Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Chapter 15
Caring for the Postpartal Woman
and Her Family
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Fourth Trimester
 Begins immediately after childbirth
 Puerperium—first 6 weeks after birth
 Close observation—identify hemorrhage and
complications during first critical hour
 Ongoing education and support
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Safety for Mother and Infant
 Prevent infant abductions
 Check ID bands
 Educate mother about safety measures
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Early Maternal Assessment
 Vital signs
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Temperature—below 100.4oF (38oC)
Pulse—bradycardia
Blood pressure
Respirations
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Fundus
 Immediate postpartum—halfway between
the symphysis pubis and the umbilicus
 1 hour postpartum—level of the umbilicus
or one fingerbreadth above
 Then, descends one fingerbreadth each
day
 Assess lochia
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Perineal Assessment
 Sim’s position
 REEDA
 Hemorrhoids
 Teach regarding comfort measures
 If severe, teach how to manually reposition
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Postpartum Assessment Guide
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
BUBBLE-HE
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Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Other Important Components
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Maternal pain
Homans’ sign
Mother’s emotional status
Infant bonding
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Breast Assessment
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Firmness, filling
Nodules
Fissures, cracks
Blood
Dried milk
Erect or inverted nipples
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Assessment of Uterus
 Placental expulsion usually occurs within
15 minutes after birth
 Uterine contractions control bleeding
 Technique for uterine palpation
 Involution
 Subinvolution
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Fundal Assessment
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Location immediately after birth
Descends 1 cm/day
Consistency
Location
Height
 Measured in fingerbreadths
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Afterpains
 Occur during process of involution
 More pronounced in multipara
 Nursing care
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Explain cause
Prone position with abdominal pillow
Sitz baths
Encourage ambulation
Administer mild analgesics
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Bladder
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Spontaneous void within 6 to 8 hours pp
Monitor first voiding
Anticipate maternal diuresis
Urinary output may reach 3000 mL/day
Urine volume, flow returns to pre-pregnant
levels within 2 to 3 days pp
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Assessment Findings: Bladder
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Incomplete emptying
Overdistention
Urinary retention
Nursing interventions
 Support and enhance attempts to void
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Bowel
 Hunger and thirst after childbirth
 Relaxin—depresses bowel motility
 Strategies to prevent constipation
 Early ambulation
 Abundant fluids
 High-fiber diet
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Lochia
 Characteristic indicative of status in
process of involution
 Lochia rubra
 Lochia serosa
 Lochia alba
 Document amount
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Episiotomy
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1 to 2 inch surgical incision
Assess REEDA
Ice for first 24 hours
Moist heat—Sitz bath
Dry heat—hot packs
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Pain Assessment
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Determine source
Document location, type, and duration
Administer Tylenol or Ibuprofen
Sitz bath
Educate regarding nonpharmacological
measures
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Assess for DVT
 Homans’ sign
 Dorsiflex foot and ask about pain
 Clinical assessment
 Erythema, unequal calf circumference, heat
 Clinical signs are NOT reliable
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Emotional Status
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Wide range of emotions
May be sad during first 1 to 2 weeks pp
Ongoing assessment and education
Educate regarding “baby blues”
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Maternal Physiological
Adaptations
 Continued Assessment of the Patient
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Hematological System
 Decrease in blood volume
 Blood loss
 Diuresis
 White blood count increased x 5 to 6 days
 Fibrinogen increased
 Returns to normal by third to fourth week
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Hormonal Levels
 Estrogen and progesterone decrease
 Anterior pituitary—prolactin
 Placental lactogen, cortisol, growth
hormone, and insulinase levels decrease
 Insulin needs decrease—“Honeymoon phase”
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Neurological System
 Altered sleep patterns—maternal fatigue
 Numbness in legs, dizziness
 Safety for infant and mother
 Headaches
 Assess quality and location, and carefully
monitor vital signs
 Implement environmental interventions
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Renal System, Fluid and Electrolytes
 GFR, Creatinine, and BUN return to prepregnant levels within 2 to 3 months
 Urinary glucose
 Proteinuria
 Rapid, sustained natriuresis and diuresis
 Output may reach 3000 mL/day
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Respiratory System
 Respiratory alkalosis and compensated
metabolic acidosis may persist
 Decrease in intra-abdominal pressure
 Relief from dyspnea
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Integumentary System
 Hormonal changes cause skin alterations
 Most disappear
 Striae gravidarum
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Cardiovascular System
 Delivery of the baby, expulsion of the
placenta, and loss of amniotic fluid can
create cardiovascular instability
 Cardiac output remains elevated
 Physiological diuresis
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Immune System
 Rho (D) immune globulin (RhoGAM)
 Rubella vaccination
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Nonimmune status
Signed consent form
Avoid pregnancy for 1 month
Flu-type symptoms may occur
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Reproductive System
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Involution of uterus
Healing of placental site
Vaginal changes
Labia majora and labia minora flaccid
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Menstruation and Ovulation
 Nonlactating women
 Menstruation returns in 6 to 8 weeks
 First cycle may be anovulatory
 Lactating women
 Delayed ovulation and menstruation
 Educate—ovulation can precede
menstruation, need contraception
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Gastrointestinal System
 Decreased gastric motility
 Decreased muscle tone in abdominal wall
 Constipation
 Stool softeners
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Musculoskeletal System
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Laxity of pelvic joints and ligaments
Relaxation of soft tissues
Muscle fatigue
Body aches
Rectus abdominis diastasis
 Correct posture
 Modified sit-ups
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Enhancing Cultural Sensitivity
 Conduct cultural assessments
 Expand knowledge and understanding
 Culturally influenced beliefs
 Common health care practices
 Customs and rituals
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Promoting Recovery
and Self-Care
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Activity and Rest
 Early postpartum ambulation
 Mild exercises
 Kegel
 Increase gradually
 Encourage frequent rest periods
 Obtain adequate sleep
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Nourishment
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Weight loss
Appetite
Balanced diet
Multivitamin supplement
Iron if hemoglobin low
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Elimination
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Void every 4 to 6 hours
Monitor intake and output x 24 hours
Increased risk of infection
Urinary retention
Constipation
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Perineal Care
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Risk of infection
Teach perineal hygiene
Hand washing
Tampons contraindicated
Cesarean births
 Nurse provides perineal care until ambulatory
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Ice Packs
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Reduce edema and pain
Vasoconstriction and numbing
Apply for 20 minutes every 2 to 4 hours
First 24 hours
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Afterbirth Pain
 Intermittent uterine contractions during
involution
 Breastfeeding (release of oxytocin)
 Duration: 2 to 3 days
 Mild analgesics
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Special Considerations
 Women with HIV/AIDS
 Gloves, safety glasses
 Discourage breastfeeding
 Patient teaching for infant safety
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Postpartal Surgical Patient
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Tubal ligation
Cesarean birth
Incisional wound
Recovery from anesthesia
Respiratory care
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Infant Feeding Choices
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Breastfeeding
Bottle feeding
Educate
Support
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Physiology of Lactation
 Breast structure
 Lactogenesis
 Milk ejection reflex—“let down” reflex
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Assisting the
Breastfeeding Mother
 Strategies for Success
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Breastfeeding
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Initiating the feeding
Achieving proper latch-on
Assessing for milk let-down
Assuming a position of comfort
Assessing for infant weight gain
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Ineffective Breastfeeding
 Incorrect latch-on (nipple trauma)
 Breast engorgement
 Complementary care
 Ethnocultural considerations
 Collecting and storing breast milk
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Expressing Breast Milk
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Manual—hand
Electric pump
Types of breast pumps
Storage of breast milk
Weaning
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Formula Feeding
 Safe Practices
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Family and Infant Bonding
 Transition to parenthood
 Assuming the mothering role
 Rubin’s phases
 Paternal bonding
 Factors that interrupt bonding
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Adjustment of
Other Family Members
 Siblings
 Tips for parents
 Grandparents
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Emotional Events
During the Puerperium
 First 3 months most vulnerable period
 Baby blues
 Postpartum depression
 Postpartum psychosis
 Physiological response—tiredness, fatigue
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Discharge Planning and
Teaching
 Maternal Self-Care
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Maternal Self-Assessment
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Fundus and lochia
Hygiene
Abdominal incision
Body temperature
Elimination
Nutrition
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Maternal Self-Assessment
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Fatigue
Weight loss
Exercise
Pain management
Mood
Sexual activity and contraception
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Special Needs Populations
 Adolescent mothers
 Woman placing infant for adoption
 Older mothers
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Community Resources
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Support groups
Home visits
Telephone follow-up
Outpatient clinics
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Chapter 16
Caring for the Woman
Experiencing Complications
During the Postpartal Period
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Postpartum Hemorrhage
 Definition
 Accurately estimating blood loss
 Early vs. late
 LARRY
 4 “T’s”
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Postpartum Hemorrhage
 Uterine atony
 Hallmark—soft uterus filled with clots and
blood
 Genital tract trauma
 Uterus firm
 Tissue
 Thrombin
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Postpartum Hemorrhage
 Late postpartum hemorrhage
 Retained placental fragments
 Ergonovine medication, antibiotics, and
possible D&C
 Hypovolemic shock
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Collaborative Management
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Frequent vital signs and fundal massage
Note patient’s behavior
Medical management depends on cause
Administer oxygen
Obtain laboratory tests
Accurate I/O
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Hematoma
 Definition
 Signs and symptoms
 Unremitting pain and pressure
 Collaborative management
 Careful assessment
 Implement pain relief measures
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Puerperal Infections
 Definition
 Types of puerperal infections
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Endometritis
Mastitis
Operative wound
Urinary tract
 Careful assessment
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Collaborative Management
 Antibiotics
 Encourage rest, increased fluids, proper
nutrition
 Comfort measures
 NSAIDs
 Educate patient and family
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Thrombophlebitis and Thrombosis
 Definition
 Pathophysiology—hypercoagulable state,
venous stasis and vein injury
 Signs/symptoms—pain, tenderness; may
be asymptomatic
 Diagnostic tests
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Collaborative Management
 Analgesics; elevate extremity; TED hose;
increase fluids; apply moist, warm packs
 Complete bedrest with bathroom privileges
 Anticoagulation therapy
 Measure leg circumference
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Complication:
Pulmonary Embolism
 Abrupt onset: chest pain, dyspnea,
diaphoresis, syncope, anxiety
 ABC response
 Limit visitors
 Educate woman and family regarding
prevention of thrombus reoccurrence
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Postpartum
Psychosocial Complications
 Postpartum blues
 Self-limiting
 Postpartum depression
 One of two symptoms exist most/all day
 Identify risk factors
 Screen at postpartum visits
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Postpartum Psychosis
 Onset within first 8 weeks after childbirth
 Distinguishing signs: hallucinations,
agitation, confusion, suicidal/homicidal
thoughts, delusions, sleep disturbances,
loss of touch with reality
 Requires hospitalization
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Psychosocial
Postpartal
Nursing Care
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Teach to seek help if feeling overwhelmed
Encourage rest
Support bonding
Perform holistic assessment
Advocate for home follow-up
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Postpartum Nursing for
Vulnerable Populations
 Victims of abuse
 Undocumented immigrants
 Limited Access to care/homelessness
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Chapter 17
Physiological Transition of the
Newborn
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Adaptations of the
Respiratory System
 Intrapulmonary fluid
 Reduces pulmonary resistance to blood flow
 Facilitates initiation of air breathing
 Surfactant
 Decreases surface tension within alveoli
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
The First Breath
 Internal stimuli
 Chemical factors
 External stimuli
 Sensory factors
 Thermal factors
 Mechanical factors
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Cardiopulmonary Transitions
 Increased pulmonary blood volume
 Conversion from fetal to neonatal
circulation
 Immediate assessment necessary
 Skin color
 Respiratory rate; breathing pattern
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Cardiopulmonary Adaptation
 Increased aortic pressure and decreased
venous pressure
 Increased systemic pressure and
decreased pulmonary pressure
 Closure of foramen ovale, ductus
arteriosus, and ductus venosus
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Assessing the
Cardiovascular Transition
 Pulse
 Within 30 minutes—120 to 160 bpm
 Capillary refill
 <3 seconds adequate
 >4 seconds possible underlying problem
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Thermogenic Adaptation
 Newborns are homeothermic
 Neutral thermal environment
 Cold stress
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Large body area
Limited subcutaneous fat
Limited ability to shiver
Thin skin and blood vessels close to surface
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Adaptations to Increase
Heat Production
 Increased BMR and muscle activity
 Peripheral vasoconstriction
 Nonshivering thermogenesis
 Brown adipose tissue
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Mechanisms for
Neonatal Heat Loss
 Evaporation
 Insensible water loss
 Conduction
 Convection
 Radiation
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Hematopoietic Adaptation
 Blood volume
 Blood components
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Erythrocytes and hemoglobin
Hematocrit
Leukocytes
Platelets
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Hepatic adaptation
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Glycogen and blood glucose maintenance
Iron storage
Conjugation of bilirubin
Coagulation of blood
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Hyperbilirubinemia
 Physiologic jaundice—appears 24 to 48
hours after birth; transient
 Pathologic jaundice—present at birth or
within 24 hours
 Breastfeeding jaundice—2 to 4 days
 Breast milk jaundice—7 days; peaks at 10
days
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Gastrointestinal Adaptation
 Stomach and digestive enzymes
 Intestinal peristalsis
 Meconium
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Genitourinary Adaptation
 Kidney function
 Bladder capacity 6 to 44 mL
 Fluid requirements—60 to 80 mL/kg
 Urine output 1 to 3 mL/kg/hour
 Nursing assessments
 Careful monitoring of I/O
 Assess appearance of urine
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Immunological Adaptation
 Active acquired immunity
 Passive acquired immunity
 Immunoglobulins
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Psychosocial Adaptation
 Early stages of activity
 First period of reactivity
 Period of inactivity and sleep
 Second period of reactivity
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Behavioral States
 Sleep
 Deep, quiet; REM
 Alert
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Drowsy/semidozing
Wide awake
Active awake
Crying
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Chapter 18
Caring for the Normal Newborn
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
The Immediate
Neonatal Assessment
 Establish airway
 Suction
 Provide warmth
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Dry the infant
Place on mother’s abdomen; heated blankets
Place beneath radiant heater
Cap
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
The Immediate
Neonatal Assessment
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Observe respiratory effort, color, muscle tone
Stimulate neonate to breathe deeply and cry
Assess heart rate, temperature
Note obvious abnormalities
Check and record number of umbilical cord
vessels
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Apgar Score—1, 5 minutes
 Assesses immediate adaptation
 Five categories—each scored 0 to 2
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Respiratory effort
Heart rate
Muscle tone
Reflex irritability
Skin color
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Immediate Nursing Care
 Mother–infant identification
 Infection/injury prevention
 Eye prophylaxis
 Vitamin K injection
 Hepatitis B vaccine (parental consent required)
 Assess blood glucose
 Hematocrit and hemoglobin
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
The Later Neonatal Assessment
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Body positioning
Skin color
Body size
Level of reactivity
Measurements and determination of gestational
age
 Ballard Gestational Age by Maturity Rating Tool
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Assessment of the Neonate:
A Systems Approach
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Integumentary System
 Inspect skin, scalp, nails, body hair
 Color, texture, distribution, disruptions,
eruptions, birthmarks
 Well-lit room
 Birth injuries
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Skin Assessment
 Smooth and soft
 Postterm infants—tough, leathery skin
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Pustular melanosis
Milia
Erythema toxicum
Pigmentation—Mongolian spots, café-au-lait
marks
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Birthmarks
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Brown nevi—brown skin marks
Nevus flammeus—“port wine stain”
Telangiectatic nevus—“stork bite”
Nevus vasculosus—“strawberry mark”
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Assessment of the Infant’s Head
 Symmetry
 Eye shape, size, placement, and
coordinated lid movement, red reflex,
gross vision
 Ears: shape, size, placement, hearing
 Movement, color of the lips
 Chin—appropriate size
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Head—Fontanels
 Estimate size
 Fullness without bulging—normal
 Bulging and tense with large head
circumference—increased intracranial
pressure
 Sunken—dehydration
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Head
 Caput Succedaneum
 Diffuse edema, crosses suture lines,
disappears in few days
 Cephalhematoma
 Subperiosteal hemorrhage
 Does not cross suture lines
 Persists for weeks
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Assessment
 Mouth
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Epstein’s pearls
Teeth
Ability to suck
Hard and soft palate
 Neck
 Torticollis
 Facial features
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Respiratory System Assessment
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Symmetry in chest movement
Breast tissue
Nasal patency
Respiration rate, pattern, and use of
accessory muscles
 Auscultate lungs anterior and posterior
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Respiratory Assessment
 Skin color
 Capillary refill
 Signs of distress
 Retractions
 Nasal flaring
 Expiratory grunting
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Cardiovascular System
Assessment
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Inspection and auscultation
Point of maximum impulse
Heart rate
Capillary refill
Peripheral pulses
Auscultate all areas—murmurs
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Gastrointestinal System
Assessment
 Abdominal inspection, including umbilical
cord
 Auscultate bowel sounds, upper abdomen
for gastric bubble, and heart sounds of the
abdominal aorta
 Palpation
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Conditions That Warrant
Further Assessment
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Abdominal distention
Absence of bowel sounds
Discharge from umbilical cord/site
Abdominal mass
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Genitourinary System
Assessment
 Hips abducted
 Palpate and inspect scrotum, testes, and
penis
 Male—retract foreskin
 Palpate and inspect female genitalia
 Anus and anal wink reflex
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Common Findings—Male Infants
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Scrotal swelling
Smegma
Hypospadius
Epispadius
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Common Findings—
Female Infants
 Hymenal tags
 Vernix caseosa on labia
 Pseudomenstruation
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Conditions That
Warrant Further Assessment
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Undescended testicles
Micropenis
Ambiguous genitalia
Imperforate hymen
Imperforate anus
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Musculoskeletal
System Assessment
 Observe infant’s movements in crib
 Inspect for differences in extremity length and
size
 Assess muscle tone and symmetry
 Gentle passive ROM to assess joint rotation
 Assess head lag
 Skin folds on thighs
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Common Findings
 Torticollis
 Developmental dysplasia of the hip
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Asymmetry of hip folds
Barlow maneuver
Ortolani maneuver
Crepitus
Unusual positions of foot
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Conditions That May Warrant
Further Assessment
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Fractured clavicle
Polydactyly
Syndactyly
Simian crease
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Neurological System
Assessment
 Reflexes
 Major—gag, Babinski, Moro, Galant
 Minor—palmar grasp, plantar grasp, rooting
and sucking, head righting, stepping, tonic
neck
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Conditions That Warrant
Further Assessment
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Shoulder dystocia
Erb’s palsy
Cerebral palsy
Spina bifida
Susan Ward
Shelton Hisley
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Teaching About Newborn Care
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Temperature assessment
Bathing
Nail Care and umbilical cord care
Clothing
Diapering
Attachment
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Newborn Care
 Circumcision
 Ensuring optimal nutrition
 Discharge planning for the infant and
family
 Child care
 Newborn metabolic screening tests