ATI Maternal Newborn Remediation (Rasmussen University)

lOMoARcPSD| ATI Maternal Newborn Remediation Maternal Child Health Nursing (Rasmussen University) ATI MATERNAL NEWBORN REMEDIATION 1. Management of Care a. Establishing Priorities Requires Further Assessment (Chp 27) tones and reflex responses, and seizures. A term newborn’s blood glucose should be 30-60mg/dL. Hypoglycemia can bring about poor feeding, jitteriness/tremors, hypothermia, diaphoresis, weak cry, and lethargy. tachypnea, nasal flaring, expiratory grunting, retractions, and cyanosis. Newborn infections like sepsis can cause an infant to have temperature instability, suspicious drainage, poor feeding, weak suck, vomiting, diarrhea, hypo or hyperglycemia, respiratory distress, and low BP. membranes, observe the newborns color for yellowish tint as the skin is blanched, and assess if there is an underlying cause that needs to be fixed. Look for hypoxia, hypothermia, hypoglycemia, and metabolic acidosis. Increased risk for brain damage. Congenital anomalies involve cleft lip/palate and tracheoesophageal fistula, excessive mucous secretions and drooling, periodic cyanotic episodes and choking, distended abdomen. PKU can result in cognitive impairment if untreated, not evident at birth and it’s found in newborn screening. Hypothyroidism: hypothermia, poor feeding, lethargy, jaundice, cretinism. Spina bifida is a protrusion of meninges and/or spinal cord, tufts of hair on the spine. Patent ductus arteriosus is another neonate complication that includes murmurs, abnormal heart rate or rhythm, breathlessness, and fatigue while feeding. has respiratory difficulties, cyanosis, tachycardia, tachypnea, and diaphoresis. Down syndrome, also known as trisomy 21, exhibits oblique palpebral fissures or upward slant of the eyes, epicanthal folds, flat facial profile with a depressed nasal bridge and small nose, protruding tongue, short broad hands with a fifth finger that has one flexion crease instead of two, a deep crease across the center of the palm, hyperflexibility, hypotonic muscles. ii. Medical Conditions: Priority Finding That Requires Further Assessment (Chp 9) ● Cervical insufficiency is a painless opening of the cervix that results in delivery of the baby in the 2nd trimester of pregnancy. Some expected findings are pink stained vaginal discharge or bleeding, possible gush of fluid, and uterine contractions w/ expulsion of fetus. The nurse needs to evaluate the client’s support system and if assistance is available for them if they are prescribed activity restrictions or bed rest. Assess the client for any vaginal discharge, monitor client reports of pressure and contractions, and check vital signs. ● For gestational HTN, some expected findings are severe continuous HA, nausea, blurring of vision, flashes of lights or dots before the eyes, HTN, proteinuria, edema, vomiting, and epigastric pain. The nurse should assess their LOC, obtain pulse oximetry, monitor urine output, and obtain a clean catch urine sample to assess for proteinuria. Also, obtain the client’s daily weight, monitor vital signs with careful attention to BP, encourage lateral positioning, perform non-stress test and daily kick counts, and instruct the parents to monitor I&Os. 2. Safety and Infection Control a. Accident/Error/Injury/Prevention Who Has Abstinence Syndrome (Chp 27) exposed to drugs in the womb before birth. Babies can then go through drug withdrawal after birth. The syndrome most often applies to opioid medicines. feedings, swaddle newborn with legs flexed, looser than normal, reduce environmental stimuli (lights off, lower noise level), and educate the mom on SIDS prevention strategies. Safety (Chp 26) until they reach maximum height and weight for seat. Rear facing car seat should preferably be placed in the middle of the back seat because they are away from the air bags and side impact. No hand me downs should be used! Set the seat at a 45-degree angle because if the car seat is too flat, the baby may slide out through the straps. If it is too upright, the head may flop forwards too much and make it difficult for the baby to breathe. b. Standard Precautions/Transmission-Based Precautions/Surgical Asepsis i. Nursing Care of Newborns: Personal Protective Equipment (Chp 24) ● Before caring for a newborn, scrub arms with antibacterial soap from your elbows to your fingertips. For a newborn’s first bath, gloves need to be worn to prevent exposure to body secretions. Individual bassinets need to be equipped with diapers, T-shirts, and bathing supplies. Nurses must follow facility hygiene protocols in between caring for newborns. All nurses must know that cover gowns and special uniforms are used to prevent direct contact with clothes. 3. Health Promotion and Maintenance conditions for up to 8 hr. It may be refrigerated in sterile bottles for use within eight days or frozen in clean containers in a two-door refrigerator's freezer compartment for up to 6 months. Also, mothers may store breast milk in a deep freezer for 12 months. Thawing the milk in the refrigerator for 24 hr preserves immunoglobulins the best. It also can be thawed by holding the container under running lukewarm water or placing it in a container of lukewarm water. Rotate the bottle often but not shaken when thawing in this manner. Do not thaw breast milk in the microwave because it can destroy immune factors and lysozymes that is contained in the milk. Once thawed, do not refreeze, just discard it. fetal heart tones are auscultated the loudest on the woman's abdomen. These tones are best heard directly over the fetal back. In vertex presentation, PMI is either in the right- or left-lower quadrant or below the maternal umbilicus. In breech presentation, PMI is either in the right- or left-upper quadrant above the maternal umbilicus. at the midline, right above the symphysis pubis, by holding the Doppler firmly on the abdomen. FHR can be detected at early appointments by ultrasound. lower-extremity edema, gingivitis, nasal stuffiness, epistaxis, Braxton Hicks contractions, and supine hypotension iv. Postpartum Physiological Adaptions: Rh Incompatibility (Chp 17) ● Administer RhO(D) immune globulin (RhoGAM) IM around 28 weeks of gestation for Rh-negative clients. Administer RhO(D) immune globulin (RhOGAM) to the client if she is Rh-negative (standard practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization). RhO(D) immune globulin (RhoGAM) suppresses the immune response of Rh-negative clients. ● RhO(D) immune globulin (RhoGAM) is administered within 72 hr to Rh- negative mothers and gave birth to Rh-positive infants to prevent sensitization in future pregnancies. If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. The Kleihauer-Betke test determines the amount of fetal blood in maternal circulation if a large fetomaternal transfusion is suspected. If 15 mL or more of fetal blood is detected, the mother should receive an increased RhoGAM dose. Test the client who receives both the rubella vaccine and RhoGAM after three months to determine whether immunity to rubella has been developed. b. Health Promotion/Disease Prevention Hemolytic Disease (Chp 27) the fetal circulation and destroys the fetal red blood cells. A condition in which there is an incompatibility between the Rh types of the mother and the fetus. Less commonly may happen with incompatible blood types between mother and fetus. Rhogam is used to prevent this disease. Some of the signs and symptoms of hemolytic disease are severe hyperbilirubinemia, jaundice, and Kernicterus. Infection (Chp 20) thrombus, history of DM, immunosuppression, anemia, malnutrition, history of alcohol/substance use, C section, prolonged ROM, retained placental fragments, manual extraction of placenta, catheters, chorioamnionitis, internal fetal uterine pressure monitor, multiple vaginal exams after ROM, PP hemorrhage, operable vaginal birth, epidural, hematomas, and episiotomy/lacerations. c. Health Screening that can go above or below the range. It also depends on the baby’s activity level. average temperature in a newborn is 37C or 98.6F up to a 1 year. This reflex happens by stroking the cheek or the edge of their mouth. As a reaction, the newborn would turn their heads to the side where they were touched and start to suck. happens by placing the examiner’s finger in the palm of the newborn’s hand. The reaction should be to have the newborn curl their fingers around the examiner’s fingers. response happens when the examiner places their finger at the base of the newborn’s toes. The appropriate reaction is the newborn curls their toes downward. months. The head and trunk of the newborn is placed in a semi sitting position, in effort to fall backwards at a 30-degree angle. The reaction should be that the newborn symmetrically extends, then abduct their arms at the elbows and fingers spread to form a “C.” newborn is lied in supine position and the examiner turns their head quickly to one side. The newborn’s arm and leg on that side extend and opposing arm and leg flex. stroking the outer edge of the sole of their feet and moving upwards toward the toes. The tan should fan upward and outward. This reflex should disappear after a year of age. lasts for about 4 weeks. The examiner holds the newborn upright with their feet touching a flat surface. The newborn responds by making stepping movements. d. High Risk Behaviors develop after menstruation, miscarriage, abortion, pelvic surgery, or even childbirth. Ovulation will remain the same. Risk factors are also the ones that are associated with other STIs like young age (common in women under 25), nulliparity, multiple partners, high rate of new partners, history of STIs, and the use of IUDs. e. Lifestyle Choices severs, burns, or blocks the fallopian tubes in efforts to prevent sperm from fertilizing the ovum. Some advantages are permanent contraception and unaffected sexual function. Disadvantages include risks related to anesthesia, complications, infection, hemorrhage, or trauma, irreversible procedure, and does not protect against STIs. A risk that may be included in this procedure is ectopic pregnancy if pregnancy occurs. 4. Psychosocial Integrity Syndrome (Chp 27) monitor newborn's ability to feed and digest intake, offer small frequent feedings, swaddle newborn with legs flexed, looser than normal, reduce environmental stimuli (lights off, lower noise level), and educate mom on SIDS prevention strategies. 5. Basic Care and Comfort a. Non-Pharmacological Comfort Interventions i. Pain Management: Teaching About Hypnosis (Chp 12) ● Hypnosis is a form of deep relaxation, similar to daydreaming or meditation. It is a trancelike state used to reduce attention to external stimuli. It enhances relaxation and perception of pain. It allows the patient to have a greater sense of control over painful contractions. Failure to dehypnotize properly may result in mild dizziness, nausea, and headache. The patient, however, can use hypnosis to relieve pain only if the patient has learnt and practiced the technique. Self-hypnosis must be learnt during childbirth/prenatal classes. It is not performed by a support person. Although hypnosis is beneficial, studies have not found it to be more effective than the use of a placebo or other interventions for pain management during labor. b. Nutrition and Oral Hydration i. Sources of Nutrition: Teaching a Client About High-Calcium Food (Chp 1) ● Calcium is important due to its involvement of bone and teeth formation. Sources include milk, fortified soy milk, fortified grains, fortified orange juice, nuts, legumes, broccoli, and dark leafy vegetables like kale and collards. Daily recommendation is 1,000 mg for pregnant and non-pregnant women over the age of 19 and 1,300 mg for those under 19. 6. Pharmacological and Parenteral Therapies a. Adverse Effects/Contraindications/Side Effects/Interactions For women diagnosed with hyperinsulinemia, clomiphene is a first-line drug for ovulation induction and may be used in combination with metformin. Breast tenderness is a common adverse effect in this medication, along with upset stomach, bloating, hot flashes, and headache. postpartum or postabortion hemorrhage caused by uterine atony or subinvolution. This drug should never be used during pregnancy to induce labor. Contraindicated for clients with HTN, severe hepatic or renal disease, thrombophlebitis, coronary artery disease, peripheral vascular disease, hypocalcemia, or sepsis or before the fourth stage of labor. iii. Medical Conditions: Client Findings and Magnesium Sulfate (Chp 9) ● Magnesium sulfate can be given to a patient who is experiencing preeclampsia as an anticonvulsant and to lower blood pressure. It is a high-risk drug, and the patient must be monitored closely. It is important for the nurse to watch for signs of toxicity including absent deep tendon reflexes, urine output of less than 30 ml/hr, respirations less than 12/min, decreased LOC, and cardiac dysrhythmias. If any of these signs are noted, discontinue IV immediately, administer calcium gluconate, and prepare for actions of cardiac or respiratory arrest. b. Medication Administration i. Therapeutic Procedures to Assist with Labor and Delivery: Candidates for Induction of Labor (Chp 15) ● Elective induction for nonmedical indications must meet the criteria of at least 39 of gestation and a Bishop score than 8 for a multipurpose client and greater than 10 for nulliparous. Some reasons or clinical presentations that someone would get an induction of labor are dystocia due to inadequate uterine contractions, prolonged rupture of membranes that predisposes the client and fetus to be at risk for infection, maternal medical complications (Rh-isoimmunization, DM, pulmonary disease, and gestational HTN), fetal demise, and Chorioamnionitis. ii. Therapeutic Procedures to Assist with Labor and Delivery: Labor Induction Using Oxytocin (Chp 15) ● Some methods to induce labor are prostaglandins applied cervically, the administration of IV oxytocin (Pitocin), amniotomy or stripping of membranes, and nipple stimulation to trigger the release of endogenous oxytocin. ● Before administering oxytocin, the nurse must confirm that the fetus is engaged in the birth canal at a minimum of station 0. Oxytocin should be connected "piggyback" to the primary IV line and administered via an infusion pump. When administering oxytocin, check the maternal blood pressure, pulse, and respirations every 30 min and every dose change. The nurse should monitor FHR and contraction pattern every 15 min and with every change in dose, assess fluid intake and urinary output, and obtain a Bishop score rating before starting any labor induction protocol. 7. Reduction of Risk Potential characteristics of uterine contractions, implement nursing interventions, and report nonreassuring patterns or abnormal uterine contractions to the provider. (Chp 4) tested in pregnancy is the blood type and Rh, antibody screen, CBC, rapid plasma reagin (RPR), Hep B and C, HIV, combined testing of chlamydia/gonorrhea/trichomonas (GC/CT), and a urine drug screen tested in pregnancy is a repeat of the CBCs and HIV, a 1-hr glucose tolerance test, and a repeat of antibody screen in Rh negative is taken. Amniocentesis (Chp 6) of the placenta and the fetus’s location. This is performed after 14 weeks of gestation. emboli, maternal or fetal hemorrhage, fetomaternal hemorrhage with Rh isoimmunization, maternal or fetal infection, inadvertent fetal damage or anomalies involving limbs, fetal death, inadvertent maternal intestinal or bladder damage, miscarriage or preterm labor, premature rupture of membranes, and leakage of amniotic fluid. assessment totaling less than 37 weeks of gestation. Periodic breathing consisting of 5- to 10-second respiratory pauses, followed by 10- to 15- second compensatory rapid respirations. They may experience periods of apnea and manifestations of increased respiratory effort and/or respiratory distress including nasal flaring or retractions of the chest wall during inspirations, expiratory grunting, and tachypnea. Low birth weight, minimal subcutaneous fat deposits, head that is large in comparison with his body, and small fontanels. covering back, forearms, forehead, and sides of face, minimal arm recoil, and few or no creases on soles of feet. Skull and rib cage that feel soft, eyes closed if the newborn is born at 22 to 24 weeks of gestation. Weak grasp reflex, inability to coordinate suck and swallow; weak or absent gag, suck, and cough reflex; weak swallow. Hypotonic muscles decreased level of activity, and a weak cry for more than 24 hr. Preterm newborns may also experience lethargy, tachycardia, and poor weight gain. e. Diagnostic Tests i. Assessment and Management of Newborn Complications: Caring for a Newborn Whose Mother has Type 2 Diabetes Mellitus (Chp 27) ● The priority nursing consideration for a newborn who has a mother with diabetes is to maintain safety because of the low glucose levels. An inadequate amount of cerebral glucose causes irritability and restlessness. Hypoglycemia affects the central and peripheral nervous systems, resulting in hypotonia. Feeding difficulties result from hypoglycemic effects on the fetal central nervous system. Hypoglycemia causes cyanosis in the newborn. 8. Physiological Adaption a. Alterations in Body Systems Who Has Necrotizing Enterocolitis (Chp 27) infection and inflammation that causes damage and the death of cells in some or all of the intestine. Medical treatment includes stopping all regular feedings. The baby receives nutrients through an intravenous (IV) catheter, placement of a nasogastric tube extending from the nose into the stomach. The tube suctions air and fluids from the baby's stomach and intestine, relieving swelling and discomfort. Taking frequent blood tests. These can detect early signs of infection and imbalances in the body's chemistry. If abdominal swelling interferes with breathing, providing oxygen or mechanically assisted breathing. In severe cases, platelet and red blood cell transfusion may be necessary. If a child does not respond to medical treatment, or if the intestine is perforated, surgery is needed. dyspareunia and itching, dysuria. Physical findings in females are discharge in the vaginal vault, which can be sampled for microscopy, and strawberry spots on the cervix (tiny petechiae), a cervix that bleeds easily. All sexual partners need to be treated and identified, and everyone muse be educated on safe sex practices. Medications that can be used is metronidazole or tinidazole. Instruct the client not to breastfeed. Procedures such as amniocentesis and episiotomy should be avoided due to the risk of maternal blood exposure. Use of internal fetal monitors, vacuum extraction, and forceps during labor should be avoided due to the risk of fetal bleeding. Administration of injections and blood testing should not take place until the first bath is given to the newborn. Intervention (Chp 9) baby’s activity level will significantly decline and contractions early in the third trimester are seen as well. A persistent severe headache, abdominal pain, visual disturbances, and some swelling on the legs can be seen. Reasons for the bleeding during the third trimester is placenta previa, abruptio placentae, and vasa previa. newborns suction mouth first then nose this is done to remove excess mucus from the respiratory tract by first compressing the bulb before insertion into one side of the mouth, avoiding the center of the mouth because of the gag reflex, and aspirate mouth first, then one nostril and then the other nostril. prolonged past 12 weeks gestation. This can lead to 5% weight loss, dehydration, dehydration, nutritional deficiencies, electrolyte imbalances, and ketonuria. Some risk factors include maternal age younger than 30, history or migraines, obesity, first pregnancy, diabetes, GI disorders, or family history of hyperemesis. the nurse needs to monitor the patient's I&Os, assess their skin turgor, weight, and vital sign. ii. Assessment and Management of Newborn Complications: Actions to Take for a Newborn Receiving Phototherapy (Chp 27) ● Phototherapy is a procedure when UV light is used to facilitate the conversion of unconjugated bilirubin in the newborn to its conjugated form so it can be excreted through fecal matter via bile. Hyperbilirubinemia is when the total serum bilirubin level is above 5mg/dL. This results from unconjugated bilirubin being deposited in the skin and mucous membranes. Phototherapy should be used if or when the levels of unconjugated serum bilirubin increase and do not return to normal levels with increased hydration. ● Place an eye mask over the newborns eyes after they are gently closed to protect the corneas and retinas. The nurse should know to avoid applying lotions or ointments to newborns because they absorb heat and can cause burns. Turn off phototherapy lights before drawing blood for testing and remove the newborn every two hours to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. The newborn needs to be kept undressed, but a surgical mask can be used to cover the genitalia to prevent testicular damage from the hat and light. The newborn should be removed every four hours to check for inflammation or injury, their mask may be removed at this time. every 3 to 4 hours, the newborn must be fed to promote bilirubin excretion in their stools. Encourage the parents to continue breastfeeding to maintain adequate fluid intake to prevent dehydration and promote excretion. Within 4-6 hours, the bilirubin levels should start to decrease after starting treatment. c. Medical Emergencies i. Assessment and Management of Newborn Complications: Identifying a Need for Intervention (Chp 27) ● There are certain manifestations that the parents need to report immediately. Reportable findings is their temperature being greater 100.4F or less than 97.9, poor feeding or little interest in food, decreased urination/diarrhea/decreased bowels, jaundice, cyanosis, inconsolable crying, bleeding or purulent drainage around umbilical cord or circumcision, and drainage in the eyes. ● Some complications that can happen because of improper understanding from the discharge instructions. The nurse needs to intervene for an infected cord or circumcision from improper care or tub bathing too soon, improper safety precautions like falls or suffocation, respiratory infections due to passive smoke or inhaled powders, injuries or death from improper or no use of the car seat. d. Unexpected Responses to Therapies i. Fetal Assessment During Labor: Nursing Action for Late Decelerations (Chp 13) ● Causes and complications for the late deceleration of FHR are slowing FHR after the contraction has started with a return to baseline well after the contraction has ended. Uteroplacental insufficiency causing inadequate fetal oxygenation. Maternal hypotension, abruptio placentae, uterine hyperstimulation with oxytocin (Pitocin). Place the client in a side-lying position and increase the rate of IV fluid administration. Discontinue oxytocin (Pitocin) and administer oxygen by mask at 8 to 10 L/min. The provider needs to be notified and prepare for an assisted vaginal birth or cesarean birth.