6 - FTT & FAS - Merged

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FTT & FAS

Maternity

FTT - Failure To Thrive The first 3 years of life

This growth failure is defined as a state of malnutrition, inadequate growth, or weight


less than 80% ideal for age within the first 3 years of life.
<80% 2.8kg

ATI Question
Causes & Risk Factors Signs & Symptoms: ... failure to thrive. Which of the
Socioeconomic following findings should the nurse
Poverty: “unemployed” Signs of malnutrition anticipate in this infant?
Primary caregiver cognitive disabilities Developmental delays The infant will avoid making
Abuse: child or spousal
Lack of nutritional knowledge
Abnormal feeding behaviors eye contact
Parents social or emotional isolation Increased metabolism
No eye contact HESI Question
Physiological
Anorexia nervosa prior to having children What clinical manifestations would
Preterm birth the nurse expect in an infant
Breast feeding difficulties diagnosed with failure to thrive?
Gastroesophageal reflux Malnutrition, developmental
Cleft Palate delays, feeding disorders

Kaplan Question
Nursing Interventions
Observe the child feeding NCLEX TIP ... failure to thrive... The nurse instructs the
toddler’s parents about mealtimes. Which
Develop a structured routine for suggestion by the nurse is most appropriate?
bathing, sleeping, and playing Develop a structured routine for bathing,
Assess overall parenting skill sleeping, and playing

FAS - Fetal Alcohol Syndrome


Fetal exposure to alcohol (from maternal drinking) is the leading cause
of intellectual disability and developmental delay in the US.
Diagnostics
History of prenatal alcohol exposure
Risk factors HESI Question Growth deficiency
NCLEX TIP Neurological symptoms like microcephaly
Prenatal exposure to which substance can result in
ANY alcohol consumption in pregnancy craniofacial anomalies in the newborn?

Signs & Symptoms Alcohol Nursing Interventions


Intellectual disability Educate the mother on NO alcohol
Developmental delay
Saunders Question consumption during pregnancy
Hypotonia (weak muscle tone)
Poor sucking reflex & feeding Q1: ... hypotonia, irritability, and a poor sucking reflex in a Monitor the newborn’s response to
Abnormal palmar creases full-term newborn … The nurse suspects fetal alcohol
feeding & weight gain pattern
Infant irritability syndrome and is aware that which additional sign
would be consistent with this syndrome?
Minimal response to stimuli
Distinct facial characteristics NCLEX TIPS Abnormal palmar creases
Indistinct philtrum Q2: ... monitoring a newborn born to a client who abuses
Thin upper lip alcohol. Which findings should the nurse expect ...?

Short palpebral fissures Irritability


Epicanthal folds Minimal response to stimuli
Flat midface

NCLEX TIP
NAS & RDS
Maternity

NAS - Neonatal Abstinence Syndrome


This results from habitual use of opioids or illicit drugs during pregnancy. Pathophysiology
Opioid abuse including those with the O’s like HydrOcOdOne, MethadOne,
mOrphine & even HerOin, but sedatives like benzOs can also contribute to Signs & Symptoms
this condition. CNS findings: Irritability,
restlessness, high-pitched cry
Symptoms typically present within 24-72 hours of birth, but can take abnormal sleep pattern
days to weeks to appear. (sleeping very short intervals)
Kaplan Question ANS findings: nasal congestion
... newborn delivered by a client addicted to & frequent sneezing, tachypnea
ocodone
narcotics. At which time is the nurse most likely
GI: poor feeding & diarrhea
Hydr

to observe symptoms of narcotic withdrawal?


Within 24-72 hours after birth “loose stools”

Nursing Interventions: ATI Question HESI Question


… mother who used oxycodone daily during The nurse is caring for a newborn with a
Swaddle and gently rock pregnancy. Which of the following is indicated high-pitched cry, tremors, diarrhea, poor feeding,
Side-lying position for feeding ATI in infants with neonatal abstinence syndrome? tachypnea, nasal stuffiness… What is the most
common reason for these symptoms in a neonate?
Small, frequent feedings Swaddling the newborn and placing in a
Drug withdrawal
side-lying position for feedings
Skin protectants

RDS - Respiratory Distress Syndrome


This is a very SERIOUS respiratory disorder in newborns that is typically due to lung immaturity related to surfactant
deficiency! As you know, surfactant helps the baby’s lungs to be lubricated & expand in order to help get oxygen in!

Most full term babies can naturally produce surfactant, but is not always the case with premature infants.
Mature lungs in a baby have a 2 to 1 L:S ratio - the Lecithin Sphingomyelin ratio unless mom has diabetes -
which delays surfactant production

Pathophysiology
Diagnostics:
Risk Factors Saunders Question
Silverman-Anderson Index HESI
Preterm birth KAPLAN ... monitoring a preterm newborn for respiratory
distress syndrome. Which assessment finding should
IUGR - Intrauterine growth restriction alert the nurse to the possibility of this syndrome? Nursing Interventions
PPROM Select all that apply.
Steroids
Maternal DM, HTN, or drug use Cyanosis
Neonatal sepsis Tachypnea Betamethasone
Retractions
Audible grunts
Surfactant (via ET tube) HESI
Signs & Symptoms Admit to NICU for stabilization
Absent breathing or crying at birth HESI
Nasal flaring
Intercostal retractions HESI Question Feature Score 1 Score 2
Respiratory
Score 3
Seesaw
Audible grunting Chest Equal Lag Respiratory
Movement
Cyanosis & Tachypnea Which infant behavior would the Intercostal
nurse recognize as indicating Retraction
None Minimal Marked

respiratory distress? Xiphoid


None Minimal Marked
Retraction
Absent cry after birth Nasal Flaring None Minimal Marked

Expiratory Audible w/
None Audible
Grunt stethoscope

Notes
SIDS & Neonatal Sepsis
Maternity

SIDS - Sudden Infant Death Syndrome Educate Parents 6 NCLEX TIPS

Sudden Infant Death Syndrome is the unexpected death of an infant less 1. Place infants in supine position during sleep
than 1 year old. It occurs most frequently during sleeping in infants less “Put to sleep on their back” in a safe crib
Dress newborn in “wearable blanket”
than 6 months.
“sleep sack”
Memory Trick 2. Breastfeed the infant

A B C 3. Have up to date vaccinations

Alone Back Crib 4. Ensure a smoke-free environment


(no pillows, blankets, (supine) (no bed sharing or 5. Provide a firm sleep surface for the infant
stuffed animals) co-sleeping)
6. NO NO list
Avoid sleeping with the infant
(NO bed sharing, NO cosleeping)
NO pillows
NO loose or soft items: blankets, toys,
stuffed animals
NO bumper pads on the sides of the crib

HESI Question
... high risk of developing sudden infant death
Risk factors syndrome (SIDS)?
An infant whose mother smokes
Boys are at higher risk than girls Infant with an Apgar score of 4

Low apgar score at birth


Infants with a caregiver that smoke ATI Question
… reduce the risk of SIDS in infants?
Placing the infant in the supine position

Neonatal Sepsis
Risk Factors
Infection contracted by the neonate before, during, or after delivery, due
to the newborn’s limited immunity and inability to localize infection, Premature birth, PROM,
infections can spread quickly into the bloodstream. prolonged labor
Maternal TORCH infection
Meconium aspiration
HESI Question
Signs & Symptoms ... signs of neonatal sepsis?
Select all that apply.
Lethargy
Lethargy, irritability, poor Tachypnea
muscle tone Apnea

Respiratory distress:
Apnea or Tachypnea ATI Question
Heart rate instability ... immediately prioritized for assessment and care? Nursing Interventions
Temperature instability
A 3-week-old infant who has been feeding
poorly with a temperature of 100.5 F and Assess infection risks
sunken fontanelle
Vomiting/diarrhea → Draw labs/cultures
sunken fontanelles IV access
Poor feeding 100.5ᴼF
Blood glucose instability
Fetal Heart Monitoring IV
Maternity

HESI questions
240

Q1: What happens when oxytocin levels are elevated…? 210

180

Uterine contractions will increase 150

120

Q2: The nurse assesses fetal well-being during labor by monitoring


90

60

which factor?
30

100

Response of the fetal heart rate to uterine contractions 75

50

25

Key Terms for Uterine Contractions


During contractions, babies will hold their breath & fetal oxygenation Key Terms for Uterine Contractions
is impaired - so knowing this is VITAL to keep the baby well
1. Frequency: measures how FAR APART
oxygenated in between. There are 4 components to know.
the contractions are
Frequency (minutes) 2. Duration: measures how LONG the
Intensity (mmHG) contractions last
0₂
3. Intensity: rates how STRONG the
contractions are
0₂ 0₂
0₂
0₂ 0₂
4. Rest (Tone & Time): the uterus should
be SOFT to palpation between
0s 60s contractions for at least 60 seconds.
Duration (seconds)

Normal Contractions 2-3 mins


(Rule of 60) Intensity: 60 mmHg
Frequency: contractions
that are 2 - 3 mins apart in
active labor.
Duration: 60 seconds
Intensity: 60 mmHg
Rest: 60 seconds or rest in
between contractions 60 seconds Duration: 60 seconds

Normal UC pattern
Tachysystole Complication!
Over 5 contractions in 10 minutes
Too many contractions → Fetal Distress!
Including Hypoxia & reduced placental
blood flow

Tachysystole pattern

10 mins
Fetal Heart Monitoring V
Maternity

Normal NOT Normal


Expected Findings Fetal Distress
1. Normal FHR 110 - 160 bpm 4. Tachy/bradycardia
2. Accelerations 5. Late decelerations
3. Early decelerations 6. Variable decelerations
7. Sinusoidal Tracing
Memory Trick:
Good to be Early With early decels Memory Trick:
BAD to be LATE Late or variable

180 210

180

150

100 120

90

60

30

8 Strips on the Nclex

Normal FHR Strips Normal 110 - 160bpm


1. Normal FHR: 110 - 160 bpm
Baseline is between contractions
2. Accelerations:
Temporary increase in FHR (this is ok!)
GOOD!
3. Early decelerations Acceleration Acceleration
Mirror contractions with decreased
FHR during contractions = ok! HESI question
• Cause: Head compression Which fetal heart rate tracing
during the contractions
characteristics are considered
• Intervention: Prepare for
reassuring or normal?
delivery of the baby
Memory Trick:
Early decelerations, either
Good to be Early present or absent
With early decels

Not Reassuring (Risky!) ATI Question HESI Questions


… client with a fractured wrist who is 36 weeks Q1: While monitoring the FHR ... the nurse notes
4 . Fetal Tachycardia
pregnant. Which of the following assessment tachycardia. Which is a probable cause for
increase in FHR over 160/min for over 10 minutes this condition?
items should the nurse prioritize?
Early sign of fetal distress! HESI
The fetal heart rate is 210/min Early signs of fetal distress
Causes
Trauma to mother (broken bone)
Maternal Infection or fever
Fetal anemia
Dehydration HESI Questions
Stimulants (Cocaine) Q2: ... a FHR baseline of 175 bpm. The nurse
Interventions knows that this can be caused by which
Oxygen factor?
IV fluids 210 Fetal tachycardia
Antipyretic

Not Reassuring (Risky!)


Saunder’s Question
5 . Fetal bradycardia HESI Questions
decrease in FHR over 110/min for over 10 minutes … slowing of the fetal heart rate and a loss of
Causes variability… nursing action? Q1: ... maternal cardiac output can be increased
Uteroplacental insufficiency by which factor?
Turn the client onto her side & give
Umbilical cord prolapse oxygen by facemask at 8-10 L/min Change in position
Maternal hypotension
Analgesic medication
Kaplan Question HESI Questions
Interventions
… Abrupt and rapid fluctuations in the fetal heart rate Q2: ... sudden drop in fetal heart rate (FHR) from its
Memory Trick
(FHR) from baseline to 90 beats per minute and back to baseline of 125 down to 80. The nurse repositions the
R Reposition mom: side lying position baseline … The fluctuations in fetal heart rate occur with client, provides oxygen, increases intravenous (IV) ...
no relationship to the contraction pattern. Which response Five minutes have passed and the FHR remains in the
O Oxygen via Facemask
by the nurse is best? 80s. Which additional measure would the nurse take?
A Alert the HCP (provider)
“This is a potential problem that requires a Immediately notify the primary health care provider
D Discontinue oxytocin position change.”
I Increase IV fluids
Fetal Heart Monitoring VI
Maternity

8 Strips on the Nclex


Amnioinfusion
CRITICAL Findings! The installation of sterile saline into the amniotic
cavity to refill the lost fluid.
6 . Variable decelerations Report Immediately
Abrupt decreases in FHR Indications of Overfilling NCLEX TIPS
Less than 30 seconds from onset to baseline Uterine resting tone that increases to 45 mm Hg
& 15 bpm below baseline for 15 sec - 2 min Dry perineal pads

Causes
Umbilical Cord Compression! NCLEX TIP
Critical: Oxygen tube is compressed!
120 120 120
100 100 100

Decreased amniotic 80 80 80
60 60 60

Interventions 40 40 40
Prolapsed cord 20 20 20
Memory Trick 0 0 0

R Reposition mom: side lying position


O Oxygen via facemask Resting tone:
A Alert the HCP (provider) 45mmHg
D Discontinue oxytocin
I Increase IV fluids

CRITICAL Findings! TOP TESTED Top Missed NCLEX Question Kaplan Question
A new nurse is evaluating the fetal monitoring strip of a client in labor who is receiving
7 . Late decelerations an oxytocin infusion. Which of the following actions should the nurse take next?
… fetus is experiencing distress if which heart
Click the exhibit Select all that apply.
Decreased FHR after contractions with prolonged rate pattern is observed?
time before returning to baseline Slow the oxytocin infusion

Indicates that oxygenation is compromised! NCLEX TIP


Reposition the client to left/right side Late decelerations
Amnioinfusion
Causes Oxygen by face mask
Placental insufficiency
ATI Question
Initiate an IV bolus of 0.9% saline
(Uteroplacental insufficiency) HESI Notify the provider & prepare terbutaline

Uterine tachysystole NCLEX TIP


Which of the following interventions ... after
Side effects of oxytocin causing severe contractions
HESI Question examining this fetal monitoring strip?
→ Reduced placental blood flow & impaired fetal
oxygenation Oxytocin induction … the last five contractions, the fetal Discontinue oxytocin
heart rate has fallen below the baseline … and returns to
Over 5 contractions in 10 minutes baseline in 20 to 30 seconds after the end of the contraction. Run the IV fluids wide open
STOP Oxytocin
Late decels What actions must the nurse take?
Hypotension Select all that apply.
Memory Trick Contact the health care provider
BAD to be LATE With late, absent or variable decels
Stop the infusion of oxytocin
Interventions Increase the infusion of the mainline IV fluid
Memory Trick Apply oxygen by facemask Oxytocin
R Reposition mom: side lying position
O Oxygen via facemask
A Alert the HCP (provider)
D Discontinue oxytocin
I IV fluids (0.9% NS bolus or LR)
Prep for C-Section if late decels persist

CRITICAL Findings! Top Missed NCLEX Question


The nurse is observing the fetal heart rate (FHR) tracings
8 . Sinusoidal FHR
of 4 clients. Which pattern would be most concerning?
Repetitive, wave-like fluctuations (hills) with 1. 240 240 240
Early decelerations Variable Decelerations
NO variability & NO response to contractions
210 210 210

180 180 180

1. 2.
150 150 150

120 120 120 240 240 240 240 240 240

90 90 90 210 210 210 210 210 210

Causes
60 60 60 180 180 180 180 180 180
30 30 30
150 150 150 150 150 150

120 120 120 120 120 120


100 100 100
80 80 80 90 90 90 90 90 90

Mother abdominal trauma


60 60 60
40 40 40 60 60 60 60 60 60
20 20 20
30 30 30 30 30 30
0 0 0

(fall, motor accident) 2.


100 100 100 100 100 100
80 80 80 80 80 80
240 240 240
60 60 60 60 60 60
210 210 210 40 40 40 40 40 40

→ leading to fetal blood loss or anemia


20 20 20 20 20 20
180 180 180
0 0 0 0 0 0
150 150 150

120 120 120

90 90 90

60 60 60

Interventions
30 30 30

100 100 100


80 80 80

Sinusoidal FHR Fetal tachycardia


60 60 60
40 40 40

Emergency Cesarean Section


20 20 20
0 0 0

3. 4.
3.
“Crash C-section”
240 240 240 240 240 240
240 240 240
210 210 210 210 210 210
210 210 210
180 180 180 180 180 180
180 180 180

150 150 150 150 150 150 150 150 150

120 120 120 120 120 120 120 120 120

90 90 90 90 90 90 90 90 90
60 60 60 60 60 60
60 60 60
30 30 30
30 30 30 30 30 30

Critical finding!
100 100 100
80 80 80 100 100 100 100 100 100
60 60 60 80 80 80 80 80 80
40 40 40 60 60 60 60 60 60
20 20 20 40 40 40 40 40 40
0 0 0 20 20 20 20 20 20
0 0 0 0 0 0

4.
Intervention required
240 240 240

210 210 210

180 180 180

150 150 150

120 120 120

90 90 90

60 60 60

Sinusoidal FHR
30 30 30

100 100 100


80 80 80
60 60 60
40 40 40
20 20 20
0 0 0
Cesarean Birth
Maternity

Contraindication
Performed after 28 weeks of gestation. C-sections can either be planned or an unplanned emergency.

Top reasons Common NCLEX Question


1. Planned C section Which client statement should prompt the nurse to
Previous C-sections request a primary cesarean birth from the provider?
Large baby or a lot of babies (triplets “I lost my acyclovir prescription and I’ve noticed
lesions on my labia that are stinging and burning.”
or twins)
Genital herpes or other infections (mom)
Placenta previa (placenta blocks the cervix) HESI Question
2. Emergency C-section Which condition places the pregnant client at a
Fetal distress: if the baby’s life is in danger higher risk for a cesarean delivery?
Placental Abruption
Placental abruption: placenta separates A client with the fetus in a transverse lie
from the wall of the uterus
Prolapsed cord: umbilical cord is
compressed, limiting oxygen to the baby
Long labor or contractions not
strong enough
Breech birth: baby is in an odd position.
Transverse lie or oblique lie
Transverse Lie

Surgical Procedure
- The client is put to sleep with anesthesia or awake with local anesthesia.
- Then Incisions are made on the abdomen through the uterus and the
health care provider will rupture the amniotic sac to deliver the baby.
- The entire process typically takes only a few minutes to get the baby out.
But can take longer in certain cases.

Complications
After a c-section, the highest priority is to monitor the client for hemorrhage & shock. This severe bleeding will
lead to low blood pressure that will kill the client!

Complications Hemorrhage & Shock


Hemorrhage & shock KAPLAN
Placenta Previa: placenta attaches in Kaplan Question
the wrong location, over the cervical
Cesarean delivery... The nurse places the
opening
highest priority on monitoring the client for
Placenta Accreta: where the placenta which potential complication?
attaches to the uterus too firmly NORMAL
Hemorrhage and shock
Uterine rupture: if this uterus is
HIGH
LOW

scarred from a previous C-section it


has weak spots that can rupture.

Post-Operative Care
Obviously the client will be in pain with a big incision that is healing.
Surgical Wound Dressing
The key point is focused on removal of the surgical wound dressing.
ONLY the surgeon removes the initial (first) dressing!
The initial (first) dressing is ONLY removed by the surgeon …
Not the nurse, not the aid, not the student, NOBODY but the surgeon!
If the surgical site is bleeding, do you remove the surgical dressing then?
No, only the surgeon removes the initial dressing.
If it’s bleeding, just keep adding pads to the site & call the surgeon. DO NOT REMOVE!
Once the surgeon removes the initial dressing, then you can assess the wound like normal.
Always assess for infection with any surgical site:
-Warm
-Red
-Draining
Epidural & Pain Control I
Maternity

Non Pharmacological
This means no medications are used for pain control during labor.

Breathing techniques HESI Question


Imagery
Which is an effective nursing intervention for a
Massage: effleurage client experiencing pain related to back labor?
Back labor pain: Sacral counter pressure Counter pressure against the sacrum

NCLEX
Monitor for nonverbal signs
of ineffective coping with labor
Panic
Anxiety
Squirming movements
Pain medication

Medication SEDATIVES

Pain control during labor with pain medications, like sedatives & opioids, are best given
during the early stages of labor, as they can cause serious side effects like respiratory Opiates
depression when given closer to birth!

These medications can be VERY DEADLY - we like babies with strong cries,
NOT FLOPPY BABIES. It’s best to give these 2-4 hours BEFORE birth so that the drug
has time to wear off BEFORE birth. 2 - 4 hours

Sedatives Opioids Opioids


Barbiturates 1. Meperidine hydrochloride (brand: Demerol)
Phenobarbital (brand: Tedral) 2. Butorphanol tartrate (brand: Stadol)
3. Nalbuphine hydrochloride (brand: Nubain)
Caution : Respiratory depression

Caution! 3 Key points for NCLEX Memory trick


1. ONLY give opioids: Opioids make labor slOw
During contractions
After the cervix is 4 cm dilated Opioid
or it will slow labor
HESI Questions 2. Assess fetal heart rate (FHR)
10 minutes prior
Q1: ... IV pain medication for a client in labor? 3. Have Naloxone (opioid antidote) ready
Select all that apply
Administer the medication only when
the client is having a contraction
Assess the fetal heart rate (FHR) for 10 Naloxone HESI Questions
minutes prior to administering the pain
medication Q2: Which action would the nurse take before
administering meperidine hydrochloride to a
Naloxone will reverse the pain relief
client to relieve labor pain?
provided by the opioid
Monitor maternal vital signs and fetal
heart rate Fetal Heart Rate

Notes
Epidural & Pain Control II
Maternity

Epidural Anesthesia

Epidural anesthesia also called an epidural block, is an injection into the lower back that temporarily blocks
pain from the waist down. For the procedure, clients will lie on their side with knees tucked in or sit up right & lean
forward. To help visualize the position, nurses tell clients to curl over like a cooked shrimp.
When in the correct position, the provider will insert a needle into the client’s epidural space between the
dura mater & the vertebral wall just outside of the spinal cord.

A catheter is threaded through and secured as the epidural needle is removed. The catheter is used by the provider
to administer pain relief when needed.
NCLEX Questions
Q1: Which laboratory value is the priority to
Epidural Anesthesia report to the provider prior to epidural
anesthesia?
Epidural Block
Platelet count of 95,000
Blocks sensation from waist down:
umbilicus (belly button) to legs NCLEX Questions
After the cervix is 4 cm dilated Q2: An epidural was administered 20 minutes
ago and now the client reports feeling dizzy and
Less than nauseated. Which action should be performed
Caution ≤ 150,000
Normal first?
Maternal hypotension (low BP) 150,000 - 400,000 Bleed Risk! Obtain blood pressure
Fetal bradycardia (low HR)
Low platelet count in the mother Kaplan Question
Normal 150k - 400k
A client is 6 cm dilated and ready for epidural
Less than 150k = risky! BLEED RISK anesthesia. Which position will the nurse assist
the client?
On the left side, shoulders parallel, legs
flexed, and back arched

Spinal Anesthesia
Spinal Block
C-section
100% loss of motor movement &
sensation
Spinal Anesthesia

Interventions: Epidural & Spinal block HESI Question ATI Questions


… spinal block in place for pain… the client’s blood Q1: Which of the following can result in fetal
IV fluids to help counteract side effects pressure is 20% lower than the baseline level. bradycardia?
Which nursing action is appropriate?
of maternal hypotension The mother has received spinal anesthesia
Turn the client to the left lateral position or
Q2: After the epidural, the nurse notes decreased
place a pillow under her hip beat to beat variability and late decelerations on
Exam Question:
the fetal heart monitor. Which of the interventions
Nursing action for hypotension should the nurse implement?
Select all that apply.
Turn the mother to the left lateral Turn client on the left side
position & increase IV fluid rate Increase IV fluid rate

Pudendal Nerve Block ATI Question Top Missed NCLEX Question


Which of the following is correct regarding a A laboring client in the later part of 2nd stage of labor is urgently
Perineum pudendal block? requesting pain relief for the perineal area… cervix is 10 cm
dilated and 100% effaced, with the fetal head at -1 station.
Vulva A pudendal block anesthetizes the What is the most appropriate pain management technique
perineum, vulva, and rectum for this client?
Rectum Breathing techniques
Epidural anesthesia
Spinal anesthesia
Good: Vulva
Pudendal nerve block
Given quickly when birth is imminent
Bad: Perineum
DOES NOT relieve contraction pain Rectum
Preterm Labor I
Maternity

Preterm Labor refers to labor that begins too early between 20 - 37 weeks of pregnancy
characterized by CERVICAL change (that can be dilation or effacement), where as labor after Preterm Labor
37 weeks is considered full term and labor before 20 weeks is categorized as spontaneous 20 - 37 weeks of pregnancy
abortion - as the newborn will not survive.
Preterm labor is the number 1 cause of neonatal mortality, as babies born prematurely
do not have fully developed organs.

For example, the lungs do not have maturity to breathe on their own & the chambers in the
heart have not fully closed yet, just to name a few. Sort of like a cake coming out of the oven
too soon - it is not fully cooked.

In the same way, the baby is like a bun in the oven that comes out too soon & does not
have enough time to fully cook or develop. Naturally, we will see less complications the longer
the baby stays in the womb.

Causes & Risk Factors ATI Questions


D - Distended Uterus Q1: A 42- year-old pregnant client … at risk
Fetal macrosomia of preterm labor. Which information
Polyhydramnios (too much amniotic fluid) from the nurse is correct regarding
Multiple gestation (twins, triplets etc.) prevention of preterm labor?
Diseases Do not lift heavy bags of groceries or
Diabetes Mellitus young children which requires use of
Eclampsia (High BP) abdominal muscles
Heart disease
Anemia (HgB less than 10) NCLEX TIP

I - Infection ATI Questions


UTI - Urinary tract infections
Q2: Which of the following factors increases
STI - Sexually transmitted infections
the client’s risk of preterm labor?
Periodontal disease (gum infection) NCLEX TIP Select all that apply.
P - Placental Abruption Periodontal disease
Urinary tract infection
Placenta separates from the wall of the uterus Multifetal pregnancy
during pregnancy Diabetes mellitus
No 1 risk
S - Stress: Emotional or Physical
Short cervical length or too thin
(cervical insufficiency) HESI Question
Smoking & Stimulants (cocaine)
Other risk factors: Which intervention would ...help prevent
preterm delivery?
History of preterm births
Lifting heavy object (if at risk) ATI Suggest that the client avoid smoking

Signs & Symptoms Notify NCLEX TIP


Key Signs of Preterm Labor the HCP HESI Question
… signs of preterm labor with a client at 28 weeks gestation.
1. Rupture of membranes 20 - 37 weeks Which client statement indicates a need for further teaching?
Report watery discharge from vagina ATI Select all that apply.
I expect the discharge from my vagina will change
2. Low back pain NCLEX TIP from thick to brown over the next two weeks
The baby’s movement will decrease and be almost still
3. Contractions every 10 minutes or less from here on out
4. Pelvic pressure I should expect low back pain and diarrhea as the baby grows
20 - 37 weeks
5. Diarrhea

Diagnostics Fetal membranes

Speculum exam: to visualize the cervix


HESI Question
Effacement - thinned out cervix A client at 26 weeks of gestation...
Dilation - opening of the cervix Which finding indicates that preterm
Fetal membranes intact or ruptured labor is occuring?
Fetal Fibronectin Test (FFN)
The cervix is effacing and
Transvaginal Ultrasound (less than 34 weeks)
dilated to 2 cm
Shortened cervix length
Preterm Labor II
Maternity

Preventative Measures
12 - 28 weeks
Prophylactic Cervical Cerclage
To prevent preterm delivery
Cervical insufficiency
Signs of Preterm Labor Notify the HCP
12 to 28 weeks gestation
Stitches are removed at 36 - 37 weeks 1. Rupture of membranes
Report watery discharge from vagina ATI
Interventions
2. Low back pain NCLEX TIP NCLEX TIP
Education (after cerclage)
Activity restriction & bed rest 3. Contractions & pelvic pressure
No sexual intercourse
Mild abdominal cramping is expected
Assess fetal movement daily HESI

Interventions SIDE NOTE

Continuous fetal monitoring Clients who have had a history of preterm labor are
Amniotomy (AROM) is the manual commonly prescribed progesterone throughout the PROGESTERONE

induction of labor by rupturing the pregnancy, as it will reduce the risk for future preterm
amniotic membranes & is contraindicated! labor.

Pharmacology 4 NCLEX TIPS Top Missed NCLEX Question


A pregnant client is admitted for preterm labor at 30
1. Antibiotics PENICILLIN weeks gestation. Which treatment options should the
nurse anticipate?
Penicillin IV piggyback Select all that apply.
Prevent group B strep infections Intramuscular betamethasone
Penicillin via IV piggyback
2. Steroids: antenatal glucocorticoids IV magnesium sulfate
Stimulate surfactant for fetal lung maturity Calcium gluconate ready

Betamethasone Steroid HESI Question


-sone
3. Tocolytic agent Betame- ...magnesium sulfate to prevent preterm
To relax the uterus thasone
labor. Which would the nurse assess in
Terbutaline the client to determine drug toxicity?

Nifedipine Respiratory status


Level of consciousness (LOC)
Indomethacin Deep tendon reflexes
4. Magnesium Sulfate
Protects the baby’s brain (neuroprotection) MAGNESIUM
Kaplan Question
Reducing the risk for cerebral palsy SULFATE
Magnesium sulfate IV ... the client’s deep
tendon reflexes are decreased. Which
Continuous fetal monitoring is required for
action does the nurse take first?
Mag Sulf infusion
Discontinues the IV infusion
Mag Toxicity
ATI Questions
Monitor mother’s respiratory rate,
blood pressure, & DTRs
STOP Q1: … 30 weeks of gestation. Which medication... to
accelerate fetal lung maturity?
MAGNESIUM Betamethasone
Discontinue: low RR, BP, & depressed DTRs SULFATE
Q2: … terbutaline. Which of the following client statements
indicates an understanding of the teaching?
Antidote: Calcium gluconate This medication is used to stop my contractions

Notes
PROM & AROM
Maternity

PROM Pathophysiology
PPROM PROM
As you know, the baby is floating in amniotic fluid within the P Preterm
chorioamniotic membrane, making up the amniotic sac.
P Premature P Premature
This is held inside the uterus, which we call the baby apartment Aminiotic fluid

since it is where the baby lives during fetal development. Chorioamniotic R Rupture R Rupture
membrane

Aminiotic sac
O Of O Of
The cervix is the door to the apartment that holds it all in. M Membranes M Membranes
In PROM, the mother’s water breaks too early & this amniotic
fluid leaks out! *Before 37 weeks *After 37 weeks

Risk factors
Treatment Over 37 Weeks
Anything that weakens the strength of
the chorioamniotic membrane Prevent infection HOURS

Infections UTI STD/STI Over 37 weeks gestation


UTI 90% of clients will go into
STI (STD) spontaneous labor within 24 hours NCLEX TIP
Bacterial vaginosis
Bacterial vaginosis
Nurse care
Short cervical length
Smoking Give prophylactic antibiotics to Prophylactic
Antibiotics

Abdominal trauma prevent GBS infection - Group B


GBS Infection

Prior distention Beta Streptococcus NCLEX TIP


Polyhydramnios - increased 1. Membranes ruptured at/over NCLEX TIP
amniotic fluid 18 hours
Multiple gestations 2. Temperature over 100.4
(twins, triplets +)
x2 3. Gestation less than 37 weeks

Diagnostics
Nitrazine Test
Speculum exam (”Pooling”) Saunders Question
A speculum is placed inside the vagina A pregnant 39 week-gestation ... has had a positive group HCP
& the client is asked to cough or bear B streptococcus (GBS) ... the cervix is dilated 6 cm and
down. If amniotic fluid is seen coming 90% effaced. Which should be the nurse’s first action? Prophylactic
Antibiotics

out of the cervix when this pressure is Call the health care provider (HCP) to obtain a
prescription for intravenous antibiotic prophylaxis
applied, the client has ROM.
Ultrasound
Screening for STIs

AROM
Amniotomy - this is a procedure performed by the health care provider to manually HESI Question
induce labor by rupturing the amniotic membrane or in other words breaking the Amniotomy ... Immediately after the procedure what is
client’s water. most important information for the nurse to obtain?
Fetal heart rate
Amniotomy 1st Priority

Manual induction of labor by rupturing


ATI Question
AROM the amniotic membrane
Amniotomy ... Which of the following is the priority for
Risk for Umbilical Cord Prolapse assessment by the nurse?

A Artificial causing fetal bradycardia due to Fetal heart rate

cord compression
R Rupture 4 NCLEX TIPS: Interventions
Normal NOT Normal
1. Assess fetal heart rate
O Of BEFORE & AFTER
Clear
Colorless
Yellow-green fluid
Meconium
No foul odor Strong foul odor
2. Assist to upright position after
M Membranes
Infection

3. Temperature every 2 hours


4. Characteristics of amniotic fluid
Color, amount & odor
Procedures to Assist Labor & Delivery
Maternity

Administering Oxytocin ATI Question


Secondary line
Use an IV infusion pump on a secondary IV line Primary line Q1: … receiving oxytocin after prolonged
Monitor 2 NCLEX TIPS labor. Intervention is necessary when
which assessment item is noted?
1. Mother’s uterine contraction pattern,
blood pressure & heart rate 6 contractions in 10 minutes
2. The fetal heart rate (continuously) Q2: Which of the following findings …
requires intervention by the nurse?
STOP Oxytocin 3 NCLEX Key Points
Duration of contraction of
1. Contractions: 100 seconds
Duration OVER 90 seconds
STOP
Kaplan Question
Frequency less than 2 minutes apart
Intensity over 90 mmHg … oxytocin infusion to induce labor. The
Resting tone greater than 20 mmHg nurse stops the infusion if it occurs?
2. Late decelerations in FHR Contractions last 90 to 120 seconds
3. Over 5 contractions in 10 minutes & are 2 minute intervals

Complications Uterine Rupture Top Missed NCLEX Questions


1. Uterine Rupture ATI A client is receiving oxytocin infusion for labor
augmentation. The provider asks the nurse to increase the
2. Late declarations oxytocin infusion rate. Which of the following actions
Abdomen should the nurse take?
3. Water intoxication (dilutional hyponatremia)
Click
Clickthe
theexhibit.
exhibit
4. Increased risk for
Recommend that the infusion rate be decreased
Placental abruption
Uterine atony Soft or boggy fundus Rupture
increased risk for postpartum hemorrhaging Oxytocin
5. Uterine tachysystole NCLEX TIP Uterine tachysystole
Side effects of oxytocin causing severe contractions
10 minutes
→ reduced placental blood flow & impaired
fetal oxygenation.
1 2 3 4 5 6
STOP Oxytocin
Over 5 contractions in 10 minutes
Late decels

Amniotomy
Manual induction of labor by
rupturing the amniotic membrane
Risk for Umbilical Cord Prolapse
Causing fetal bradycardia due to
cord compression

NCLEX TIP
Forceps spoon like devices used to assist delivery
Bishop Score
HESI Question
Caution! Never apply fundal pressure during forcep use System for assessing cervical
Uses: fetal distress or abnormal fetal presentation
Complication... forceps-assisted delivery? readiness for induction of labor.
Complication Presence of vaginal lacerations
Uterine rupture
OVER 6 - 8 score indicates
Bladder injury induction will be successful
Vaginal Lacerations

Vacuum traction applied to the fetal head NCLEX TIP


Cervix
Bishop score
Caution! Never apply fundal pressure NCLEX TIP
0 1 2 3
Uses:
Consistency Firm Medium Soft
Mother not pushing effectively or unable to push
Fetal distress, rotation, or abnormal FHR Position Mid-
Posterior Anterior
positon
Complication
Dilation 0 cm 1-2 cm 3-4 cm ≥ 5 cm
Uterine rupture
Lacerations Effacement 0% - 30% 40 - 50% 60 - 70% ≥ 80%
Infant subdural hematoma
Station -3 -2 -1, 0 +1, +2
Labor Complications I
Maternity

Amniotic Fluid Embolism


Pathophysiology
This is a deadly condition that occurs when amniotic fluid inside the uterus leaks
out & enters the mother’s blood stream, leading to very high risk for mortality in Amniotic fluid inside the uterus leaks
out & enters the mother’s blood stream
both the mother & baby! Most do not survive. It occurs most often during delivery
or in the immediate recovery period.

Symptoms Interventions
Sudden chest pain Notify the provider!
Hypotension (low BP) IV fluids & blood transfusion
Tachycardia (fast HR) Assist with intubation
Dyspnea (difficulty breathing) Oxygen
Cyanosis (blue, pale skin)

0.9% PRBC 0₂
Sodium Chloride 0₂

0₂
NORMAL

0₂
HIGH
LOW

0₂
0₂

Dystocia

Pathophysiology Interventions
Slow or difficult labor or delivery Reposition or ambulate the mother
Oxytocin: induce labor
Memory trick
Amniotomy: the provider manually
D - Dystocia
breaks the water
D - Difficult Labor

Oxytocin

Saunders Question
Causes & Risk Factors ... labor dystocia... which risk factors in the client’s
history placed her at risk for this complication?
Macrosomia (big baby over 8lbs 13 oz) Select all that apply.
Age 54
Overweight (BMI over 25) Body mass index of 29
Over 8lbs 13oz
Older age Previous difficulty with fertility

Previous difficulty with fertility


Age 54 BMI = 29
Failure of the uterus and cervix to
contract
Insufficient cervix dilation, effacement,
4cm
& descent of the baby
Labor Complications II
Maternity

Shoulder Dystocia

Pathophysiology Nursing Interventions


Fetal head delivers, but the top of the NCLEX TIPS
shoulder becomes wedged behind or 1. Document the time of events & position for example
Fetal head position, should maneuvers
under the mother’s symphysis pubis.
2. Verbalize passing time to guide provider for example
Longer than 5 minutes → HIGH RISK “1 minute has passed”

for fetal asphyxia (hypoxia) 3. Maneuvers to relieve shoulder impaction


McRoberts maneuver: Flex the client’s legs back
against the abdomen
Suprapubic pressure: Press downward on the
symphysis pubis
4. Request additional assistance from other nurses &
5
mins
staff

0₂
Shoulder Dystocia

AVOID NCLEX Traps


?
MAGNESIUM McRoberts
Terbutaline SULFATE Maneuver
Administering tocolytic agents
(Terbutaline, Mag Sulfate)
Fundal pressure
Use of forceps or vacuum

Precipitous Labor
This is quick labor - some professors call these “cannonball” babies, because they shoot out with impressive force
and everything can get damaged - baby & mom included!

Pathophysiology Risks
Labor within 3 hours or less! Hypertonic uterine contractions
After the onset of contractions
Use of Oxytocin
Memory trick:
Multiparous mother
P - Precipitous Labor
P - Pretty Quick labor (multiple previous births)
Within 3 hours or less

Complications Interventions
Prepare to assist with birth
1. Mom:
Keep the infant warm! NCLEX TIP
Postpartum hemorrhage
Uterine rupture O2 Dried & placed skin-to-skin on the
mothers abdomen
Amniotic fluid embolism
AVOID NCLEX Traps
2. Baby
APGAR SCORE

2 points
Do NOT pull on the cord!
Intracranial hemorrhage → Uterine inversion or cord avulsion
Fundal massage ONLY after placenta is
Hypoxia delivered
Labor Complications III
Maternity

Uterine Rupture
Causes
Pathophysiology Previous C-section attempting a vaginal
delivery (weak spots in the uterus that
Spontaneous tearing of the uterus that
can rupture)
may result in the fetus being expelled
Forceps delivery
into the peritoneal cavity Uterine Rupture
Traumatic events (car accident or fall)
Overdistension of uterus: Twins,
triplets, or more

Symptoms Too much oxytocin

Severe sudden abdominal pain! Saunders Question


“Tearing or ripping” ... risk of uterine rupture if which occurred?
Fetal heart rate that is non assuring Forceps delivery
for example
Bradycardia
Variable or late decels
Decreased variability
Interventions
Fetal distress Immediate Cesarean delivery
Mother s/s of bleeding (C-section)
Hypovolemic shock Hysterectomy
Hypotension (low BP) IV fluids & blood products
Tachycardia (fast HR)
ATI Question
… 38 weeks gestation who reports severe sudden
! abdominal “ripping” pain when receiving an
oxytocin infusion during labor. The client's heart
! NORMAL

rate is 130/min and she is tachypneic. The fetal


HIGH
LOW

heart rate monitor reveals minimal variability and


! bradycardia. Which of the following tasks does the
nurse anticipate?
Prepare for immediate cesarean delivery

Uterine Inversion

Pathophysiology Symptoms Interventions


Placenta fails to detach from the uterine Severe abdominal pain 1. Relax the uterus: (Tocolytic)
wall and pulls the uterus inside-out Mother s/s of bleeding Terbutaline
Hypovolemic shock Magnesium sulfate
Causes Hypotension (low BP) 2. Provider repositions the uterus
Tachycardia (fast HR)
Excess cord traction 3. AFTER the uterus is repositioned
Oxytocin
(pulling the umbilical cord)
Saunders AVOID
Excess fundal massage
Placenta accreta: the placenta is too ... immediately after delivery of the placenta. IV oxytocin before the inverted
Which … could indicate uterine inversion? uterus is corrected NCLEX TIP
firmly attached to the uterus
Complaints of severe abdominal pain
4. IV fluids & blood products

0.9% PRBC
AVOID
Sodium Chloride

AVOID
Labor Complications IV
Maternity

Umbilical Cord Prolapse & Compression


Signs
This is a potentially deadly emergency for the fetus! Common after spontaneous rupture of
membrane (water breaks) or amniotomy
Pathophysiology FHR - Fetal Heart Rate
Fetal bradycardia
Umbilical cord protrudes out of the
mother’s cervix or vagina BEFORE the baby Abrupt fetal heart rate decelerations
→ cuts off oxygen rich blood to the baby NCLEX TIP

So if the oxygen tube is compressed, it leads to DEADLY Abrupt fetal


low oxygenation! This results in lifelong brain damage or heart rate
death for the baby! Very serious!
decelerations

HESI Question
… cause of variable fetal heart rate (FHR)
deceleration is which factor?
Umbilical cord compression

Saunders Question
… umbilical cord compression if which is noted on
the external monitor tracing during a contraction?
Variable decelerations

Nursing Interventions Saunders Question


1. Call for assistance ... umbilical cord protruding from the vagina…
nursing action?
2. Insert sterile gloved hand:
Wrap the cord loosely in a sterile towel
Sterile

1 or 2 fingers into mother’s vagina


Normal
Saline

soaked with warm sterile normal saline


to relieve compression
3. Reposition mother: ATI Question
Knee-chest position
... extrusion of the umbilical cord ... priority
Trendelenburg position nursing intervention after calling for assistance?
4. Wrap cord loosely with a Use a sterile gloved hand and apply finger
sterile towel or gauze soaked with pressure to elevate the presenting part of
the fetus
sterile normal saline
5. Prepare for emergency C-section HESI Questions
(cesarean delivery)
Q1: … umbilical cord protruding from the client’s
vagina. The nurse immediately positions the client in
O2
the Trendelenburg position and inserts a finger into
O2
O2
O2
O2 O2
O2 O2 O2
O2
O2
O2 O2
O2
the client’s vagina. Which additional care?
O2 O2
O2
O2
Prepare for an emergency cesarean delivery
O2

Q2: … amniotic membrane rupture, and a prolapsed


cord is suspected… priority intervention?
Knee-chest position

Notes
Labor Complications V
Maternity

DIC

Pathophysiology This is severe bleeding inside & outside the mother’s body.
As the body uses up all clotting factors & platelets, it makes little clots all
DIC = disseminated intravascular over the body & uses up all means to stop bleeding elsewhere in the body,
coagulation leaving the mother with no means to stop bleeding anywhere!

Causes & Risks Placenta


HESI Question
Placental abruption: placenta separates … high risk for disseminated intravascular
from uterine wall coagulation (DIC)?

Intrauterine fetal demise (stillbirth) Placental abruption


Placental Abruption Fetal demise

Interventions
Signs & Symptoms Priority! NCLEX TIP Coagulation Fibrinogen
test
External bleeding: venipuncture site Draw coagulation tests, fibrinogen,
Internal bleeding: petechiae & ecchymosis & platelet count
Organ damage: Administer blood products, volume Platelet

Respiratory distress expanders & oxygen


Renal failure Monitor for bleeding which is
sudden & deadly

Meconium Stained Amniotic Fluid HESI Question


... amniotic fluid was meconium stained
during labor. Which further assistance
Pathophysiology Signs would the nurse provide to the newborn?
Amniotic fluid color: green, yellow, or brown Provide endotracheal tube suction
Fetus has defecated in the amniotic assistance with ventilation
Foul smelling odor
fluid.
Key Points ATI Question
Common in: … warning signs of potential complications?
Breech position Select all that apply.
When the mother’s water breaks, we After events of fetal distress
expect it to be clear, but with meconium Term/ post term infants Meconium stained amniotic fluid
Foul-smelling vaginal discharge
stained, the fluid changes color to Indicates fetal hypoxia
various shades of green, yellow or Prep for neonatal resuscitation
brownish & it often even smells foul. Endotracheal tube & ventilation

Meconium Aspiration Syndrome HESI Question


Risk Factors
… 41 weeks of gestation. Which complication?
Pathophysiology Over 40 weeks gestation
Meconium aspiration syndrome
Diabetes
Newborn breathes a mixture of meconium
& amniotic fluid into the lungs High blood pressure ATI Question
Long or difficult labor
… meconium aspiration syndrome. Which of
Newborn breathes a mixture of meconium the following is true?
& amniotic fluid into the lungs around the Pneumothorax may occur
time of delivery. It’s like coating the inside
Complications
of the lungs with tar! KAPLAN Question
Fetal distress
Gas exchange is nearly impossible, making Pneumothorax Meconium-stained amniotic fluid alerts the
nurse to the possibility of which problem?
it the leading cause of severe illness & Perinatal asphyxia Fetal distress and perinatal asphyxia
death in newborns.
Apgar Score I
Maternity

Contraindication
APGAR SCORE
0 points 1 points 2 points

The APGAR is a simple quick assessment tool used to rapidly describe a newborn's well-being
immediately after birth & how they’re adjusting to life outside the womb.

Infants are rated on a scoring system from 0 to 10. The higher the score the healthier the baby
1
It's important to note it is done twice - at 1 minute & at 5 minutes after delivery. min

& It may be reassessed for a 3rd time at 10 minutes if the score is less than 7. 1st
5
mins

NCLEX 2nd < 7 points


10

7 or Less = Reassess
mins

3rd

Sign 0 points 1 points 2 points


Interventions Based on Score
Appearance (skin color) Blue/ Pale Blue arms Completely
A Core & legs Pink

Pulse (heart rate) Absent


Pink Body

Less than OVER


0-3 Severe Distress
= Resuscitate Fully!
P 100/ min. 100/ min.

4-6: Moderate distress


G
Grimace (reaction & reflex) Absent Grimace Cry & Pull
away
= Some resuscitation
7-10: Adequate
A Activity (muscle tone) Limp Minor flexion Active flexion
& extension = Provide post delivery
R Respiratory effort Absent Weak cry Strong cry (Oxygen, Suction, Stimulate baby
by rubbing back & feet)

Always remember to start with 10 points & then focus on what’s BAD! Start subtracting bad signs so:
REALLY BAD - subtract 2 points
KINDA BAD - subtract 1 point.

TEST TIP Be sure to write out this chart at least 10 - 15 times, every day the week of your exam.

Sign 0 points 1 points 2 points


Appearance (skin color) Blue/ Pale Blue arms Completely
A Core & legs Pink
Pink Body

It's vital to know these numbers & how to rate it. P Pulse (heart rate) Absent Less than OVER
100/ min. 100/ min.
You need to spot lower ratings - as this means the newborn
Grimace (reaction & reflex) Absent Grimace Cry & Pull
is in severe distress! G away

Activity (muscle tone) Limp Minor flexion Active flexion


A & extension

R Respiratory effort Absent Weak cry Strong cry

Notes
Apgar Score II
Maternity

Sign 0 points 1 points 2 points Sign 0 points 1 points 2 points

A Appearance (skin color) Blue/ Pale


Core
Blue arms
& legs
Completely
Pink
A Appearance (skin color) Absent Less than
100/ min.
OVER
100/ min.
Pink Body
P P Pulse (heart rate)

G G <100 >100

A A
R Acrocyanosis R

Sign 0 points 1 points 2 points Sign 0 points 1 points 2 points

A Appearance (skin color) Absent Grimace Cry & Pull


away
A Appearance (skin color) Limp Minor flexion Active flexion
& extension

P Pulse (heart rate) P Pulse (heart rate)

G Grimace (reaction & reflex) G Grimace (reaction & reflex)

A A Activity (muscle tone)

R R

Top Missed NCLEX Questions


Sign 0 points 1 points 2 points While conducting an Apgar assessment, the nurse discovers the newborn is completely blue, has a
heart rate of 115/min, weak cry, active movements, flexes extremities, and shows facial grimaces
A Appearance (skin color) Absent Weak cry Strong cry when nose is suctioned. The nurse should assign which Apgar score to the newborn?

Apgar score of 6
P Pulse (heart rate)
1 2 Sign 0 points 1 points 2 points

G
Appearance Blue/ Pale Blue arms Completely
Grimace (reaction & reflex)
115 A

6
(skin color) Core & legs Pink
Pink Body

Pulse Absent Less than OVER


P
A
(heart rate) 100/ min. 100/ min.
Activity (muscle tone) Grimace Absent Grimace Cry & Pull
G
0
(reaction & reflex) away

R
Activity Limp Minor flexion Active flexion
A
Respiratory effort (muscle tone) & extension

Respiratory Absent Weak cry Strong cry


R effort

2 1

Sign 0 points 1 points 2 points Sign 0 points 1 points 2 points


Saunders Question Appearance Blue/ Pale Blue arms Completely
ATI Question Appearance Blue/ Pale Blue arms Completely

… Apgar score. The nurse notes a heart


A (skin color) Core & legs Pink A (skin color) Core & legs Pink
Pink Body ... Apgar score. The infant is crying lustily Pink Body
rate of 92, a weak cry, some flexion of
Less than OVER and has a heart rate of 130 bpm; he has Pulse Absent Less than OVER
extremities, grimacing with stimulation, P Pulse
(heart rate)
Absent
100/ min. 100/ min. some muscle tone and his body is pink P (heart rate) 100/ min. 100/ min.
and a pink body with blue extremities.
but his hands and feet are blue. Which
On the basis of this score, what should Grimace Cry & Pull Grimace Absent Grimace Cry & Pull
the nurse determine? G
Grimace
(reaction & reflex)
Absent
away
of the following is the most appropriate G (reaction & reflex) away
Apgar score?
The newborn requires some Activity Limp Minor flexion Active flexion
resuscitative interventions A Activity
(muscle tone)
Limp Minor flexion Active flexion
& extension
8 A (muscle tone) & extension

Respiratory Absent Weak cry Strong cry Respiratory Absent Weak cry Strong cry
R effort R effort

4 2 1 1
130 8

Saunders Question HESI Question

When should the nurse plan to 1st 2nd ... Apgar score of 10 at 1 minute after birth?
An infant having no difficulty adjusting
determine the Apgar score?
to extrauterine life but who should be
At 1 minute after birth and assessed again 5 minutes after birth
5 minutes afterbirth 1 min 5 mins
Newborn Assessment III
Maternity

Top Missed NCLEX Question


The nurse is performing assessments on several newborns. Which of
Newborn Vital Signs Kaplan Question
the following should be reported to the health care provider (HCP)? Assessed every 30 min after birth for 2 hours ... apical pulse on a 8 lb 4 oz newborn infant. The
Select all that apply nurse takes which action?
Then every 4 - 8 hrs. reassess
Chest wall retractions Places the bell of the stethoscope at the fourth
No bowel sounds immediately after birth Heart rate (resting - not crying) intercostal space at the left midclavicular line
No voiding in 24 hours • 110 - 160 /min. We assess at the apical pulse
Decreased muscle tone
Sacral dimple with a small skin tag listen for 1 full minute
Single artery in the umbilical cord • Put the bell of the stethoscope at the
Peeling skin in a 42 week newborn • 4th intercostal space - left midclavicular line
Side note 4th intercostal space
• 80/min during rest
Resolve on its own • 180/min when crying or agitated
Respirations:
• 30 - 60 breaths/min - assess for 1 full minute
Axillary temperature: (No rectal temp!)
• 97.7-99.5 F (36.5-37.5 C)
Blood pressure:
• 73/55 mm Hg

Newborn Glucose Levels


Blood glucose 40 or more mg/dL
1 hour after birth is expected
During pregnancy the fetus stores large quantities of glycogen that are used → encourage breastfeeding!
during the transition to life outside the womb & into the world!
As a result glucose levels are decreased 1 hour after birth, then stabilize within
2 to 3 hours. HESI Question
Glycogen In most healthy newborns,
Glucose Glucose Glucose
blood glucose levels stabilize at
____mg/dL during the first hours
after birth.
50 - 60
1 hour 2-3 hours

Medications HESI Question Interventions for LGA


Eyes: Erythromycin ointment administer vitamin K ..
(given within 1 hour of birth) 1. Assess for birth injuries
Vastus lateralis muscle cephalhematoma, or clavicular fracture
Prevents Ophthalmia neonatorum
(conjunctivitis) → blindness HESI
Thighs (Vastus Lateralis Muscle) ATI 2. Monitor for hypoglycemia
ATI Question Blood glucose < 40 - 45 mg/dL
Vitamin K: helps produce clotting
factors to prevent internal bleeding vitamin K ... Report to HCP
(given within 6 hours after birth) “The injection prevents Glucose checks prior to feedings
Hepatitis B vaccine: bleeding as newborns Encourage breast feeding every
provides antibodies against Hep B have a higher risk.” 2-3 hours
(given within 24 hours after birth) Discuss the need for feeding
supplementation if s/s of
Body Measurements hypoglycemia occur

Head circumference: 33 - 35 cm Saunders Question


Chest circumference: 30 - 33 cm 2,500 - 4,300 grams ... the infant's weight is 4400 g... may
be at risk for which complications?
Length: 45 - 55 cm Hypoglycemia
Fractured clavicle
Weight: 2,500 - 4,300 grams (5.5 to 9.5 lb) Congenital heart defect
� SGA: less than 10th percentile
� AGA: between 10th & 90th percentile 4.3kg HESI Question
� LGA: over the 90th percentile ... low birth weight (LBW) based on
which assessment finding?
� Macrosomia: more than 4000 grams Weight is less than 2.5 lbs
Parent Education For Newborn Care
& Circumcision Care
Maternity

Parent Education For Newborn Care Umbilical Cord Care


Goal: prevent infection & hemorrhage
Newborn GERD Interventions:
24-48 hrs: Cord clamp can be removed
Gastroesophageal Reflux Disease when cord is DRY
Clean cord stump with WATER and
NCLEX Key Points
AIR DRY (NOT Alcohol)
Burp during & after feeds Assess for SIGNS OF INFECTION
-Redness
Hold baby upright 20-30 minutes -Swelling
after each feeding -Drainage
Offer smaller, frequent feeds Parent Teaching:
Fold diaper down & away from the stump
NO bathing in a tub (submerged) until
cord stump falls off
Let cord fall off on its own
DO NOT PULL CORD
Kaplan Question (infection + hemorrhage risk)
NO alcohol to clean the cord only water
… newborn’s umbilical cord... teaching is effective?

“I will clean the cord and skin around it with water.”


“I will allow the cord to fall off on its own.”

HESI Question
... newborn’s cord care at home?
Allow the cord to air-dry as much as possible

24 - 48 hrs

Circumcised & Uncircumcised


Newborn circumcision is an elective procedure that removes the foreskin from the
male infant's penis using the clamp method or the plastic ring. It can be performed
before discharge on the postpartum unit or on an outpatient basis with a pediatrician.

Nursing Care Kaplan Question


1. Hand washing before care Which action should the nurse take immediately after
the newborn is circumcised?
2. Petroleum Jelly application at Applies petroleum gauze and observes carefully
diaper changes for bleeding
1 day 3 days
3. Normal healing: yellow exudate ATI Question
after the first day NCLEX TIP
HCP
1

… neonate who just underwent circumcision. If


4. Signs to report: bleeding should occur, what is the initial priority?
Bleeding exceeding the size Use a sterile gauze pad to apply light
of a quarter pressure to the area
Dry diaper or No voiding
6 - 8 hours after circumcision Saunders Question
5. Cleaning: ... newborn after circumcision … the circumcised
area is red with a small amount of blood drainage.
Warm water without soap Which nursing action is most appropriate?
AVOID alcohol-based wipes Document the findings
or soap water

Notes
NRP & NEC
Maternity

NRP - Neonatal Resuscitation Program


Critical Interventions
As you know, newborns are evaluated using APGAR
immediately after birth. Any baby presenting unresponsive, 1. Place the newborn on NCLEX TIP
or limp without spontaneous respirations should be the warmer
immediately handled in the following way: 2. Sniffing position “appropriate
for ventilating” NCLEX TIP
Indicator 0 Points 1 Point 2 Points 3. Suction airway
4. Dry & stimulate the newborn
A Appearance
(Skin color)
Blue; Pale
Pink Body;
Blue Extremities
Pink for 30 seconds

P Pulse Absent Below 100 bpm Over 100 bpm

G Grimace
(reflex irritability)
Floppy
Minimal Response
to Stimulation
Prompt Response
to Stimulation
Critical Interventions
A Activity
(muscle tone)
Absent Flexed Arms
and Legs
Active

Infant's heart rate


R Respiration Absent Slow and Irregular Vigorous Cry 160 - 100/ minute → Positive 60-100
Pressure Ventilation (PPV) PPV - Positive Pressure Ventilation
NCLEX TIP
Below 60/ minute
� Epinephrine
� Chest compression
30 seconds after quality PPV
(heart rate remains less than 60)

Necrotizing Enterocolitis
This is an inflammatory disease of the gastrointestinal mucosa due to ischemia (low oxygenation), resulting in necrosis
(dead tissue within the GI tract), & perforation of the bowel (basically an explosion of the bowel).

Pathophysiology

Signs & symptoms HESI Question


Which are risk factors for
Nursing Interventions
Feeding intolerance
Abdominal distention necrotizing enterocolitis (NEC) Daily abdominal girth
Bloody stools in preterm infants? measurements NCLEX TIP
Select all that apply.
Risk Factors Polycythemia
Prematurity Myelomenigocele
Polycythemia
Myelomenigocele ATI Question
... necrotizing enterocolitis
(NEC). Which of the following
findings should the nurse
recognize as a risk factor?
Gestational age of 35 weeks
20 - 37 weeks
Newborn Complications I
Maternity

Hyperbilirubinemia
Hyperbilirubinemia, or jaundice, is the yellowing of skin from too much bilirubin - those dead RBCS in the blood.
Patho & Causes
Pathologic
Structural defects in the liver HESI Question
→ build up of bilirubin
… highest priority to which finding?
Physiologic
RBCs breakdown (from birth trauma) Skin color that is slightly jaundiced YES!
1 Always report yellow skin!
produces bilirubin
Immature & can’t keep up
hyperbilirubinemia → Jaundice Saunders Question
Can cause multisystem organ damage
& irreparable brain damage Which assessment finding should alert the
nurse to suspect the potential for jaundice
Signs & Symptoms in this infant?
Yellowish hues Report to HCP Presence of cephalhematoma
Face or eyes (sclera)
Trunk & extremities

Treatment
Phototherapy - In the hospital setting most commonly include fiberoptic phototherapy blankets & pads.
Bili lights (lamps) - where the baby is placed under heat lamps like a food item at a buffet

Treatment: Phototherapy
Nursing Interventions PRIORITY ATI Question
1. Skin Care
Monitor skin temperature closely
37.5
… plan of care for an infant
Reposition every 2 hours receiving phototherapy?
Giving additional fluids
Saunder
2. Dehydration risk → Give fluids NCLEX

every 2 hours every two hours


3. Eye care → Cover infants eyes
with protective pads

Hypothermia (cold stress)


Cold babies with low body temperature, although easy to treat, it is VERY dangerous and can lead to hyperbilirubinemia,
hypoxia (low oxygen), & hypoglycemia (low blood sugar)! This is because oxygen consumption and metabolism are
increased leading to an unstable baby.
HESI Question
Signs & Symptoms 5 NCLEX TIPS
Which signs indicate the need for placing the
1. Altered mental status neonate in a prewarmed radiant warmer?
Select all that apply.
“Irritability or lethargy”
Hypotonia
2. Bradycardia, tachypnea & hypoxia Bradycardia
Feeding intolerance
3. Hypoglycemia & feed intolerance
4. Hypotonia, weak suck & cry ATI Question
5. NO shivering ability Q1: Which of the following findings is
unexpected when assessing a
preterm newborn for cold stress?
Causes & Risk Factors Shivering

Thin layer of subcutaneous fat Q2: … cause of neonatal hypoglycemia in


relation to cold stress?
Wet infant - Evaporation
Increased metabolic rate

Notes
Newborn Complications II
Maternity

Hypothermia (cold stress) ATI Question


Warm that baby up! The newborn infant is pale and doesn't cry...
Remember a warm baby will most appropriate action?
decrease the risk for hypoglycemia, Place the infant in a radiant warmer

Interventions 5 NCLEX TIPS hypoxia, & hyperbilirubinemia! and dry him with a towel

Saunders Question
Skin-to-skin contact newborn & mother
Dry the newborn immediately after delivery … most effective in preventing heat loss
& place hat by evaporation?
Provide care under radiant warmers Drying the infant with a warm blanket
Cover scale with warmed blankets
before weighing the newborn HESI Question
Use prewarmed incubator when transporting Which nursing action ... immediately
following the vaginal birth?
Drying the infant on the mother’s chest
and then placing a hat on the infant

Hypoxia
As you know the newborn must transition quickly from a fluid-filled environment to an air-filled environment
so the lungs must expand with the help of surfactant which prevents collapse of the alveoli within the lungs

Causes Interventions
Signs of Respiratory Distress Fluid or mucus Dry, stimulate, suction
obstruction
Pathologic apnea 00:15
Intercostal retractions Prematurity Support ventilation
Central cyanosis (lack of surfactant)
Give surfactant
Nasal flaring (Betamethasone)
Grunting, wheezing
Cardiac Defect Monitor & Surgery
Intercostal retractions
(PDA or PFO)

Hypoglycemia

Newborn blood glucose should be kept above 40mg/dL at all times. Risk Factors
Mom with diabetes (all types)
Newborns are at risk for hypoglycemia because the placenta (the source HYPOTHERMIA
of maternal glucose) is removed & the infant’s pancreas is still producing Sepsis
insulin at a rate that matches the levels of maternal glucose during pregnancy.
Signs & Symptoms
Less than 40 mg/dL
Shaking, sweating, & irritability
Lethargy
>40 High-pitched or weak cry
Seizures
Nursing Interventions
Breast feeding is #1 !
Identify high risk newborns
Keep infant warm

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