put to sleep".
* A splitting sensation due to extreme
vaginal stretching as baby is born.
(The doctor may do an episiotomy to
facilitate delivery of baby.
WHAT SHE MAY DO
Notify nurse of desire to bear down.
Respond to urge to push...
If in own bed:
1. take deep breath
2. bend knees, spread them
apart and grasp them firmly
while bringing them up toward
shoulders
3. with mouth closed, pull back
on knees while bearing down
or pushing, keeping hips flat on
bed.
If in delivery room:
1. take deep breath
2. grasp hand grips at side of
delivery table and relaxing pelvic
floor continue to push down
as long as each contraction
lasts. Rest completely between
contractions.
Take anesthesia as it is offered.
Pant when asked to do so or when
asked not to push.
53
STAGES OF LABOR CHART -- A GUIDE FOR SUPPORTING MOTHERS IN LABOR
STAGE THREE -- THE PLACENTAL STAGE: This period begins with the birth of the baby and ends with the expulsion of the
placenta and membranes
DURATION
Total time of third stage: anywhere
from 1 to 20 or more minutes.
CHARACTERISTICS
Contractions temporarily cease upon
birth of the baby. When they resume,
they usually are painless and may
be accompanied by upward rise of
uterus in abdomen. Uterus assuming
globular shape. Visible lengthening of
umbilical cord as placenta moves into
vagina. Trickle or gush of blood.
HOW SHE MAY FEEL
Exhausted, but elated and proud of
achievement.
She may also feel:
* Eager to hear and see baby.
* A sense of relief.
* Delight that abdomen is flat.
* Ravenously hungry.
*Thirsty.
WHAT SHE MAY DO
* Relieve tension by giving into
emotions.
* Watch expulsion of placenta and
membranes in overhead mirror.
* Ask to have baby put to breast for
a first feeding.
STAGE FOUR -- THE RECOVERY STAGE: Period of immediate recovery, when homeostasis is reestablished.
Important to
I
observe for complications.
DURATION
Nulbiparas -- 2 hours
Multiparas -- 2 hours
CHARACTERISTICS
54
* Pulse may be slow.
* BP should remain within normal
limits.
* Uterus should remain firm,
positioned in the mid-line at or
slightly above the umbilicus.
(Mid-way between symphysis and
umbilicus immediately p delivery,
gradually rises to umbilicus.)
* Perineum should be intact.
* Moderate to large amount lochia.
* May need to be catherized.
HOW SHE MAY FEEL
* Hungry and thirsty
* Initial excitement may be replaced
by drowsiness.
* Desire to rest not curtailed by
discomfort, hunger, or emotional
upset.
WHAT SHE MAY DO
*Sleep
* Visit with husband, friends, support
persons
*Withdraw
* Ask to have baby
* May want privacy to breast feed
8-POINT POSTPARTUM ASSESSMENT
Before beginning the assessment, be sure that the mother has emptied her bladder and that she is lying in
a supine position on a flat bed. Explain each procedure to her and inform her of your findings.
1. BREASTS: Gently palpate each breast. What is the contour? Are the breasts full, firm, tender,
shiny? Are the veins distended? Is the skin warm? Does the patient complain of sore nipples and are
her breasts so engorged that she requires pain medication?
If you feel nodules in the breasts, they may be there because the ducts were not emptied at the last
feeding. Stroke downward towards the nipple, then gently release the milk by manual expression.
Take this opportunity to explain the process of milk production, tell her what to do about engorgement, show her how to perform self-breast examinations, and answer any questions she may have
about breastfeeding.
2. UTERUS: Palpate the uterus. It should be firm and should decrease approximately one fingerbreadth below the umbilicus each day. Have the patient feel her uterus as you explain the process of
involution.
If the uterus is not involuting properly, check for infection, fibroids and lack of tone. Unsatisfactory involution may also result if there are retained placental pieces or the bladder is not completely
empty.
3. BLADDER: Inspect and palpate the bladder simultaneously while checking the height of the fundus.
Bladder distention should not be present after recent emptying. When it does occur, a pouch over the
bladder area is observed, resistance is felt upon palpation, while at the same time, the mother usually feels a need to urinate. An order from the physician is necessary so that catheterization may be
done. The physician may also order a culture and sensitivity test, since definitive treatment may be
required.
Infection of the urinary tract must be prevented from occurring. This is why it is imperative that the
first three postpartum voiding be measured and should be at least 150 cc. Frequent small voidings,
with or without pain and burning, may indicate infection or retention. If voidings are frequent and
large, explain the diuresing process to the mother.
Talk to the mother about proper perineal care. Explain that she should wipe from front to back after
voicing and defecating. This helps prevent urinary tract infection and is a hygenic principle that
pertains to females of all ages.
4. LOCHIA: Assess the amount and type of lochia on the perineal pad in relation to the number of
postpartum days. For the first 3 days, you should find a very red lochia similar to the menstrual flow.
During the next few days it should become watery or serous, and on the tenth day, it should become
thin and colorless.
55
Notify the doctor if the lochia looks abnormal in color or quantity. Tell the mother when her next
menstrual period will probably begin and when she can resume sexual relations. You may also want
to discuss family planning at this time.
5. EPISIOTOMY: Although episiotomies are routine, don’t overlook the importance of inspecting
them thoroughly. Use a flashlight if necessary for better visibility and have patient turn over on her
side. To determine if the wound is healing properly, check for infection, inflammation and suture
sloughing. Is the surrounding skin warm to the touch, and does the patient complain of discomfort?
You should notify the doctor if any occur.
Also check the rectal area. If hemorrhoids are present, the doctor may want to start the patient of a
sitz bath and local analgesic medication.
Most postpartum patients — especially those who are mothers for the first time -- will have questions about the stitches: “When will they be removed?” “Will they pull out during bowel movements?” Reassure her as you answer these and other questions she may have regarding pain, cleanliness, and coitus.
6. BOWEL FUNCTION: Question the patient daily about bowel movements. She must not become
constipated. If her bowels have not functioned by the second postpartum day, you may want to start
her on a mild laxative. Encourage her to drink extra fluids and to select fruits and vegetables from
her menu.
7. HOMAN’S SIGN: Press down gently on the patient’s knee (legs extended flat on the bed) and ask
her to flex her foot. Pain or tenderness in the calf is a positive Homan’s sign and an indication of
thrombophlebitis. The physician should be notified immediately.
8. EMOTIONAL STATUS: Throughout the physical assessment, notice and evaluate the mother’s
emotional status. Does she appear dependent or independent. Is she elated or despondent? What
does she say about family support? Are there other nonverbal clues?
Explain to her and to her family that she may cry easily for a while and that her emotions may suddenly shift from high to low. These changes are normal and are probably caused by the tremendous
hormonal changes occurring in her body.
56
CIRCULATORY CHANGES AFTER BIRTH
1. Initiation of respiration
Alveoli expand
Blood flow to the lungs increases
Pulmonary blood flow increases
Pulmonary vascular resistance decreases
Causes:
L. atrial pressure ↑
R. atrial pressure ↓
Therefore: The foramen ovale (structured to permit flow from R to L) closes.
2.O2 saturation following above changes stimulates constriction and closure of ductus
arteriosus.
3. With ligation of umbilical cord, the ductus venosus, umbilical vein, and umbilical arteries no longer transport blood, therefore they are obliterated.
THUS EXTRAUTERINE CIRCULATION IS ESTABLISHED.
57
NEWBORN TRANSITION
FETUS
I. Respiratory System
Primary respiratory organ is the placenta.
Gas exchange occurs through diffusion at
the intervillous space. By 28 weeks, two
significant anatomic events occur:
a) approximation of blood vessels to air sacs to allow gas exchange and
b) production of surfactant which allows alveoli stability by altering surface tension during expansion and contraction, so these air sacs can fill with air.
The lungs are nonfunctional before 26 weeks
of gestation, primarily because of the lack of
the above anatomic events. Fetal respiratory
movements do exist.
CHANGES AT BIRTH
NEWBORN
Entrance into an atmospheric environment demands
immediate respiratory function. Mechanisms
involved in initiating mandatory respirations are:
Primary respiratory organs are lungs. Neonate's
first breath is possible only after the infant overcomes resistive forces from surface tension, viscosity of fluid in airway and tissue resistance. The first
obstacle to overcome is fluid in the lung. Due to the
high resistance of this fluid, extreme forces (pressures of 60-80 cm) are required to open alveoli for
the first time. Removal of this fluid is rapid since
the FRC (functional residual capacity) (25-30 ml/kg)
is established in two steps: the first consists of the
initial gasp for air (6-10 seconds after birth) and the
second involves maintenance of rhythmic breathing
pattern. Associated with the onset of breathing at
birth is the filling of pulmonary capillaries with blood.
A. Peripheral chemoreceptors are stimulated by
low oxygen and high carbon dioxide resulting
when cord is clamped and umbilical blood flow
is interrupted.
B. Combined effects of the following:
1. cold stress from heat loss from wet body in contact with air,
2. release from fluid environment alters gravitational forces,
3. release of resistance from vaginal walls on infant's chest,
4. pulmonary reflexes help inflate lungs by initiating inspiratory gasps.
There is a transitional period for respiratory patterns
in the neonate. This is related to the hypoxic challenge associated with birth. The healthy infant will
recover from this by 10 minutes of age. Delivery is
asphyxiating to the neonate (pH 7.10 PCO2 76 PO2
20). The neonate responds to this hypoxia by:
a) hyperventilation for 2 minutes and then reduction
in ventilation,
b) decrease in metabolism to minimize oxygen
consumption.
Maintenance of breathing in the neonate is influenced by acid-base balance and elastic properties
of the lung and chest involved in the mechanics
of breathing. Metabolic demand of the neonate is
twice that of the adult, therefore, pulmonary ventilation is higher. This is accomplished by increasing the rate of breathing. Inspiratory capacity of
the newborn is 40 cc/kg. Normal blood gases -pH 7.35-7.45 PCO2 40 PO2 60.
58
NEWBORN TRANSITION
FETUS
II. Circulatory System
CHANGES AT BIRTH
Certain anatomic changes take place at birth which
permit oxygenation of blood by the lungs in place of
The cardiovascular system functions early; first the placenta:
heart beat at 3 weeks; RBCs begin to form at 3 a) Immediately at delivery the baby breathes and
weeks.
the pulmonary circulation changes.
b) A much larger amount of blood is pumped into
Fetal circulation differs from the neonate in
pulmonary arteries by the right ventricle and a
several ways:
smaller amount passes through the D.A. The
a. high blood flow to the placenta, 50% of the D.A. atrophies and becomes a ligament.
cardiac output,
c) Pulmonary circulation increases and more blood
b. Anatomic structures which divert blood to is returned from the lungs to the left atrium. The
organs performing vital functions:
pressure rises in the left atrium and the foramen
1. Ductus venosus -- arterialized from ovale closes. Closure takes place an hour after
UV to IVC
birth.
2. Foramen ovale -- allows major part of d) The placental circulation ceases to function
oxygenated blood entering heart to go when the cord is clamped.
directly to left atrium and ventricle and e) The ductus venosus becomes occluded.
aorta so as to immediately support f) Umbilical vein becomes obliterated.
heart and brain
3. Ductus arteriosus -- blood from right ventricle bypasses lungs into descending aorta
c. Oxygenated blood to fetus travels via umbilical vein, unoxygenated blood returns to placenta via umbilical arteries
To insure more oxygen to the fetus there are
two arteries and one vein.
NEWBORN
Newborn circulation now functions identical to adult
circulation. High blood flow to lungs (50% of cardiac
output). Anatomic shunts are no longer functional.
Normal blood pressure: 48-60 MM Hg RBC, million/
mm. 4.5-5.7 Hemoglobin, g/100 ml 16 Hemotocrit,
45-65 Platelets per mm. 100,000-300-000 WBC per
mm. 6,500-28,000 WBC per mm.
59
NEWBORN TRANSITION
FETUS
III. Renal System
The organ which becomes the permanent
kidney appears in the 5th week and begins
to function the 8th week of gestation. Urine
formation continues actively throughout fetal
life. This urine is excreted into the amniotic
fluid. Waste products such as urea and uric
acid are filtered primarily by the placenta
and maternal kidney. Electrolyte balance is
also primarily regulated by the placenta and
maternal kidney.
CHANGES AT BIRTH
Removal of the placenta at birth relegates filtration
of wastes and electrolyte balance to the neonatal
kidney.
NEWBORN
The neonate's kidney is functionally immature and
does not meet adult performance levels until 2 years
of age. The limitations in renal functioning are due
to diminished renal blood flow which is related to
low arterial blood pressure. Neonatal limitations are
reflected in low glomerular filtration rate and immature tubular function. Volume and composition
of body fluids can easily be deranged. The consequences of such limitations are:
a) decreased ability to concentrate urine,
b) hindered ability to maintain water balance by
excretion of excess water or retaining water
when needed,
c) comprised ability to maintain acid-base compensatory mechanisms; predisposed infant to
dehydration, hyperkalemia, and mild acidosis.
60
NEWBORN TRANSITION
FETUS
IV. Gastrointestinal System
The digestive system begins to form during
the 4th week and continues to develop thru
the 10th week of gestation. The GI tract in
utero is relatively inactive. Some activity is
demonstrated by fetal ingestion and absorption
of amniotic fluid and production of meconium.
There is insufficient peristalsis to expel a
significant amount of meconium from the
bowels. The exception to this would be fetal
hypoxia which results in increasing peristalsis
and relaxing anal sphincter.
The placenta functions to transfer nutrients,
i.e. glucose and water from the mother to the
fetus.
CHANGES AT BIRTH
The removal of the placenta necessitates
functioning of the GI tract in order to provide
essential nutrients.
NEWBORN
Air begins to enter the gastrointestinal tract and peristalsis is present by 15 minutes of life. Meconium
is passed by 4-6 hours of life. The GI tract shows
development of secretory and absorption activities.
There are adequate enzymes to digest and absorb
simple carbohydrates and amino acids. There are
many inabilities and limitations. The consequences
are identified as:
a) lesser supporting musculature, thus the common distended appearance of the abdomen,
b) unpredictability in relaxation of cardiac and
pyloric sphincters, thus regurgitation or slight
vomiting is seen,
c) tendency for "air pocketing" in upper curvature
of the stomach, this creates need for frequent
burping,
d) fast stomach emptying time; begins 1/2 to 1
hour after feeding and is complete 2 1/2 to 3
hours later. Stomach capacity is about 90 ml.
e) peristalsis increases in lower bowel, this results
in stool frequency (1-6/day); absence of stool 24
hours after birth is indicative of obstruction,
f) gastric contents are neutral at birth, becoming
more acid each day; initial neutrality prevents
growth of normal flora which can lead to vitamin
K deficiency.
61
THERMAL REGULATION
MECHANISMS OF HEAT PRODUCTION IN THE NEWBORN
The maintenance of a constant internal body temperature requires a complex interaction of the
neurologic, cardiovascular and metabolic systems for both adults and newborns. An adult is
capable of producing heat by both chemical (metabolic) means and physical (muscular activity,
shivering, etc.) means, and generally is more readily able to accept cold stress. The neonate,
however, with his limited physical abilities and his lack of a shivering response, is almost
completely dependent upon the complex processes of chemical thermogenesis (metabolic heat
production).
As compensation for his physical limitations, the newborn has a special type of fat, located
between his scapulae, around his neck, behind his sternum and around his kidneys and
adrenals, called [4mbrown fat[0m. The brown fat cells have a particularly rich supply of blood
vessels that give them their distinctive color.
PROBLEMS IN HEAT PRODUCTION
The premature infant has particular problems that place him at risk from a cold stress:
1. Decreased subcutaneous fat to act as insulation against cold.
2. A relatively large skin surface area for his weight exposed to the cold and from which heat
can radiate.
3. Decreased norepinephrine production abilities.
4. Reduced amounts of brown fat.
5. Reduced caloric intake to augment metabolic means of heat production.
6. Decreased available O2 to use in metabolic thermogenic processes.
MEANS OF HEAT LOSS
Heat loss from all substances through four basic mechanisms, all of which have direct
application to special care of the newborn. Some of these mechanisms are easily understood
and prevented, others are more subtle and, therefore, potentially more dangerous.
1. EVAPORATION: Evaporation occurs when surface moisture, warmed by the infant’s body
heat, comes in contact with dry air. As the moisture vaporizes, it carries heat with it. Such
evaporative heat loss can occur when a newborn, covered in amniotic fluid, is not dried and
wrapped immediately, or if an infant is bathed improperly.
2. CONDUCTION: Heat loss by conduction occurs when a cold surface comes into direct
contact with the baby’s body. Placing an infant on a cold surface — scales, treatment table,
etc. — causes such conductive heat loss.
3. CONVECTION: Heat loss by convection occurs when a current of air carries away the layer
of warm air generated by the baby’s body. Placing an infant in any sort of draft will cause
immediate convective heat loss.
4. RADIATION: Heat loss by radiation occurs as the infant radiates heat to the environment or
to a large colder environmental surface not in direct body contact. This frequent problem
is often the most difficult to recognize as heat can be lost by a baby through the walls of
an incubator to a cold wall window, etc., even though the temperature inside the incubator
appears to be sufficiently warm.
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PROVIDING THE PROPER THERMAL ENVIRONMENT
With an understanding of the ways in which a newborn generates heat, the threat that
cold stress poses to his survival, and the mechanisms through which a cold stress can be
introduced, it is important to know the optimal temperature for a newborn and the specific steps
that should be taken to minimize his heat loss.
Although a room’s temperature may be perfectly comfortable for the staff, it probably is not
appropriate for the premature or sick newborn. The proper climate for such infants is called
a neutral thermal environment, and is provided when the infant has the lowest O2 and caloric
consumption and least metabolic effort. The actual temperature of this environment will vary
according to the baby’s size, gestational age, and general condition.
USING THE EQUIPMENT
There are three usual ways to provide the proper thermal environment for a newborn.
1. BASSINET WITH BLANKETS: For the normal healthy, term newborn fully capable of his
own thermal regulation.
2. INCUBATOR: With servo-controlled temperature and servo-alarm system for the baby
with thermo-regulatory problems. The servo-control mechanism turns on the heat in the
incubator as indicated by the needs of the baby’s skin temperature. Skin temperature
should be checked regularly on infants in incubators, and portholes, etc., should be kept
closed at all other times. The incubator only reduce the temperature difference between the
baby’s skin and the air. It requires that the baby be able to supply his own metabolicallyprovided heat. A special transport incubator with it own O2 supply and battery power should
always be used to transfer an infant from delivery room to nursery or from one hospital to
another.
3. OVERHEAD RADIANT WARMER BEDS: Also with servo-control and alarm — for the
newborn who requires special additional medical cares such as ventilatory assistance,
extensive intravenouos therapy, etc. Overhead radiant warmers should also be used in all
delivery rooms for both routine care of the newborn — eye care, clamping the cord, finger
printing, etc. — and for resuscitation, if needed. They must, of course, be equipped with
an adequate examining light and provide sufficient warmth for the baby without overheating
the staff. When a newborn is first taken to the nursery, he should be placed under such a
warmer until his temperature has stabilized at a normal level. The baby can then be bathed,
etc., and then have his temperature re-checked.
MONITORING
The appropriate use of each of these particular means of thermal support for the neonate
must be clearly understood by the nursery staff. Careful observation and routine temperature
monitoring of all babies is essential. A warmer bed can generate a great deal of heat, therefore,
the temperature probe for the servo-control device must be attached securely to the baby’s
skin in order to assure accurate readings. Servo-control can also mask the temperature
changes that occur in septic infants. So with infants on servo-control it is important to alert for
other physiologic indices of infection, lethargy, abdominal distension, feeding problems, rapid
breathing, dehydration, seizure activity, mottling or shock. It is useful to keep a regular chart
only of the baby’s core or skin temperature, but also of his environmental temperature.
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CHILLING
If the infant is allowed to become hypothermic it will result in:
1. increased oxygen needs
2. increased metabolic rate
3. increased acidosis
4. increased hypoxia
5.hypoglycemia
Maintain temperature between 97.8° - 98.6°F.
Always record infants temperature and incubator temperature together.
Do not give 1st bath until temperature is 98.6°F.
REVIEW OF PRACTICAL STEPS
1.
2.
3.
4.
5.
Immediately wrap, then dry the newborn.
Perform routine care of resuscitation under a radiant heat source.
Transport the baby in warmed, transport incubator.
Place the baby in a warmer in nursery to check temperature stabilization.
a. Place most healthy prematures in an incubator — check servo-control.
b. Place normal newborn in a bassinet with blankets. (Most NBs stay in incubator 2 - 12
hours)
c. Place sick newborn under radiant heater — check servo-control and fluid intake and
output.
6. Monitor temperature of all newborns.
7. Maintain the proper neutral thermal environment until the baby goes home.
By understanding the various processes involved in heat production and heat loss and then
carefully applying this understanding in your treatment of the infants in your care, you can make
the difference to their well-being and perhaps, their survival.
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GUIDELINES FOR THE PHYSICAL EXAMINATION OF THE NEWBORN INFANT
1. General appearance. General inspection of the infant is the first and most important step in
the examination and this will tell much in a short time.
A. Gross anomalies such as anencephaly, omphlocele, and phocomelia are immediately
obvious and should be recorded in as much detail as possible.
B. State of maturity. If the infant seems mature, no description is required, but if there is
evidence of immaturiety or malnutrition, these should be described. Assess gestational
age. In dysmature (placental insufficiency) infants, not evidence of acute or chronic
weight loss, eye movements, “old man” appearance, dryness of skin, desquamation,
long fingernails and toenails, etc.
C. State of nutrition, e.g., loss of subcutaneous tissue in dysmature infants, or plethoric
infants.
D. Activity. Note whether activity of the infant is excessive or if it is lethargic.
E. Cry. The cry is described — if it is high pitched, hoarse, or if the child is slow to respond
by crying when stimulated.
F. Color. Presence or absence of cyanosis, jaundice, pallor, and plethora should be noted.
Also note evidence of mottling or vasomotor instability, such as harlequin color change.
G. Edema should be noted as to location and degree.
H. Evidence of respiratory difficulty as evidenced by tachypnea, flaring of nares, expiratory
grunt, xyphoid and intercostal retraction, etc.
I. Posture. The newborn infant tends to retain a posture reflecting his recent intrauterine
position. We call this “position of comfort” because attempts to change it produce
resistance and often crying. If unusual, it should be described, e.g., posture in breech
presentations is usually quite characteristic; the legs are not bowed but straight, and
in a frank breech, they are markedly abducted and externally rotated. In face or brow
presentations the head is usually extended in a position of opisthotonos and the neck
appears long.
J. Measurements. The head and chest circumferences and the length of the infant are
measured and recorded. The head at birth should be 2 to 3 cm. larger than the chest
in the term infant and more than 3 cm. larger in the premature infant. If there is any
question about hydrocephalus, developing measurements should be repeated at daily
intervals. In low-birth-weight infants, do head measurements routinely every week.
2. Skin. Note the skin color, consistency and hydration and any evidence of tumors, injuries,
rashes, etc.
A. Color.
1. Cyanosis. Note whether generalized or localized and whether persistent or variable.
2. Pallor, e.g., due to blood loss or hemolysis of red cells.
3. Red color, e.g., as seen in infants of diabetic mothers.
4.
Jaundice
5. Meconium staining of skin, umbilical cord or nails.
6. Vasomotor changes, e.g., harlequin color change, cutis marmorata(dappled or marble-like appearance especially seen in premature infants).
B. Vernix caseosa. Note whether present and if discolored — virtually absent after 40
weeks gestation.
C. Consistency and hydration. Dehydration immediately after birth may indicate
malnutrition or placental insufficiency. Generalized edema is common in premature
infants and infants of diabetic mothers, especially if infant has respiratory distress.
Localized edema may be noted in a presenting part, e.g., genitalia in a breech delivery.
Generalized hardness of the skin (sclerema) occurs with overcooling of infant and also
occurs in debilitated infants. Isolated scleroderma-like indurated areas (subcutaneous
fat necrosis) may occur in the skin, especially at forceps pressure areas, and on the
back, buttocks, and pectoral areas.
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D. Excessive dryness of the skin with desquamation is noted, especially in malnutrition or
placental insufficiency.
E. Congenital skin anomalies and tumors are common and should be described (including
size and location).
1. Mongolian spots are almost universally present over the sacrogluteal area in Negro
infants and also occur in about 10 per cent of Caucasian infants. In addition to
the sacrogluteal area, they may occur over the back and extensor surfaces. They
are due to pigment cells in the deep layers of the skin and become less and less
conspicuous as the overlying epidermal pigment becomes more intense.
2. Telangiectatic nevi are commonly found at the back of the neck and often over the
forehead, the upper eyelids, the wings of the nose, and the upper lip. These tend to
become less and less conspicuous with increasing age.
3. Vascular nevi, pigmented nevi, lymphangiomata, branchial clefts or cysts, dermal
sinuses, etc., should be noted.
F. Trauma as a result of delivery or application of forceps should be recorded. Abrasions,
petechiae, and ecchymoses are frequently seen. However, petechiae and ecchymoses
in the newborn can be caused by sepsis, erythroblastosis fetalis, and blood diseases.
G. Rashes are very common and should be described in detail, e.g., milia, heat rash, and
erythema toxicum.
H. Nails. Note the length of nails (short in premature infants and unusually long in
postmature infants). Also note any defects of nails or staining due to meconium.
3. Head. The head, being the usual presenting part, seldom fails to show evidence of molding
and some degree of “physiologic” trauma. Note is made of the following:
A. Size. Measure head and chest circumference and note if the head is larger or smaller
than expected.
B. Molding and shape of head. Immediately after birth, the fontanels may appear to be
very small or entirely closed and the suture lines will be represented by hard ridges due
to overriding. Within a few days the distortion caused by molding disappears and one
can estimate better the shape of the head, the fonatels, and the suture lines. Failure of
normal expansion may be the earliest sign of microcephaly or craniostenosis.
C. Fontanels and suture lines. Note is made of the shape and size of the fontanels.
A tense fontanel any time after birth indicates increased intracranial pressure. A
depressed fontanel may be normal or may be early evidence of dehydration in the
newborn infant. Describe the sutures as to location and size. Absence of separation
of sutures is as significant as excessive separation. Remember that hydrocephalus or
microcephaly must be substantiated by evidence other than just the size of the fontanels
and width of the sutures.
D. Caput succedaneum is an example of “physiologic” trauma to the area of the head that
presents at the cervical os. The presence of caput should be noted as to its position and
extent. It is seen on examination as a soft, ill-defined swelling with pitting edema and a
bruised-looking scalp and is not limited by the margins of the cranial bones.
E. Cephalhematoma is frequently not present at birth but appears on the first or second
day. It is a fluctuant tumor due to a subperiosteal hemorrhage, and has a well-defined
outline confined within the margins of a cranial bone (usually the parietal on one or other
side). It begins to calcify in the first few days of life and a ridge, giving the impression of
a depressed fracture, can be felt at the limits of the tumor.
F. Craniotabes is especially noted in the parietal region where, as a result of areas of
thinness in the bone, it gives under pressure like a ping-pong ball.
4. Eyes. These are difficult to examine as they are often swollen and edematous as a result
of prophylactic use of silver nitrate. If conjunctivitis persists or is thought to be purulent, do
bacteriologic study. Note is made of the following:
A. Conjunctival or scleral hemorrhage and edema.
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B. Size of the eyeball. Exoplthalmos is rare but may occur with buphthalmos and congenital
glaucoma. Enophthalmos usually is due to Horner’s syndrome (ptosis and constricted
pupil).
C. Cornea and lens. Note any haziness or cloudiness of these.
D. Pupil. May be constricted for about three weeks or may respond to light at birth by
contracting.
E. Retina is examined for hemorrhage, etc., and a red reflex is obtained.
5. Ears. The canals are usually filled with vernex so that the drums may not be visualized
at birth, but after a few days they are usually easily visualized. Abnormalities and/or
abnormally positioned ears are noted, as are brancialcleft cysts or sinuses.
6. Nose. Patency of the nasal canals may be tested by closing the infant’s mouth and listening
to breathing through the nostrils. Also note presence of nasal discharge.
7. Mouth. Cleft lip and cleft palate are noted. The gums should be checked carefully for
epidermal patches, inclusion cysts, or tooth buds. The palate should be checked for
completeness, Epstein’s pearls, Bednar’s aphthae, and high arching.
8. Neck. The neck is checked for mobility and masses. It should be flexed to examine the
posterior portion and then extended to examine the anterior portion, since many infants’
necks are physiologically short at birth in cephalic presentations.
A. Mobility. Normal flexion and extension should be obtained. Resistance is rare but may
indicate meningeal irritatioin. Poor mobility also occurs with the Klippel-Feil syndrome.
B. Masses. Small cystic masses in the upper part of the sternocleidomastoid may be
branchial cleft cysts. A mass in the lower part is usually due to a hematoma and causes
a torticollis, but this does not usually become evident for several weeks.A midline mass
may be a thyroglossal duct cyst or a congenital goiter, and a soft mass over the clavicle
which transilluminates may be a cystic hygroma. Always palpate the clavicles carefully
for evidence of fracture.
9. Thorax. The following are noted:
A. Shape. Normally the chest of the newborn is almost circular but sometimes there are
peculiarities of the shape such as flattening of the lateral aspects due to compression by
the arms in utero or to the presence of funnel chest or breast deformities. Occasionally
an enlarged heart will cause a bulging of the thorax on the left.
B. Breast hypertrophy or abnormality.
C. Evidence of respiratory distress.
10.Lungs. Note the following.
A. Rate and character of respiration.
B. Retraction-xyphoid, subcostal and intercostal.
C. Grunting and flariong of the alae nasi.
D. Percussion to be of any value must be very light, since the chest wall is thin, and make
certain that the infant lies so that the head and neck are not turned, because increased
or decreased areas of dullness may occur simply because of the position of the infant.
E. Auscultation requires patience as breathing may be so shallow that vesicular sounds can
scarcely be heard, but if one waits long enough, the infant will take a succession of deep
inspirations from which conclusions can be drawn. Remember that in the first day of life,
fine crepitant rales are very often normal.
11. Heart
A. The heart size is percussed and the apical impulse palpated, but heart size is difficult
to evaluate clinically (and even radiologically) due to its great variability in the neonatal
period.
67
B. Heart rate and rhythm are noted. The heart rate at birth varies from 100-200 but
stabilizes shortly after birth at 120-140. The rhythm is usually regular. Any arrhythmia
or tachycardia should be considered abnormal. Poor or distant heart sounds occur with
pneumothorax or pneumomediastinum and cardiac failure.
C. Heart murmurs should be described as to loudness, location, and intensity, but at this
age can be misleading. If present, they are usually heard at the third or fourth interspace
along the left sternal border, or over the base of the heart.
D. Palpate femoral and brachial pulses.
E. Check blood pressure by flush method, palpation, etc.
12.Abdomen.
A. General inspection. Abdominal examination should include an overall evaluation of
the size of the abdomen as to roundness, distention, or concavity. If the abdomen is
distended, one should consider intestinal obstruction, a ruptured viscus, enlargement of
abdominal organs, ascites, and tumors. If the abdomen is flat or scaphoid, consider a
diaphragmatic hernia or esophageal atresia without a fistula. Diastasis recti is a normal
finding. Visible peristlasis indicates intestinal obstruction but remember that it may be
seen in otherwise normal infants, especially shortly after birth.
B. Palpation of abdomen is easy in the normal newborn if it is not crying. The liver is
normally palpated as much as 2 cm. below the right costal margin. The spleen is usually
not palpable, but sometimes the tip is felt in nomal infants. The lower pole of the right
kidney and the left kidney can usually be palpated. The bladder can be palpated or
percussed 1-4 cm. above the symphysis. Any other masses palpable in the abdomen
must be identified and described.
C. Umbilical cord is inspected and the following are noted:
1. Abnormal staining of the cord as with meconium.
2. Whether it is excessively large and jelly-like, or excessively small.
3. Any oozing of blood from the stump.
4. Redness around the cord or a fetid odor, as these usually signify the presence of omphalitis.
5. Pulsations of the cord.
6. Number of vessels-single umbilical artery is associated with an increased incidence of congenital abnormalities.
D. Examination for inguinal and umbilical hernia.
13.Genitalia. Any abnormalities of the male or female genitalia should be described.
A. Male. Physiologic phimosis is the rule in newborn males, but in some, the foreskin may
be retracted sufficiently to reveal the urethral meatus. The testes, whether in the canal
or scrotum, should be palpated. The scrotum is often edematous, especially following
breech delivery and note should be made of the amount of pigmentation. Also note the
presence of a hydrocele.
B. Female. Note the presence of any discharge from the vagina and describe this, as it
may be blood-tinged or frankly bloody (withdrawal bleeding). Also note large clitoris
is found in pseudohermaphroditism. Hymenal tags are not uncommon. The labia,
especially the labia minora, are relatively large in the newborn. Normal labia may
be confused with a bifid scrotum. The genetalia, as in the male, may be edamatous,
especially following breech delivery.
14. Anus. The anus should be inspected for hemorrhoidal tags and patency. Routine rectal
examination in the neonatal period is superfluous and, because it is traumatic, is unwise. It
should, however, be done if there is any question about the free passage of meconium or if
the nurse has had difficulty in passing a thermometer.
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15. Trunk and spine. Note and obvious deformity of the trunk or spine and check the end of
the coccyx for a pilonidal sinus or dimple.
16. Extremities. Check extremities for any congenital abnormalities such as polydactyly and
syndactyly. Fractures, paralysis, and dislocations are looked for. The hips are examined
for dislocation by flexing the knees and then abducting the thighs. Intrauterine posture is
responsible for some deformities of the extremities, especially of the feet. In nearly every
newborn, the feet are markedly dorsiflexed and the dorsum of the foot can be made to lie
against the anterior aspect of the tibia without effort. This is talipes or pescalcaneus and
corrects itself. There is often pronation of one or both feet and a metatarsus varus is also
fairly common.
17. Neuromuscular status.
A. Reflexes. The nervous system of the neonate is still immature and this is
demonstrated in evaluation of reflexes. The following reflexes should be observed:
1. The Moro Reflex — record whether this is complete or incomplete and if a unilateral response is obtained.
2. The grasp reflex as elicited in the hands and feet.
3. The plantar reflex, which may give a postive (Babinski) response in the newborn.
4. Chvostek’s sign, which is frequently normally present.
5. Patellar reflex.
6. Rooting and sucking reflexes and if these are absent then do the gag and swallow reflexes.
B. Tone should be checked.
C. Tremulousness, jitteriness, etc., should be noted.
18. Other characteristics.
A. Passage of meconium is to be checked for. Normally in the majority of infants,
the passage of the first meconium stool is seldom delayed longer than 12 hours.
If delayed, then check patency of anus and also check for intestinal obstruction.
Presence of bright red blood in the meconium is usually due to the infant ingesting
mother’s blood and can be checked by the Apt test.
B. Voiding of urine. Urine is usually passed soon after birth, but may be unnoticed. If,
however, there is no voiding of urine by 24 hours of age, it is highly suggestive of
urinary tract obstruction, etc., and requires further investigation.
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PREDICTABLE PROBLEMS BASED ON GESTATIONAL AGE
PREMATURE:
SMALL FOR GESTATIONAL AGE:
RDS
Hypothermia
Hypothermia
Hypoglycemia
Hypoglycemia
Aspiration Syndrome
Infection
Birth Asphyxia
Apnea
Polycythemia
Hypocalcemia
Intrauterine Infection
Hyperbilirubinemia
Problems r/t the etiology of the
Intracranial Hemorrhage
infant’s poor growth
Difficulty feeding
POSTMATURE:
LARGE FOR GESTATIONAL AGE:
Birth Asphyxia
Hypoglycemia
Aspiration Syndrome
Birth Trauma
Hypoglycemia
Polycythemia
SGA
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HYPOGLYCEMIA
DEFINITION: Blood glucose less than 40 milligrams percent. (This is the textbook
definition and refers to a laboratory analysis.) If the Dextrostix is below 45
mg%, many practitioners consider this infant hypoglcyemic and treat as
indicated below.
INFANTS AT RISK:
Large for gestational age (LGA)
Infant of diabetic mother (IDM)
Infant of gestational diabetic mother (IGDM)
Infants with erythrobastosis
Small for gestational age (SGA)
Infants with physiologic stress, increased metabolic and caloric demands
Low Apgars
Hypothermic
Anoxic
Premature/Preterm
Respiratory Distress Syndrome (RDS)
Smaller of twins (May be SGA)
Infants of toxemic mother
Infants with CNS hemorrhage (usually are hyperglycemic first)
Infants with infections
SIGNS AND SYMPTOMS:
Tremors (jitteriness)
Cyanosis
Convulsions or localized seizures
Apnea (more common in low birthweight newborn)
Irregular respirations
Apathy, lethargy
High-pitched cry
Limpness or change in muscle tone
Refusal to feed
Eye rolling
Inability to regulate temperature
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SCREENING NEWBORNS FOR HYPOGLYCEMIA:
Review the records for risk factors.
Examine the newborn on admission and observe for other risk factors.
Continue to observe the newborn.
Do a Dextrostix on all infants (especially those considered to be at risk) within one hour
of birth. If it is below 45 mg% treat as indicated below.
TREATMENT:
Early feeding (nipple if possible, gavage if necessary) with glucose water. Recheck
Dextrostix one hour after feeding or just prior to the next feeding. If unable to feed by
nipple or gavage, start a continuous infusion of D5W or D10W. Check Dextrostix at least
every 8 hours. (IV’s per order or protocol.)
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THE PHYSIOLOGIC STATUS OF THE PREMATURE INFANT
FUNCTION AND STATUS
PROBLEMS TO BE
ANTICIPATED
REGULATORY FUNCTIONS
1. Temperature regulation:
Increased conductive and radiant heat losses
due to increased total body water but reduced
insulating fat.
Poor vasomotor control of blood flow to skin
capillaries.
Relatively large surface area to body mass ratio.
Restricted metabolic rate and heat production due
to reduced muscle and fat deposits, low enzyme
activities, and reduced muscle activity.
Poor sweat production due to sweat gland immaturity.
Hypothermia
Overheating
2. Respiratory regulation:
Near-normal chemoreceptor response to changes in
blood 02, CO2 and H+ (pH), but accentuated dependency
on baroreceptor, lung stretch receptor, and cold
stimulus input to maintain threshold activity level
of respiratory center neurons.
Periodic breathing
and apnea
LIVER AND METABOLIC FUNCTIONS
Reduced glycogen, fat, vitamin, and mineral storage
(especially calcium) at birth Hypoglycemia,
hypocalcemia
Reduced enzyme activities for intermediate protein
metabolism.
Transient phynylketonuria, tyrosinemia, etc.
Reduced synthesis of proteins such as albumin,
fibrogen and liver-dependent clotting factors.
Hypoalbuminemia
and edema; bleeding
Poor clearance of bilirubin
Hyperbilirubinemia
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FUNCTION AND STATUS PROBLEMS TO BE
ANTICIPATED
RENAL FUNCTION
Reduced GFR (glomerular filtration rate)
Water retention, edema poor drug
clearance
Dehydration
Reduced ability to concentrate urine or
conserve water.
Reduce tubular reabsorption of glucose, amino acids and bicarbonate.
Glucose uria, hypoproteinemia, and
transient proximal
renal tubular
acidosis
Reduced tubelular secretion of fixed acid,
phosphate and drugs.
Metabolic acidosis,
hyperphosphatemia
(and hypocalcemia),
drug accumulation
IMMUNE FUNCTION
Low levels of alpha and beta globulins or opsonization factors important for leucocyte
phagocytosis.
Susceptiblity to
viral and fungal
infections.
Low specific antibody IgG levels received
passively from the mother. Susceptiblity to
gram negative
bacterial infections.
Reduced WBC bacteria-killing ability due to
perioxidase and other intracellular enzyme inactivity.
Sepsis
RESPIRATORY FUNCTION
Tendency towards CO2 retention due to irregular
breathing, weaker respiratory muscle activity
less rigid thoracic cage.
Hypoventilation
(CO2 retention)
Tendency towards alveolar collapse due to reduced
surfactant production and sparse pulmonary elastic
tissue, made evident by reduced compliance and low
FRC (functional residual capacity).
Hypoxemia
(low blood PO2)
Weak gag and cough reflexes. Aspiration
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FUNCTION AND STATUS
PROBLEMS TO BE
ANTICIPATED
CARDIO-VASCULAR FUNCTION
Tendency towards persistence of fetal circulation
due to delayed closure of the ductus arteriosus and
relatively higher pulmonary artery pressure.
Venous admixture
(R to L shunting)
and hypoxemia
Patent ductus
arteriosus
Reduced capillary density so less gass exchange,
foodstuff delivery and waste-product removal.
Tissue hypoxia and
acidosis
Increased capillary fragility Petechiae, cymosas,
frank hemorrhage
DIGESTIVE FUNCTION
Weak suck and swallow, delayed stomach emptying,
reduced intestinal mobility. Low secretion of
gastric acid and digestive ensymes.
Slow weight gain.
Abdominal distention
and necrotizing
enterocolitis.
Delayed bacterial colonization of the gut and poor
fat absorption. Fat, protein & CHO
loss in stools;
vitamin K deficiency,
bleeding
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APPENDIX C
CLINICAL OBJECTIVES
GUIDELINES
and
WORKSHEETS
78
NURS 1124 Maternal Neonatal Nursing
Clinical Competencies
Human Flourishing
1. Perform and document accurate assessments expected in the maternal-neonatal
unit.
Nursing Judgment
2. Demonstrate competency in performing the following skills:
a. Assessment of the pregnant patient
b. Insertion of peripheral IV
c. Safe administration of medications
d. Correct application of the tocotransducer and ultrasound transducer
e. Basic interpretation of the electronic fetal monitoring strips
Spirit of Inquiry
3. Demonstrate clinical reasoning skills in the following situations:
a. Care of a couple experiencing infertility.
b. Care of an antenatal patient experiencing a complication.
c. Care of a patient experiencing labor.
d. Care of a newborn at delivery.
Professional Identity
4. Participate in high and low fidelity simulation and technology available in the
nursing simulation lab.
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CLINICAL GUIDELINES
I.
Preparation for clinical and clinical conferences is required. Clinical rotations will
be distributed to each student and in the appropriate units at the clinical agency
assigned. Agency-specific guidelines will be provided by the clinical instructor.
A.
Students are expected to be prepared for clinical. Faculty at each clinical
site will make appropriate assignments. Each student will be observed and
evaluated accordingly on preparation and the ability to perform in the
following areas:
1. Verbally relate process of assessment used to identify patient’s
stressors and needs.
2. Verbally relate establishment of priorities based on the patient’s
stressors and/or need.
3. Verbally relate planned nursing objectives and nursing interventions.
4. Verbally relate scientific rationale in the implementation of nursing
interventions.
5. Ability to actually implement nursing interventions.
6. Utilization of scientific principles while caring for patients.
7. Evaluation of plan of care and altering it appropriately as needed.
8. Verbally relate knowledge of treatments and nursing procedures.
9. Verbally relate information on drugs and administer drugs safely.
10. Demonstrate personal and professional growth.
B.
Standards for written work:
1. No written work will be accepted late.
2. Assignments need not be typed, but should be written legibly.
3. The quality of written work is enhanced by its neatness. Students
should not use paper torn out of a notebook.
4. Never identify a patient by name or other identifying data.
Confidentiality is imperative. Use the patient’s initials or first name,
but not surname.
5. Use references where appropriate. Plagiarism in any form violates
faculty’s belief in the importance of honesty in nursing.
6. Proper grammar and spelling are expected.
II.
Evaluation will be based on the student’s ability to successfully achieve clinical
requirements and clinical objectives. Students are encouraged to schedule
conferences with their instructor as often as necessary to review care plans,
discuss strengths and weaknesses of clinical performance and seek guidance to
enhance learning.
III.
Clinical absences are strongly discouraged because of the limited amount of time
in each rotation and the impossibility of duplicating clinical experiences missed.
Refer to the clinical absence policy in the Registered Nurse Program Handbook.
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NURSING 1124 – MATERNAL/NEONATAL NURSING
CLINICAL OBJECTIVES
At the completion of this semester, the nursing student should be able to:
Labor and Delivery
1.
Accurately monitor uterine contractions manually and electronically.
2.
Monitor fetal heart rate with the use of the fetoscope and Doppler.
3.
Describe measures to maintain bladder and bowel elimination in the client in
labor.
4.
Document all pertinent observations and/or activities concerning the patient in
labor.
5.
Provide supportive care for the patient in labor.
6.
Describe the effects of analgesic agents on maternal and fetal behavior.
7.
Provide nursing measures for the management of pain during labor and delivery.
8.
Provide and/or maintain environment conducive to relaxation of the patient
throughout the labor process.
9.
Properly identify the mother and infant before transfer to recovery room and
newborn nursery.
10.
Safely administer intramuscular and/or IV medications during labor.
11.
Observe and report significant changes in the condition of the labor patient.
12.
Monitor the uterine contractions of the patient receiving oxtoxic drugs, accurately
record your observations, report any deviations from normal and initiate
appropriate nursing action.
13.
Evaluate the condition of the newborn with the use of APGAR scoring system.
14.
Apply nursing interventions to maintain body temperature and respirations in the
newborn infant.
15.
Assess and record pertinent observations during the fourth stage of labor. (i.e.
fundus, pain, vital signs, IV, etc.)
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Post-Partum
1.
Utilize the nursing process in the management of the post-partal patient.
2.
Provide perineal care for the post-partal patient, including teaching the patient to
do self-care.
3.
Assess uterine contractability and initiate appropriate action.
4.
Assess lochia discharge and explain the significance of your findings.
5.
Assess learning needs of the client related to care of self and infant and initiate
teaching to meet these needs.
6.
Assess behaviors of the mother and father that are indicative of bonding with the
infant.
Newborn
1.
Monitor temperature, heart rate and respiratory rate of the newborn and compare
your reading to the normal rates of the newborn.
2.
Perform an initial examination on the newborn and accurately chart your
observations.
3.
Perform a gestational age and maturity rating assessment on a newborn.
4.
Instill ophthalmic ointment or drops in the newborn eyes.
5.
Apply the principles of asepsis to the care of the newborn in the hospital nursery.
6.
Provide immediate and daily umbilical cord care on the newborn infant.
7.
Provide post-circumcision nursing care and instruct mother in caring for the infant
after discharge.
8.
Safely administer an IM injection to the newborn.
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ASSESSMENT OF CLIENT IN LABOR
Student _____________________________
Date_________________________
Client Initials______
A.
Age_____
G_____
T____
P_____
A______
L____
EDD____
Summarize client data from time of admission to the time your observation begins.
Include admission data related to labor status, therapies instituted, any abnormal
findings or developments and labor progress.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
B.
Record observations of stage(s) and phase(s) of labor that occur during your clinical
experience.
Textbook Data - expected physical findings, client behavior and duration of specific
stage(s)/phase(s).
Client Behavior - physical findings and client’s response and coping related to the
stage/phase of labor. Include time when a change in stage/phase
occurs. Include pertinent data related to fetal well-being. Also include
behavior of father-of-baby if present.
Interventions -
interventions by yourself, the nurse or the physician.
Evaluation -
response of patient to interventions – i.e. effectiveness of comfort
measures, response to analgesia, correction of FHR pattern, etc.
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TEXTBOOK DATA
Stage/Phase:
CLIENT BEHAVIOR
INTERVENTIONS
EVALUATION
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Student____________________________
Date________________________
ASSESSMENT OF POSTPARTAL CLIENT
I.
Patient History:
Age______
Primary Language _____________________________________
Cultural Considerations ______________________________________________
Spiritual Considerations______________________________________________
G______
P______
EDD______
A______
L_____
Date/Time of Delivery______________
Total labor time_______
c/s______
Method_____________
Labor Complications__________________________
________________________________________________________________
Concurrent Medical Conditions________________________________________
Infant:
Wt______
Sex______
Apgar______ Br/Bo fdg________________
general condition__________________________________________________
II.
Physical Exam
Fundus:
position____________________
height____________________
firm/boggy___________________
tenderness___________________
interventions________________________________________________
Lochia:
type_______________________
amount_____________________
odor_______________________
clots_______________________
Perineum:
episiotomy________________
lacerations__________________
swelling____________________
bruising_____________________
hematoma_________________
discomfort____________________
interventions________________________________________________
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Breasts:
engorgement________________
lumps__________
nipples____________________
redness__________
discomfort__________
interventions________________________________________________
Elimination:
Voiding pattern________________________________________
c/o pain/burning________________
bowel sounds______________
date last BM___________________
interventions_________________________________________________
C-Section:
incision location_______________
drainage_____________________
appearance______________
discomfort_________________
interventions_______________________________________________
Circulation/Oxygenation:
BP______
P______
breath sounds___________________
R______
T______
Pulses__________________
c/o leg pain_________________________________________________
interventions________________________________________________
Nutrition:
pre-pg wt______
appetite___________________
wt gain______
present wt______
special diet___________________
past or current eating disorder________________________________
interventions_______________________________________________
Lab Tests (explain significance of results)_______________________________
________________________________________________________________
ABO/Rh________
III.
Rubella________
HBsAg________
GBS________
Psychosocial
Marital Status_____________________
Support System_________________
Serious financial problems___________________________________________
Labor/Delivery Experiences as perceived by pt. __________________________
________________________________________________________________
Pt. Interaction with family and staff_____________________________________
________________________________________________________________
Bonding behaviors between parent(s) and infant__________________________
________________________________________________________________
________________________________________________________________
History of Mental Disorder/Depression__________________________________
IV.
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Learning Needs r/t self-care, newborn care, contraception:
Student___________________________
Date_______________________
NEWBORN ASSESSMENT
I.
Infant History:
DOB________________
Sex_____
EDD________________
Apgar Scores______
Gestational Age_____
Birthweight___________
Current Weight______
Voiding:_____
Stool_____
Method of Feeding___________________
Last feeding__________________
Assessment of Feeding__________________________
LATCH Score:_____
Delivery Complications______________________________________________
________________________________________________________________
II.
Maternal History:
Age_______
Length of labor_________________
G____
T____
P____ A____
L____
Delivery Method____________________
Pregnancy Complications: __________________________________________
________________________________________________________________
Newborn Treatments & Procedures:
Newborn Medications/Vaccines:
Family Teaching Needs:
Priority Family Needs:
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III.
Physical Assessment:
ASSESSMENT
COMPONENT
VITAL SIGNS
Temperature
Pulse-Rate
Rhythm
Heart Sounds
Respiration Rate
Rhythm
Breath Sounds
MEASUREMENTS
Head
Chest
Length
Weight
INTEGUMENT
Color
Texture
Turgor
Integrity
Mucus Membrane
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NORMAL FINDINGS
COMMON VARIATIONS
ASSESSMENT
FINDINGS
ASSESSMENT
COMPONENT
NORMAL FINDINGS
COMMON VARIATIONS
ASSESSMENT
FINDINGS
HEAD
Shape
Hair Texture
Fontanelles
Face
Eyes
Ears
Nose
Mouth
NECK/SHOULDER
Shape
Movement
Trachea
CHEST
Shape
Breasts
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ASSESSMENT
COMPONENT
ABDOMEN
Shape
Tone
Umbilical Cord
Bowel Sounds
Femoral Pulses
GENITALIA
Male
Female
BACK, HIPS, BUTTOCKS
Knee Height
Hip Stability
Spine
Gluteal Folds
Anus
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NORMAL FINDINGS
COMMON VARIATIONS
ASSESSMENT
FINDINGS
ASSESSMENT
COMPONENT
EXTREMITIES
NORMAL FINDINGS
COMMON VARIATIONS
ASSESSMENT
FINDINGS
Arms (pulses)
Hands & Fingers
Legs (pulses)
Feet & Toes
REFLEX
Babinski
STIMULUS/RESPONSE
ASSESSMENT FINDINGS
Moro
Stepping
Tonic Neck
Palmar Grasp
Rooting
Sucking
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Chart Review Exercise
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PUBLIC HEALTH CLINIC WRITTEN ASSIGNMENT
1.
List the services available to the childbearing family through the state
health department. What are eligibility requirements for these
services?
2.
Describe the prenatal care provided by the nurse practitioner and
staff nurses.
3.
Explain the nutrition program offered through the clinic to pregnant
women and children. Include the criteria for eligibility.
4.
Describe care of the infant during his/her initial clinic visit. List the
immunization schedule at the clinic.
5.
Identify the legal responsibilities and liabilities of the RN in the
provision of maternal-child care at the clinic.
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APN Clinical Written Assignment
Maternal-Neonatal Nursing
1.
Describe the Advance Practice Nurse role in an Obstetrics and Gynecological
clinic.
2.
Identify what is routinely assessed on a patient at each visit.
3.
Compare the use of the nursing process in the care of a high risk client to that of
a normal pregnancy.
4.
Discuss preventative and community resources available to the obstetric client.
5.
Summarize the importance of cultural competence in providing care to the
obstetric client and family members.
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NURS 1124, Maternal- Neonatal Nursing
Post-Conference Suggestions:
Chapter 9
1.
Discuss the interpretation of fetal heart rate monitor strips and nursing interventions and
responsibilities. Emphasis of time should be on elements of reassuring pattern versus
elements of non-reassuring and ominous patterns. Example strips should include:
a.
Reassuring FHR
b.
Minimal, moderate, and marked variability
c.
Early deceleration
d.
Variable deceleration
e.
Late deceleration
2.
Hold a discussion of the advantages and disadvantages of external and internal EFM and
intermittent versus continuous EFM
3.
Discuss patient/family response to EFM.
Chapter 6
1.
Discuss antepartal testing:
a. Untrasonography
b. Umbilical Artery Doppler Flow studies
c. Amniocentesis
d. Chorionic Villus Sampling
e. Alpha-Fetoprotein/Maternal Serum Alpha-Fetoprotein
f. Daily fetal movement counts (kick counts)
g. Non-Stress Test
h. Contraction Stress test
2.
How is this test used at the assigned clinical agency?
3.
Discuss teaching for families undergoing antepartal testing.
Chapter 7
Case Studies:
Patient #1: A 33-year-old married woman who is a gravida 3, para 1, EAB 1, at 32 weeks
gestation is admitted to the antepartal high-risk unit with a diagnosis of
preeclampsia at 35 weeks gestation. Her BP is 150/94. She has 2+ protein in her
urine, 2+ DTR, and no clonus. Fetal heart rate is reassuring.
Patient #2:
A 37-year-old married woman who is a gravida 3, para 0 with a history of two
spontaneous abortions during the second trimester was admitted 2 weeks ago at
26 weeks gestation with a diagnosis of preterm labor. Vaginal exam upon
admission indicated that her cervix is 2 cm dilated and 75% effaced and
membranes are intact. Vital signs are within normal limits. She is experiencing
three to four contraction per hour and is on oral terbutaline as a tocolytic agent.
Fetal heart rate is reassuring.
Assign students to:
a.
Describe how the physiological and psychosocial concerns and needs are similar and how
they are different, and provide rationale for why they are similar and different for these two
patients.
b.
Develop four interventions for each case study that reflect their analysis.
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Chapter 11:
Scenario 1:
Intrapartum and Postpartum Care of Cesarean Birth
The patient is a 30-year-old gravida 2, para 1 who is admitted to the birthing unit
for a scheduled repeat cesarean birth. The father of the baby will be
accompanying her in the OR. Her older child is a 3-year-old boy. Her previous
cesarean birth was also planned due to a breech presentation. Her vital signs are
within normal limits, and FHR is reassuring.
Scenario 2:
The patient is a gravida 1, para 0 who has been in labor for 22 hours. She has
progressed slowly in labor to complete dilation of cervix with oxytocin
augmentation. She pushed for 2 hours during the second stage of labor. Her
obstetrician has just informed her that she will need a cesarean section for failure
to descend. Her membranes have been ruptured for 28 hours, and she has a
temperature of 39°C.
Discussion questions:
1. Explain how and why the preoperative nursing care is different for each of the two
patients.
2. Identify each patient’s intraoperative risk factors for complications.
3. Discuss the postoperative management of both patients. How is the nursing care similar,
and how is it different?
Chapter 12 Postpartum
The nurse on the day shift is assigned to the following three patients.
Patient #1: A 35-year-old gravida 4, para 4 woman who is 3 hours postpartum. She
experienced a precipitous labor and birth. Her newborn son weighs 4120 grams,
and this is her fourth boy. She has a first-degree peri-urethral tear, which was
repaired. Her husband was at work and did not have time to get to hospital to be
part of the birthing experience. In report you were told that she has moderate to
heavy lochia with occasional clots and has not voided since delivery.
Patient #2: A 17-year-old gravida 1, para 0 woman who delivered the day before and is 28
hours postpartum. She had an epidural for labor pain management and
experienced a 3-hour second stage of labor, and her daughter was delivered by
vacuum extraction. She has a fourth-degree laceration, which was repaired. She is
bottle feeding her daughter, who weighed 3280 grams at birth. In report you are
told her pain scale was 8 out of 10, for which she received pain medication an hour
ago.
Patient #3: A 28-year-old gravida 1, para 0 who is preparing to go home this morning. She is
48 hours post–spontaneous delivery and is breastfeeding her son. In report you
are told that she has had difficulty breastfeeding. The report stated that her nipples
are sore and her breasts are engorged. Her previous nurse also reported that she
is “weepy” and seems nervous about caring for her son.
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Discussion Questions:
 Which patient will the nurse assess first? Provide rationale for your decision.
 What are the priority physical and psychosocial needs of each patient/couple?
 What are the primary nursing actions (excluding patient teaching) for each of the
patients/couples? Provide rationale for the selection of these interventions.
 What are the learning needs of each patient/couple? Provide rationale for selection of
teaching topics.
Chapter 15, 16, 17
The purpose of this activity is to prepare students to care for newborns by reviewing the
assessment data and rationale for assessment in the care of normal neonates.
Instructions: Use the Newborn Assessment worksheets in the syllabus (p. 75-77) to complete all
biological and psychosocial assessment data for the normal term neonate. Prior to clinical,
complete the first column. After the clinical day, complete the worksheet by entering the
assessment data on the assigned patient. Be prepared to discuss findings with the instructors
and peers in clinical or in post-conference.
Other ideas:
Complete a postpartum chart review and discuss documentation of care in post-conference.
Plan discharge teaching for a patient who had a vaginal delivery of a healthy newborn. Then
discuss how teaching is altered for the patient experiencing a cesarean delivery or whose
newborn experienced distress/or is at risk following discharge.
Reference:
Chapman, L. & Durham,R. (2010) Maternal-Newborn Nursing: The Critical Components of Nursing Care.
Philadelphia, PA: F.A. Davis.
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