Study Guide Exam 3
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Nursing assessment postpartum: uterus, bladder retention, atony
Phases of taking in, taking hold, letting go after birth
Engorged breasts and nursing interventions to facilitate infant nursing
Lab values: CBC, BUN, creatinine, arterial blood gas
Postpartum blues and depression S&S
Substance abuse: complications of pregnancy and care of infant after birth
Infant care re bathing and cord care
Physical exam of neonate: normal findings, normal feedings, color, respiration, heart
murmurs
Colostrum and breastfeeding
Postpartum vital sign changes and what assessments to make, what do changes mean,
why, nursing interventions
Lochia normal appearance and normal findings
+ signs of infant bonding
Indications of fetal distress during labor
Cephalohematoma and caput succedaneum
Hypovolemic shock and vital signs
Postpartum cardiac changes and decompensation, p. 397
Hypothermia in neonate and vital signs
Radiant heat loss in infant
Discharge teaching for postpartum client
Phases in neonate: reactivity and sleep
Acrocyanosis
Neonate of diabetic mother, blood glucose and hypoglycemia
Nursing assessment postpartum: uterus, bladder retention, atony
Post partum hemorrhage and uterine atony
 life-threatening event that can occur with little or no warning, often profound
symptoms before it is recognized
 blood loss >500mL after vaginal and >1000mL after C-section, low
 uncontrolled by uterine massage or oxytocin
 blood flow of 650mL/minute to uterine vasculature can lead to exsanguination in
minutes
 early post partum hemorrhage within 24h of birth, late = >24 hrs but <6 weeks
 leading cause of early hemorrhage is uterine atony
 bleeding between separation and expulsion of placenta from incomplete
separation, manipulation of fundus, excessive traction on the cord
 after placental expulsion  uterine atony  failure of the uterus to contract
 due to over stretching from multifetal gestations, polyhydramnios, macrosomic
fetus, instrument delivery and oxytocin induced, prolonged or precipitate labor
S&S - first 24h:
 uterus feels soft or boggy, fundus difficult to locate or becomes firm with massage
but loses tone when massage is stopped, fundus above expected level, increased
lochia
 nursing intervention is initial treatment: massage fundus in a circular motion
during post partum hours until contracted and after massage expel clots by firm,
gentle pressure toward vagina. Be sure bladder is empty.
 If unsuccessful, oxytocin IV - rapid infusion of 20-40 units/1000mL NS or RL
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Study Guide Exam 3
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If no response: 0.2mg methergine (contraindicated for BP/PIH) IM or IV (for
emergency only) q2-4h or prostaglandin 0.25mg IM or intramyometrially q15
minutes x 5 doses.
Replace intravascular fluid volume - packed RBCs, whole blood, platelets and
fibrinogen, RL, albumin to maintain urine output @ 30mL/hr
For uncontrolled hemorrhage  hysterectomy.
If fundus is firm, but bleeding is excessive, lacerations of cervix or birth canal
may be present. Hematoma into soft tissue in vulva, vagina or retroperitoneal
areas. Concealed blood  BP and tachycardia, fundus is firm and lochia is
normal. Small hematomas are absorbed, large hematomas may need incision and
evacuation
Nursing Interventions (in the order they should be performed):
1. massage fundus;
2. if atony persists, check for bladder distension and catheterize if necessary;
3. Methergine administration.
Phases of taking in, taking hold, letting go after birth
Puerperal Phases - replenishes energy lost during labor and attains comfort in role of
mother:
1. "taking in" - mother focused primarily on her own need for nurturing and
care, needs "mothering" 1st 24 hrs after birth, food, fluid, sleep, needs to
talk about birth experience over and over. Passive and willingly dependent
on others.
2. "taking hold" – 2nd or 3rd day, independence asserts itself, "take charge"
phase, eager to learn about baby care and practice it, classes on child care
etc. Most mothers discharged during this phase. Primiparas report fatigue,
feeling uncertain and overwhelmed.
3. "letting go" - parents relinquish their previous role and loss of carefree
lifestyle. Relinquish fantasy infant, let go of ideal and accepts reality.
Engorged breasts and nursing interventions to facilitate infant nursing
Engorgement – 3rd to 5th post partum day, common response to change in hormones and
increased volume of milk. Breasts are tender, swollen, hot, hard and red. Mother may
have headache and fever. Breastfeed q2h and empty breasts with pump. Ice 15 minutes,
then 45 minutes off. Warm shower just before feeding can help soften areola and nipple
so baby can latch on. Prevent with early and frequent feedings.
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Study Guide Exam 3
Lab values: CBC, BUN, creatinine, arterial blood gas
WBC: 5,000 - 10,000/mm3
RBC: 4.2 - 5.4 x 106/µL
Plt: 150,000-400,000/mm3
Hematocrit - % of red blood cells in a
blood sample.
NORMAL VALUES
Male: 45 - 62%
Female: 37 - 48%
Fetal: 48-69%
Hemoglobin - oxygen-carrying part of red
blood cells.
NORMAL VALUES
Male: 13 - 18 gm/dL
Female: 12 - 16 gm/dL
Fetal: 14.5-22.5 gm/dL
BUN: 10-20 mg/dL
Creatinine: 0.5 – 1.2 mg/dL in blood, 110-180 in urine during pregnancy
Liver Enzymes
ALP: 30-120 units/L
AST: 0-35 units/L
LDH: 100-190 units/L
ABG
ph
PaCO2
HCO3
PaO2
SaO2
7.35-7.45
35-45 mmHg
22-26 mEq/L
75-100 mmHg
95-100%
Postpartum blues and depression S&S
Post partum Blues - mild depression affecting 75-80% of women 1-10 days after birth.
Includes sadness, fatigue, insomnia, anger, headache, restlessness, emotional lability.
Probably physiologic, social and cultural factors, compounded by fatigue and 24/7
demands of baby care. Approximately 12% suffer severe depression and a small number
suffer postpartum psychosis. Fathers, siblings and support system are important.
Father's developing bond is called engrossment. Characterized by intense interest in how
baby looks and responds, wants to hold baby. Attachment behaviors similar to mothers.
 fathers look forward to parenting, but feel they lack confidence in infant care
 research shows fathers experience intense emotion during transition to parenthood
 perception of decreased attention from mother and jealousy of baby
 fathers who feel support and affection from partners or mates are more involved
with their infant.
Affective Disorders - mood disorders including post partum blues, a transient, selflimiting disorder related to hormone fluctuations, present in 70-80% of new mothers.
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Study Guide Exam 3
Post partum depression - an intense and persistent sadness with severe and labile mood
swings – 10-15 % with intense fear, anger, anxiety, and despondency. Guilt and worry
about being an adequate parent. Permanently depressed state for longer than 2 weeks,
must have at least 5 of these symptoms every day:
  mood with spontaneous crying
  interest in formerly pleasurable activities
 insomnia or hypersomnia
 gain or loss of weight
 psychomotor depression or agitation
 fatigue or loss of energy
 feelings of worthlessness or inappropriate guilt
  ability to concentrate and/or suicidal ideation without a plan
Also characterized by irritability that explodes into violent outbursts or uncontrolled
sobbing with little provocation, severe anxiety, panic attacks, disinterest or annoyance
with infant and care demands, obsessive thoughts about harming child. Gradual
improvement over 6 months with antidepressants.
Post partum psychosis - generally occurs within 3 weeks of delivery, characterized by
depression and thoughts of mother harming herself or the infant. Begins with fatigue,
insomnia, restlessness, tearfulness, suspicions, confusion, irrationality, hallucinations,
obsessions, auditory hallucinations may command her to kill the baby, thinks baby is
possessed, has special powers or is destined for a terrible fate. Grossly disorganized
behavior interferes with ability to care for child. Will insist something is wrong with the
baby or accuse others of trying to harm or poison child.
***psychiatric emergency - high risk for suicide or infanticide, hospitalization, lithium
and anti depressants, psychotherapy. Women with history of mood disorders, absent or
little social support, poor marital relationship, stressful life events and low self-esteem are
at higher risk for this.
Substance abuse: complications of pregnancy and care of infant after birth
A drug that causes intoxication in the woman causes it for prolonged periods in the fetus.
The fetus is unable to metabolize drugs efficiently and will experience the effects longer.
Maternal effects
 Caffeine: vasoconstriction; CNS and cardiac stimulation
 Tobacco: placental perfusion; PROM; preterm labor; spont. abortion; anemia
 Alcohol: spontaneous abortion
 Marijuana: incidence of anemia and inadequate weight gain
 Cocaine: vasoconstriction; hypertension; spontaneous abortion; abruptio
placentae; preterm labor; stroke; heart attack; seizures; STDs
 Sedatives: CNS depression; spontaneous abortion; IUGR
 Amphetamines: malnutrition; tachycardia; vasoconstriction
 Narcotics (heroin, morphine): spontaneous abortion; PROM; preterm labor;
incidence of STDs; HIV exposure; malnutrition
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Study Guide Exam 3
Fetal or neonatal effects
 Caffeine: fetal stimulation
 Tobacco: prematurity; LBW; fetal demise; developmental delays; incidence
SIDS; neurological problems
 Alcohol: fetal demise; IUGR, FAS (facial/cranial anomalies, developmental
delay, mental retardation, short attention span) congenital defects
 Marijuana: irritability; tremors; sleep problems; sensitivity to light;
 Cocaine: stillbirth; prematurity; IUGR; irritability;  ability to interact with
environmental stimuli; poor feeding; nausea; vomiting; diarrhea; intellectual
development; prune belly syndrome – lack of abdominal muscles;
 Sedatives: withdrawal, seizures, delayed lung maturity.
 Amphetamines: withdrawal symptoms; IUGR; fetal death
 Narcotics: IUGR; perinatal asphyxia; intellectual impairment; withdrawal
symptoms; neonatal infections; neonatal death (SIDS, child abuse, neglect)
Care of Infant after birth
 swaddle infant tightly, arms flexed;
 vertical rocking, facing away from you;
 limited “en face” interaction;
 keep external stimuli to a minimum; and
 assess for poor feeding and frequent diarrhea.
***INTRAPARTUM PERIOD & SUBSTANCE ABUSE
Cocaine
S&S associated with frequent or recent use include:
 Diaphoresis;
 BP
 irregular respirations
 dilated pupils (hyperstimulated, SNS-activated state; Narcan to reverse)
 Temperature
 sudden onset of severely painful contractions
 fetal tachycardia
 excessive fetal activity
 angry, caustic, abusive reactions and paranoia
Heroin
S&S associated with frequent or recent use include:
 Withdrawal symptoms such as yawning, sweating, restlessness, excessive nasal
discharge, excessive tearing of the eyes.
Infant care re bathing and cord care
Bathing
The infant receives a bath to remove blood, amniotic fluid, and vernix soon after birth to
decrease exposure to possible blood borne organisms. Parents are taught to give sponge
baths until the cord is off and the circumcision is healed.
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Study Guide Exam 3
Cord care
 Cord should be checked for bleeding or oozing during early hours after birth;
 Purulent drainage or redness or edema at base indicates infection;
 Cord becomes brownish black within 2-3 days and falls off by 10-14 days;
 May be treated in hospital with bactericidal, alcohol, or mild soap;
 Parents taught to fold diaper below cord to keep it dry and away from urine.
Physical exam of neonate: normal findings, normal feedings, color,
respiration, heart murmurs
Initial Assessment after birth:
1. Apgar Score @ 1 and 5 minutes = Heart Rate, Respiratory Effort, Muscle
Tone, Reflex Response (to suction or gentle slap to soles), Color (Gorrie, p. 324)
2. Quick exam for obvious anomalies and a brief review of systems.
3. ID - matching # bracelet on mother and infant, footprints with mother's thumb
print, name, date of birth, sex and # (if more than one baby). Must be done in
delivery room before mother and baby are separated.
4. Eye prophylaxis - may be delayed up to 2 hours. Erythromycin ointment to
prevent ophthalmia neonatorurn from gonorrhea or Chlamydia infection
contracted from vaginal tract.
5. Vitamin K IM - necessary for blood clotting, infant cannot produce in GI tract
until after feeding, takes approximately 8 days.
6. Umbilical cord - cared for as a surgical wound. Follow protocol, e.g., triple dye,
alcohol, erythromycin to prevent infection. Clamp removed after 24 hours when
cord is dry
7. Vital signs, weighing and measuring length when infant is quiet
8. Bathe when approximately one hour old, removes blood and fluids which are also
a risk to staff. Provide for infant-parent bonding. If mother's condition allows –
early breast feeding will increase oxytocin and prolactin levels during first 30-60
minutes after birth – first period of reactivity.
Physical Assessment
1. Molding - changes to shape of head caused by over riding of sutures. Palpate
sutures, should have no space in between. Increased molding in a long 2nd stage,
resolves in few weeks.
2. Fontanelles – flat or level with surface, feel soft, increased bulging when crying;
anterior may be misshapen from molding.
3. Caput succedaneum - an edematous area over vertex from pressure against cervix,
causing local edema or from vacuum extraction. Crosses suture lines, resolves in,
12 hours to several days.
4. Cephalohematoma- bleeding between periosteum (bone sheath) and skull from
pressure during birth. Over parietal bones, unilateral or bilateral, does not cross
suture lines.
5. Cord - 2 arteries and 1 vein, single vein is larger and resembles a slit. Sponge bath
until cord falls off.
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Study Guide Exam 3
Infant Feeding
 Infant should be weighed each day in hospital and at every health care visit
 Newborns lose 5-10% of birth weight in first few days from meconium and
extracellular fluid loss, and generally do not take in enough calories to maintain
weight in first few days. They regain the weight by 10th day.
 Majority of newborns do not experience hunger or thirst after birth, but will
suckle if given the opportunity
 Baby is physiologically ready when vital signs are stable, nares are patent with
unlabored respirations, + breath sounds, no abdominal distension.
 Baby will exhibit signs of readiness: rooting, mouthing, hand to mouth or hand to
hand movements, sucking movements
 Usually small amount of milk in 1st 3 days, 15-30mL/feeding in 1st 24h, 60-90mL
after 24h.
 Fluid: 150mL/Kg  100mL urine/24h.; does not need additional water.
o Calories 110-120/Kg
o Breastfed: 45-75mL/feeding q2-3h.
o Bottlefed: 75-105mL/feeding q3-4h.
Newborn Assessment THESE ARE THE NORMAL FINDINGS. For abnormal findings
and possible causes, see table 20-1 on p. 471.
Initial Assessment: Assess for obvious problems. Continue with complete assessment if
infant is stable and has no problems requiring immediate attention.
Vital signs
Temp
36.5-37.5°C axillary
Pulse
120-160bpm (100 sleeping, 180 crying)
Respirations
30-60/minute
BP
65-95 mm Hg / 30-60 mm Hg
Measurements
Weight
2500–4000 g
Length
48–53 cm
Head circumference
33–35.5 cm. Approximately ¼ of infant’s
length.
Chest circumference
30.5–33 cm. 2-3 cm less than head
circumference.
Posture
Flexed extremities resist extension, return quickly to flexed state.
Cry
Lusty, strong.
Skin
Pink or tan with acrocyanois.
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Head
Sutures palpable with small separation between each.
Ears
Ears well formed and complete. Startle response to loud noises. Alerts to high-pitched
voices.
Face
Symmetric in appearance and movement. Parts proportional and appropriately placed.
Eyes
Symmetric and clear. Pupils equal, react to light. Alerts to interesting sights.
Nose
Both nostrils open to airflow.
Mouth
Mouth, gums, tongue pink. Normal in size and movement. Sucking, rooting,
swallowing, gag reflexes present.
Feeding
Good suck-swallow coordination.
Abdomen
Rounded, soft. Bowel sounds present soon after birth. Meconium passed within 12-48h.
Urine passed within 12-24h.
Colostrum and breastfeeding
Breast milk - species specific for human infants.
1. colostrum - thick, yellow substance, major secretion of breasts during first week.
Rich in immunoglobulins, especially IgA which protects GI tract from infection.
Helps establish normal flora and has laxative effect to pass meconium.
2. transitional milk - by 7-10 days, ↑ in lactose, fat and calories and ↓ in
immunoglobulins.
3. mature milk - 20 cal/oz, "bluish" color & thinner than colostrum.
Breastfeeding is “supply and demand” system, as milk is removed from breast, more is
produced. Drop in estrogen and progesterone after birth triggers prolactin from anterior
pituitary which helps synthesize and secrete milk, increases in response to infant suckling
and emptying of breasts. Prolactin makes milk. Oxytocin allows milk to come down.
Oxytocin from posterior pituitary triggers milk “let-down" reflex which moves milk
forward through ducts to nipple. This reflex can be stimulated by thoughts, sights, sounds
and odors associated with the baby, or by hearing a baby crying, sexual activity-orgasm
releases oxytocin.
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Study Guide Exam 3
Postpartum vital sign changes and what assessments to make, what do
changes mean, why, nursing interventions
BP
 Near baseline levels established during pregnancy.
 Systolic & diastolic BP may have small transient rise initially for approximately 4
days
 Orthostatic hypotension from rapid fall in intrabdominal pressure with dilation
and engorgement of abdominal blood vessels  rapid fall 15-20mmHg with risk
for injury e.g., fainting or lightheadedness.
PULSE
Normally 60-90, but bradycardia may occur (50-60 bpm) as a result of the increased
amount of blood returning to the central circulation – will usually resolve 24 to 48 hours
after delivery. If tachycardia present, assess for hemorrhage
RESPIRATIONS
The respiratory rate should remain within the normal range of 12–20 respirations per
minute.
TEMPERATURE
< 38° C.
 Mild temperature rise 38ºC (100.4ºF) 24 hrs.
Lochia normal appearance and normal findings
Lochia
1st two hours postpartum  similar to heavy menstrual period, then begins to decrease:
 lochia rubra: 3-4 days  blood with particles of decidua and mucus
 lochia serosa: 4-10 days  pink or brown with old blood, serum, leukocytes and
tissue debris, cervical mucus
 lochia alba: 10 days-6 weeks +  leukocytes, serum, mucus, serous drainage.
Lochia is decreased with C-section, increases with breastfeeding and ambulating 
sudden gush of blood which pooled in the vagina while supine.
+ signs of infant bonding
Steps in becoming acquainted include:
1. bonding - initial attraction felt by parent when they interact with baby.
Parents use eye contact, touching and talking to infant. 1st 30-60 minutes after
birth, infant is quiet and alert, gazes at and responds to parents, face-to-face
position
2. attachment - begins in pregnancy; development of strong affectionate ties
developed through pleasurable, satisfying parent-child interaction over time.
Must be reciprocal.
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These steps include:
 Claiming process - careful scrutiny and ID of new baby in terms of other family
members, likenesses, differences and uniqueness. "He has my toes, eyes, etc. She
looks like my older sister."
 Finger tipping - mother may gently explore infant with her fingertips only, then
with palms (stroking), finally enfolding him near her, strokes his hair, presses
against his cheeks, etc.
 Eye contact is important in American culture. Infants respond to parents voice
with movement and can distinguish their parents’ voices from others
Baby and parents develop a rhythm and synchrony with each other as they learn to read
cues
Indications of fetal distress during labor
 FHR outside normal range of 110-160 bpm;
 Meconium-stained amniotic fluid;
 Cloudy, yellowish, or foul-smelling amniotic fluid (infection);
 Excessive frequency or duration of contractions (reduces placental blood flow);
 Incomplete uterine relaxation and intervals < 30 seconds between contractions;
 Maternal hypotension (may divert blood from placenta to maternal vital organs);
 Maternal hypertension (vasoconstriction  placental perfusion);
 Maternal fever (38°C/100.4°F or higher)
***Nursing Priorities for an Emergency Birth***
1. Prevent or reduce injury to the mother and infant; and
2. Maintain the infant’s airway and temperature after birth.
Cephalohematoma and caput succedaneum
1. Caput succedaneum - an edematous area over vertex from pressure against cervix,
causing local edema or from vacuum extraction. Crosses suture lines, resolves in,
12 hours to several days.
2. Cephalohematoma- bleeding between periosteum (bone sheath) and skull from
pressure during birth. Over parietal bones, unilateral or bilateral, does not cross
suture lines.
Remember the nursing process to assess the mother postpartum!
Postpartum Assessment – BUBBLE HEB
B.reasts
U.terus
B.ladder
B.owel movement
L.ochia
E.pisiotomy
H.oman’s signs
E.motional state
B.onding
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Hypovolemic shock and vital signs
Early signs
 Pallor and pale, cool skin due to vasoconstriction
 Tachycardia
 BP, P, R
Late signs
 Anxious, confused, then lethargic when loss is ≤40% of total volume;
 Urine output decreases to less than 5mL/hr when loss is ≥40% of total volume;
 Anoxia, cardiac and brain death at 30-40% loss of vascular volume.
Emergency treatment
 Fluid replacement with large bore IV, 16g needle
 O2 by mask @ 6L/minute, VS q3-5 minutes + capillary refill
 Monitor fundus, lochia
 Foley catheter  maintain urine output @ 30mL/h
Postpartum cardiac changes and decompensation, p. 397
From textbook:
Maternal blood volume is  40-50% at term, allowing the woman to tolerate a substantial
blood loss during childbirth.
Cardiac Output  slightly after childbirth, despite blood loss due to:
  Flow of blood back to heart when blood from uteroplacental unit returns to the
central circulation
  Pressure from the pregnant uterus on the vessels; and
 Excess extracellular fluid movies into vascular compartment.
  Cardiac output  bradycardia (50-60 bpm).
 Cardiac output returns to normal 6-12 weeks after pregnancy.
The body rids itself of excess plasma volume by two methods:
1. Diuresis via aldosterone   sodium retention   fluid excretion.
Urinary output of 3000mL/day is common days 2-5.
2. Diaphoresis. Prepare mother for possible excessive sweating. Comfort
measures include showers and dry clothes.
Coagulation factors  during pregnancy as protection against postpartum hemorrhage.
Elevation in clotting factors continues for several days postpartum, causing a risk of
thrombus formation.
Thromboembolic Disorders
The most common conditions of concern in the post partum period:
1. superficial venous thrombosis - involves saphenous veins and is confined to the
lower legs. Low risk of embolus.
2. deep vein thrombosis – can extend from foot to iliofemoral region.
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3. pulmonary embolism - potentially fatal, when part of a clot dislodges and is
carried to the pulmonary artery  obstructs blood flow to the lungs
 Incidence is 5 times greater in pregnancy  1-2/2000
 Risk factors include: venous stasis and hypercoagulation in pregnancy and
post partum period, C-section, obesity, age >35, smoking, history of DVT
 Superficial thrombosis is characterized by pain and tenderness in lower
extremities, warmth, redness, enlarged hard vein over site, often associated
with varicose veins
 Deep vein thrombosis is characterized by unilateral leg pain, calf tenderness
(+ Homan's sign, which may also be caused by muscle strain), swelling,
redness, warmth, and peripheral pulses. Leg feels cool and pale.
 Treatment superficial VT:
o elevate lower extremities to improve venous return;
o warm soaks, analgesia, NSAIDs;
o 5-7 days bed rest  with improvement can ambulate;
o support hose, avoid long periods of standing.
 Treatment deep VT: diagnosed by Doppler, venography, ultrasound
o Early ambulation helps to prevent DVT formation.
o Flexing and straightening leg,
o avoid pressure on popliteal artery which pools blood in lower extremity,
o Venodyne boots if mother can't ambulate or had C-section
o Bed rest with legs elevated, anticoagulant treatment with Heparin 5-7
days, check APTT or Warfarin.** If still pregnant, keep on Heparin
because Warfarin is teratogenic and causes fetal bleeding
o Antibiotics if necessary, analgesics for pain
o Slow, gradual ambulation, monitor for signs of spontaneous bleeding,
bruising, petechiae
o Mother can continue breast feeding
Blood values
WBC count  as high as 30,000/mm3 (14K-16K/mm3 average). Neutrophils, which  in
response to inflammation, pain, and stress, account for the major increase.
 Hct during first few days postpartum due to dilution as excess plasma enters vascular
space. As excess fluid is excreted, Hct gradually returns to normal limit, usually within
4-8 weeks.
From notes:
 Hypervolemia during pregnancy with 50% increase in blood volume 
hypovolemic shock does not occur with average blood loss of 500mL for vaginal
birth and 1000mL for C-section.
 Also, increased blood flow to heart with elimination of uteroplacental circulation
and movement of extracellular fluid into vascular space and decreased
vasodilation = increased cardiac output in 48 hrs with increased stroke volume
and bradycardia.
 Return to complete pre-pregnancy levels by 6 months.
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Diureses –  excretion of urine from venous pressure of lower extremities,
 aldosterone. 3000mL/day for first few days (2.25Kg).
Diaphoresis - profuse perspiration especially at night for 2-3 days.
Hypercoagulation state - early ambulation to prevent clots.
Hypothermia in neonate…
Heat production - newborns cannot shiver as adults do to create heat. They increase
metabolism and if not warm enough, use non-shivering thermogenesis, primarily by
oxidation of brown fat (unique to newborns). Brown fat is located in superficial deposits
between scapulae and back of neck, axillae, around kidneys, adrenals and along
abdominal aorta. Brown fat has a rich vascular and nerve supply. When metabolized it
creates intense heat, warming blood passing through it, which is then carried to rest of
body.  production of heat ≥100%, lasts several weeks and reserves are depleted rapidly
with cold stress. Preemies may not have accumulated brown fat if born too early.
Cold stress causes decrease in body temperature and increased metabolism and O2
consumption and increased glucose consumption that may lead to hypoxemia and
hypoglycemia and metabolic acidosis. Oxygen and glucose are used for heat production
instead of maintenance of normal brain cell and cardiac function; pulmonary and
peripheral vasoconstriction follow with arterial O2, CO2 and pH .
Radiant warmer with skin probe attached to abdomen to prevent hyperthermia.
…and vital signs
Normal
TEMP
36.5-37.5°C axillary
PULSE
120-160bpm
(100 sleeping, 180 crying)
RESPIRATIONS
30-60/minute
BP
65-95 mm Hg / 30-60 mm Hg
Abnormal (Possible Causes)
Decreased: cold environment, hypoglycemia,
infection, CNS problem.
Increased: infection, warm environment, dehydration
Tachycardia: respiratory problem, anemia, infection,
cardiac conditions.
Bradycardia: asphyxia, intracranial pressure.
Murmurs: congenital heart defects.
Arrhythmias: coarctation of the aorta.
Tachypnea after 1st hour. Slow respirations (maternal
meds). Nasal flaring, grunting (RDS). Gasping
(respiratory depression). Apnea > 20”. Moist, coarse
breath sounds (crackles, rhonchi, fluid in lungs).
Hypotension: hypovolemia, shock, sepsis.
Coarctation of aorta: difference of 15 mm Hg
between arms and legs.
Radiant heat loss in infant
Maintenance of balance between heat loss and heat production, this is secondary to
establishment of respiration and circulation for survival. Babies are 85% fluid, which is
why dehydration is more dangerous in babies.
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evaporation - vaporization of moisture from the skin, occurs during birth and from
failure to dry infant quickly after birth, wet diapers or clothing, insensible loss
from lungs. Nursing Interventions: change wet diapers/clothing promptly,
maintain hydration
conduction - flow of air away from body to cooler surfaces in direct contact scales, cold stethoscopes, cold hands. Nursing Interventions: Wrap in warm
blankets, place against mother’s skin.
convection - flow of heat from body surface to cooler surrounding air; drafts, air
conditioners, people moving creates currents. Nursing Interventions: Place
newborn under warmer until stable, then dress and move to open crib. Nursery
usually kept warm, ≥24°C.
radiation - loss of body heat to cooler objects not in direct contact but close
proximity, sides of crib, outside facing window. Nursing Interventions: Place
newborn in center of crib, away from sides. Crib on opposite wall from window.
Discharge teaching for postpartum client
o Process of involution:
- how to assess lochia; and
- how to locate and palpate fundus
 Self-care
- Handwashing;
- Breast care for lactating mothers, as well as measures to suppress
lactation in non-breastfeeding mothers;
- Care of the C-incision
- Perineal care
- Kegel exercises
 Promoting rest and sleep
- infant sleep and feeding schedules
 Nutrition counseling
 Promoting regular bowel elimination
 Exercises and good body mechanics
 Counseling about sexual activity
- Dyspareunia possible up to 6 months postpartum
- Ovulation may occur before menstruation returns
 S&S that should be reported immediately
- Fever
- Localized redness, swelling or pain in either breast not relieved by
analgesics
- Persistent abdominal tenderness
- Feelings of pelvic fullness or pelvic pressure
- Persistent perineal pain
- Frequency, urgency, or burning on urination
- Abnormal lochia
- Localized redness, swelling or pain of the legs
- Abdominal incision swelling, redness, drainage or separation.
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Study Guide Exam 3
Phases in neonate: reactivity and sleep
Periods of reactivity occur in early hours after birth.
1st period of reactivity - begins at birth. Infant wide-awake and attentive, appears
interested in surroundings, lasts 30-60 minutes. Parents hold in the "en face" position and
infant gazes at them intently. Moves arms and legs, roots & appears hungry. May latch on
well and suck from breast.  respirations (60-80) and heart rate (160-180).
Period of Sleep - infant becomes quiet and falls into deep sleep, lasts 2-4 hours. Pulse
and respiration normal but temperature decreases.
2nd period of reactivity - begins approx. 4 hours after birth, after sleep, infant awake and
alert, interacts with parents, lasts 4-6 hours. May pass meconium. Pulse and respiration
increase, may gag on mucus and regurgitate.
Most infants go through these stages in the first 24 hours, with great variations after
infant stabilizes.
Acrocyanosis
Acrocyanosis common 1-2 days from poor peripheral perfusion. Cyanosis causes bluish
discoloration in hands and feet while central body pink. Greenish brown discoloration of
nails, skin and cord = exposure to meconium before birth.
Neonate of diabetic mother, blood glucose and hypoglycemia
Tremors are commonly caused by low glucose levels (hypoglycemia). Other causes
include low calcium levels or prenatal exposure to drugs. Differentiated from seizures by
ceasing when the extremities are held firmly in a flexed position.
S&S of hypoglycemia:
 Tremors
 Lethargy
 Poor sucking reflex;
 T and respiratory difficulty as O2 is used for nonshivering thermogenesis.
Nursing Interventions:
 Heal stick
 Values <40-45 mg/dL = feeding
 Recheck 30 minutes after feeding
Infants of Diabetic Mothers
  % of congenital anomalies, e.g., CNS neural tube defects, CV heart, renal and
musculoskeletal
  % RDS
 Typically LGA, macrosomia, but may be SGA if mother had severe vascular
disease.
  Risk for hypoglycemia after birth  maternal shift of high levels of glucose to
fetus during pregnancy increases fetal insulin. When cord is cut, infant has high
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Study Guide Exam 3
insulin level and glucose falls rapidly 1-3 hrs after birth  jitteriness, apnea,
tachypnea and cyanosis. Do heel stick for blood glucose and feed infant.
Puerperal Infections
Puerperal Infections - also known as puerperal sepsis or childbed fever, bacterial
infections of the genital tract within 28 days of childbirth. Physiologic risk factors
include:
 blood, amniotic fluid and lochia, which are alkaline and change acidity of
vagina.
 The necrosing endometrial layer provides a growth medium for anaerobic
bacteria.
 Many microscopic and small lacerations of cervix, vagina and endometrium
present.
 C-section incision, sutures, contaminated during surgery.
 PROM ≥24h, vaginal exams during labor.
Characterized by fever ≥38ºC after first 24h, over 2 successive days, during first 10 days;
leading cause of maternal death in the world.
1. endometritis (most common) – infection of uterus itself  fever, chills, malaise
abdominal pain, lethargy, profuse, foul-smelling lochia, WBC & RBC, sed rate
uterine tenderness, tachycardia, + cultures. Can spread to tubes (salpingitis),
ovaries (oophoritis), peritoneal cavity (peritonitis). Treat with antibiotics, fluids,
rest, peri care, sitz bath. Offer comfort and allow mother/infant interaction.
Mother can continue breast feeding.
2. wound infections – C-section incision, episiotomy  fever, pain, redness, foul
discharge, would separation. Treat with I&D, antibiotics, debridement, comfort
measures.
3. UTIs – from Foley catheters, frequent pelvic exams, C-section, GU tract trauma
 frequency, burning, urgency, retention, hematuria, low-grade fever, flank pain
if upper UTI, usually gram negative E. Coli. Treat with antibiotics, increase fluid
intake, teach hygiene (front-to-back) measures.
4. mastitis - breast infection - mostly first time mothers who are breast feeding.
Usually caused by Staph Aureus, enters through crack or blister, skipping
feedings or incomplete emptying of breasts, abrupt weaning. Flu-like symptoms
with fever ≥ 101ºF, localized redness, tenderness, pain, purulent discharge may be
present  abscess, enlarged, tender axillary lymph nodes. Prevent with correct
position of infant, avoid stasis of milk - empty breasts, change nipple shields
when wet. Treat with moist heat, shower, antibiotics, analgesics, bed rest, fluids
3000mL/day.
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