NUR 327 Chamberlain Advanced Study
Guide Exam 3 2026
Normal fetal HR - -110-160 beat/min
Accelerations in FHR - -
■ Temporary increase -
■ Reassuring - no interventions
Early decelerations - -
■ Normal - no interventions, expected finding
■ Cause: compression of head on the pelvis
Late deceleration: response after contraction - -
■Non-reassuring - needs intervention
■ Interventions: side-lying position, fluids, d/c oxytocin, O2, notify the provider, palpate
uterus for tachysystole
■ Cause: uteroplacental insufficiency
Variable decelerations - -
■ Requires intervention
■ Intervention: knee to chest position or side-side reposition, d/c oxytocin, O2,
notify provider
■ Cause: cord compression
VEAL CHOP MINE - -Menomic for decelerations
■ Variable Cord compression Move the patient
■ Early Head compression Identify labor progress
■ Accelearate Okay No action
■ Late Placental insufficiency Execute "STOP"
(stop
Pitocin, turn patient on side, O2 via face mask, plain IV fluid increased)
Fetal bradycardia - -FHR drops below 110 for at least 10 minutes
Fetal Bradycardia - Cause & Intervention - -
■ Causes: uteroplacental insufficiency, umbilical cord prolapses, maternal
hypotension, anesthetic meds mom received
NUR 327
NUR 327
■ Interventions: stop oxytocin, left side position, O2, notify provider
Fetal tachycardia - -FHR increases above 160 for over 10 minutes
Fetal tachycardia - Cause & Intervention - -■ Causes: infection, cocaine use,
dehydration
■ Interventions: antipyretics, oxygen, IV fluid bolus
(B)UBBLE - -Breasts
(size, contour, asymmetry, engorgement, redness, nipples: cracking, inverted,
bleeding)
B(U)BBLE - -Uterus
(Fundal Height, Uterine Placement, and Consistency)
■ 2 hrs after birth- Fundus is between the umbilicus and the symphysis pubis
■ 6-12 hrs after birth the fundus usually is at the level of the umbilicus
■ The fundus progresses downward at a rate of 1 fingerbreadth (or 1 cm) per day
after childbirth
■ If the fundus is not firm gently message the uterus using a circular motion until it
becomes firm
BUB(B)LE - -Bladder
■ Assess the bladder for distention and adequate emptying after efforts to void
■ Note the location and condition of the fundus , a full bladder tends to displace
the uterus up and to the right
■ Be alert for signs of infection, including infrequent or insufficient voiding (less
than 200 ml)
BU(B)BLE - -Bowels and GI function
■ Spontaneous bowel movements may NOT occur for 2-3 days after giving birth b/c
of a decrease in muscle tone in the intestines during labor
■ Normal patterns of bowel elimination usually return within 8-14 days after birth
■ Inspect the woman's abdomen for distention, auscultate for bowel sounds in all 4
quadrants, & palpate for tenderness
■ Ask the woman if she has had a bowel movement or has passed gas since giving
birth
Lochia rubra - -Rubra- red 1-3 days
Reddish or red-brown vaginal discharge that occurs immediately after childbirth;
composed mostly of blood.
NUR 327
(COAT)
Lochia serosa - -Serosa- pink 3-10 days
Lochia alba - -Alba- white 10-14 days
Lochia Scant - -The amount of lochia on the perineal pad is described as follows:
Scant: 1-2-inch lochia stain or approx. a 10 mL loss
Lochia light - -The amount of lochia on perineal pad is described as follows:
Light or small: an approx. 4-inch stain or a 10-25 mL loss
Lochia moderate - -The amount of lochia on the perineal pad is described as follows:
Moderate: a 4-6-inch stain w/ an estimated loss of 25-50 mL
Lochia large or heavy - -The amount of lochia on the perineal pad is described as
follows:
Large or heavy: a pad is saturated within 1 hour after changing it
BUBB(L)E - -Lochia
■ the postpartum vaginal discharge that typically continues for 4-6 weeks after childbirth
■Report any abnormal findings, such as heavy, bright-red lochia w/ large tissue
fragments or a foul odor to the physician
■ Teach patient about frequent changing of perineal pads, continuous use of the
peribottle, and proper handwashing before & after changing the pad
BUBBL(E) - -Episiotomy/Perineum:
■ Inspect the episiotomy for irritation, ecchymosis, tenderness, hematomas
■ Assess for hemorrhoids
■ Redness, swelling , increased discomfort, or purulent drainage may indicate
infection
■ Ice can be applied to decrease comfort and reduce edema; sitz baths can also
promote comfort and perineal healing
NUR 327
NUR 327
(H)ER - -Homan's sign
■ Assess legs for DVT, unilateral swelling, erythema, & warmth
■ Encourage ambulation
Cardiovascular changes after delivery - -Blood loss:
■ Vaginal - 500 mL
■ C-section - 1,000 mL
■ Coagulation factors increased for 2-3 weeks after birth, which increases
risk for blood cloth
■ Elevated WBC for the first week
■ Check if calves & legs are soft & NOT painful - has she been up since
delivery
H(E)R - -Emotion: emotional status
■ Be alert of mood swings, irritability, or crying episodes, which could show
postpartum depression or psychosis
■ Remember cultural considerations
■ Edenberg's PPD screening
HE(R) - -Rhogam
■ Administered 72 hours after birth to Rh negative moms who gave birth to Rh
positive babies to prevent the formation of antibodies to protect future babies
■ Also, given at 28 weeks
Postpartum Assessment - Lochia - -Lochia:
■ Red/rubra - 1-3 days
■ Pink/serosa - 3-10 days
■ White/alba - 10-14 days
Postpartum Assessment - Timing's - -Assessments:
■ Every 15 min. during the 1 st hour
■ Every 30 min. during the 2 nd hour
■ Every 4 hours during the first 24 hours
■ Every 8 hours after the first 24 hours
Postpartum Assessment Vitals - Temp - -Temp.:
NUR 327
NUR 327
NUR 327
■ May rise up to 38 °C (100.4 °F) - during the first 24 hours in some women
due to dehydration
■ If temp. is above 38 °C (100.4 °F) at any time or an abnormal temp. after
the first 24 hours may indicate infection & MUST be reported
Postpartum Assessment Vitals - Pulse Rate - -Pulse rate:
■ Bradycardia may be noted due to changes in blood volume & cardiac
output after delivery
■ Pulse usually stabilizes to pre-pregnancy levels within 10 days
■ Tachycardia in the postpartum woman can suggest anxiety, excitement,
fatigue, pain, excessive blood loss, infection, or underlying cardiac
problems
Postpartum Assessment Vitals - BP - -Blood pressure:
■ Compare BP w/ client's usual range
■ Elevations in BP from baseline may suggest pregnancy-induced
hypertension; decreases may suggest dehydration or excessive blood loss
■ Be alert for orthostatic hypotension
Postpartum Assessment Vitals - Pain - -Pain
■ Assess patient's pain on a scale of 0-10
■ The goal of pain management: have the client's pain on a scale of 0-2 at all times
■ If the client complains of severe perineal pain - inspect & palpate for
hematoma
Psychological adaptations: Taking-in - -Taking in:
■ Occurs immediately after birth when the mother needs sleep, depends on
others to meet her needs, & relieve the event surrounding the birth
process
■ Occurs during the first 24-48 hours after birth, mother assumes a passive
role in meeting her own basic needs for food, fluid, & rest (dependent on
nurse to make decisions for them)
NUR 327
NUR 327
■ Spend time telling others about labor experience
■ Touches & explores infants
Psychological adaptations: Taking-hold - -Taking hold:
■ The second phase is characterized by dependent & independent maternal
behavior
■ Starts 2-3 day postpartum, & may last several weeks
■ Mother starts to regain control over body functions & thought of the
present (concerned about her health, infant condition, & ability to care for
infant)
■ Demonstrate increased autonomy & independence by expressing strong
interest
Psychological adaptations: Letting-go - -Letting go:
■ The third phase occurs when the woman reestablishes relationships w/
other people
■ Begins to adapt to parenthood through her new roles
■ Becomes focused on moving forward by assuming the parental role by
separating herself from the symbolic relationship she & her newborn had
during pregnancy
■ Establishes a lifestyle that includes the infant
Psychological adaptations: Role-attainment - -■ a process when mother forms an
emotional relationship w/
infant over time
■ Commitment, mother attachment to unborn baby, & preparation for
delivery & motherhood during pregnancy
■ Acquaintance/attachment to the infant, learning to care for the infant, &
physical restoration during first 2-6 weeks following birth
■ Moving toward a new normal
■ Achievement of maternal identity through redefining self to incorporate
motherhood (around 4 months). During this time mother feels self-confident &
competent in her mothering roles & expresses love for &
NUR 327
pleasure interacting w/ her infant
Baby blues (1-10 days) - -characterized by mild depressive symptoms - mood swings,
anger,
anxiety, irritability, tearfulness (often for no reason)
■ the "blues" typically peak on postpartum 4 th & 5 th day, may last
hours to days
■ usually resolves by day 10 w/o therapy - nursing management:
■ encourage the mother to express her feelings to ease
■ be patient & understanding to her & family
■ suggest getting outside help w/ housework & infant care
■ provide telephone numbers that she can call when she's
down
■ reassure patient that feelings are normal &; temporal
postpartum depression - -usually occurs if symptoms of "baby blues" last longer than 6
weeks & seems to get worse
■ s/s: more severe than "baby blues", requires treatment
■ feeling restless, worthless, guilty, hopeless, moody, sad, &
overwhelmed
■ also, at risk of hurting self or infant - treatment:
■ antidepressant, antianxiety, & psychotherapy
■ marriage counseling may be required if marital problems
are contributing to symptoms
postpartum psychosis - -severe depressive disorder
■ Severe depressive disorder
■ Evident within the first three months postpartum
■ Symptoms include agitation, hyperactivity, insomnia, confusion,
NUR 327
NUR 327
NUR 327
difficulty remembering or concentrating, delusion, hallucinations,
irrationality, anger toward self and infant
■ Nurse Management: Assist patient with measures on self-control,
encourage to verbalize feelings, encourage and assist in getting help
Bonding - -develops during the first 30-60 minutes after birth, but begins
during pregnancy
■ Involves mothers visually & physically "explore" infant (fingertips
on face & extremities, massaging, palm contact on trunk, infant
held close)
Newborn response to attachment - -by cooing, grasping, smiling, & crying
Positive attachment behaviors r/t parent - -direct eye contact, pointing out
common features, speak positively
Positive attachment behaviors r/t infant - -alert, strong grasp reflex, sucks
well, enjoy being held close, follows parent's face
Negative attachment behaviors r/t infant - -feed poorly cries for long
periods, flat affect, stiffens body when held, doesn't pay attention to
parent's faces
Negative attachment behaviors r/t parent - -disappointment in infant, fails
to "explore" infant, avoids caring for infant, negative self-concept, appears
uninterested, call baby negative names (frog, monkey)
Father bonding - -similar, but pace may differ
■ Attachment for fathers increased if they viewed caregiver role as
important
■ Fathers also begin attachment behaviors during pregnancy
■ Becoming a father requires a man to build on experiences
throughout childhood & adolescences
Another family member - Bonding - -May view them as competition or fear that they will
be replaced
■ Reassurance & attention from parents will help them feel loved &
important
■ Expect regression (sucking thumb, bedwetting)
NUR 327
NUR 327
■ Encourage discussion about the infant
■ Arrange for child to see infant in the hospital
■ Show photos of baby growing in mommy's belly
■ Encourage others to pay attention to the older child when visiting
Postpartum uterus - -The uterus returns to its normal size through a gradual process,
which
involves retrogressive changes that return it to its regular size
Postpartum cervix - -Cervix returns to normal size 6 weeks after birth
Postpartum endocrine changes - -Levels of circulating estrogen & progesterone drop
rapidly when the placenta is delivered
■For non-lactating women, estrogen levels begin to increase 2 weeks after
birth
■ For breastfeeding women, levels remain low until breastfeeding frequency
decreases
postpartum cardiovascular changes - -■ Cardiac output remains high for the 1 st few
days after birth & gradually
declines
■ Blood volume also drops after birth & gradually returns to pre-pregnancy
levels
Postpartum integumentary changes - -■ Decreased levels of estrogen & progesterone
cause linea nigra, nipples, &
melisma to fade
■ Some women experience hair loss during the postpartum period
■ Frequent profuse sweating is common during the early postpartum period
■ It's a mechanism to reduce the amount of fluids retained during
pregnancy
Postpartum Immune system - -■ WBC's increase during labor &remain elevated for 4-6
days after birth (25,000-30,000)
■ WBC's fall back to the normal range after this early postpartum period
NUR 327
NUR 327
Rubella vaccination - -provide vaccine if the mother is NOT serologically
immune (titer less than 1:8)
Engorgement - -Swelling of the breasts resulting from increased blood flow, edema, and
the presence of milk
can be alleviated by frequent feedings, at least every 2 to 3 hours.
Instruct mother can be alleviated by frequent feedings, at least every 2 to 3 hours.
Wear supportive bra 24 hours a day
Non-breastfeeding mothers - -In the non-breastfeeding woman let her know that
engorgement is self-limiting and lactation will
begin to disappear as estrogen levels increase and suppress milk formation. Wearing a
snug bra and ice packs and help with the symptoms
■ Engorgement resolves in 24 to 36 hours after milk comes in
■ Estrogen levels begin to increase 2 weeks after delivery
Breastfeeding contraindications - -■ HIV
■ Street Drugs
■ Chemotherapy Drugs
■ Herpes Simplex
■ Untreated TB
■ Galactosemia
T or F - Breastfeeding makes the breasts sag - -False
Pregnancy, heredity, & aging cause the breasts to sag, NOT breastfeeding
T or F - A mother needs to clean her nipples before breastfeeding - -False
■ The nipple area has natural protective oils to keep it germ free
■ Soap & alcohol irritate the nipples & should be avoided
■ Mothers only need to rinse the breasts w/ water once a day
T or F - Breastfeeding can help a mother shed baby weight & allows your body to
recover
from pregnancy & childbirth more quickly - -True
■ Moms who breastfeed burn about 300-500 extra calories a day
■ Breastfeeding also releases hormones that trigger your uterus to return to
NUR 327
NUR 327
its pre-baby size & weight faster
T or F - Women who smoke should NOT breastfeed - -False
■ All women are encouraged to stop smoking or at least cut down
■ It is better for the baby if the mother smokes & breastfeeds than it is if the
mother smokes & does not breastfeed
■ Second-hand smoke is considered worse for the baby
T or F - Breastfeeding can be painful to mothers - -False
■Breastfeeding should not hurt
■ Soreness happens when the baby is incorrectly positioned or latching on
T or F - Breast fed babies do NOT require extra water to support the baby - -True
■ Human milk is about 87% water, just what a body needs
■ Even in the desert, breastfed babies do NOT need additional water
T or F - Breastfeeding makes the baby too dependent on the mother - -False
■ Loving, holding, & meeting baby's needs makes the baby feel secure &
help to become independent
■ All babies need to develop a strong attachment to 1 person first before
they expand their circle of attachments
Advantages of Breastfeeding - -■ Less likely to result to overfeeding leading to obesity
■ Immunological properties help fight infection in infant
■ Provide protection against food allergies
■ Promote optimal mother-infant bonding
■ Less expensive than formula
■ Promote postpartum weight loss
■ Lowers the risk of breast cancer
Disadvantages of breastfeeding - -■ Breastfed babies need to be fed more often
■ Some medications are passed through breast milk
■ You need to eat a balanced diet
■ You do NOT know how much milk they're getting
■ Breast soreness
Breastfeeding Nutirtion - -■ 4 servings of Fruits and Vegetables
NUR 327
■ 4-5 servings of milk
■ 12 or more servings Bread, Pasta, Cereal
■ 7 servings Meat, Poultry, Fish, Eggs
■ 5 servings Fats, Oils, and Sweets
■ Lower intake of saturated fats, trans fat, & cholesterol
newborn hypothermia - -■ Normal temp. range for infant: 97.7 °F-99.7 °F
s/s:
■ temp. less than 97.7 °F (36.5 °C)
■ cyanosis
■ increased RR
■Assess temperature q30 min for the first 2 hours then q8 hours until discharge
Predispositions to heat loss - -■ Thin skin
■ Lack of shivering ability
■ Lack of subcutaneous fat
■ Little ability to conserve heat
■ Inability to communicate hot or cold
Hypothermia nursing interventions - -■ Monitor for cyanotic trunk, depressed
respirations
■ Warm infant slowly over a period of 2-4 hours in a radiant warmer - Preferred method:
skin-to-skin
■ Check temp. every hour until stable
■ All exams & assessment should be performed under radiant warmer or during
skin-to-skin - -■ Performed within the first 48 hours following birth
■ Take measurements &use the Ballard Scale
o Ballard Gestational Age Tool
■ Provides estimation of gestational age
■ Baseline for growth & development
■ Neuromuscular Maturity
■ 6 ranges
■ assigned # value from -1 to 5
Appropriate for Gestational Age (AGA) - -Weight, length, and head circumference are
between the 10th and 90th percentiles for gestational age.
NUR 327
NUR 327
Small for Gestational Age (SGA) - -weight is less than the 10 th percentile
Large for Gestational Age (LGA) - -weight is greater than the 90th percentile
Low Birth Weight (LBW) - -a birth weight of less than 5.5 pounds
Term - -37-42 weeks of gestation
Preterm or premature - -birth prior to 37 weeks
Posterm (postdate) - -birth after 42 weeks
Postmature - -born after the completion of 42 weeks w/ evidence of placental
insufficiency
Newborn assessment - -Immediate assessment: initial
■ drying - prevention of heat loss is essential to help support thermoregulation
■ temp. regulation - assess body temp. q 30 mins for the first 2 hours, then q 8
hours until discharge
■ palate - check for intact & hard palates
■ length - 17-22 inches
■ weight - 5 lbs. 8 oz. to 8 lbs. 14 oz.
■ eye care - erythromycin 0.5% or tetracycline 1% ointment given in single
application in 1-2 hours after birth
■APGAR
Average newborn length - -17-22 inches
Average newborn weight - -5.5 to 8.8
APGAR - -Apgar score: assessed at 1 & 5 minutes
■ A = appearance (color)
■ P = pulse (heart rate)
■ G = grimace (reflex/irritability)
■ A = activity (muscle tone)
■ R = respiratory effort
APGAR: HR - -0 = absent
1 = 100 bpm
2 = 100 bpm - count HR for 1 min: place fingers at junction of umbilical cord and skin (if cord still
pulsates) or place fingers or stethoscope over 5th intercostal space
NUR 327
NUR 327
APGAR: Respiration - -0=absent
1=slow/irregular weak cry
2=Good/Crying
APGAR: muscle tone - --0=flaccid -1=some flexion -2=well-flexed, active movement of extremeties
APGAR: Reflex irritability - -0= none
2= grimace, weak cry
3= Good cry
APGAR: Appearance - -0 = blue/pale all over
1 = pink w/ blue extremities
2 = All pink
Newborn Blood Pressure - -50-75 systolic, 30-35 diastolic
(Taken if low APGAR Score)
Newborn HR - -120-160 bpm
can increase to 180 if crying
newborn reflexes - -Rooting, sucking, grasping, moro reflex (startle), Babinski,
PKU test - -Test that is mandatory for all babies
Assess if infant has the necessary enzyme needed to breakdown and
phenylalanine, a necessary amino acid to help w/ the infant's growth and
development
congenital hypothyroidism (cretinism) - -■Screened b/c the thyroid is necessary for brain
growth calorie metabolism
and development
■Expected findings -
pot belly
pale
puffy face
protruding umbilicus/tongue
poor brain dev
Galactosemia Screening Tests - -■ When there is a lack of the enzyme needed to turn
the sugar from milk
into glucose
NUR 327
NUR 327
NUR 327
■ Complications: poor weight gain, N/V, seizures, loss of eyesight,
galactose buildup causing damage to brain, eyes, & liver
Sickle cell anemia screening - -■ Recessively inherited gene in the structure of
hemoglobin causing the
RBC
■ Risks: increased infections, growth restriction, vasocclusive crisis (VERY
PAINFUL)
Behavioral responses - Orientation - -newborn responding to stimuli, moving head &
eyes
Behavioral responses - Habituation - -newborn's ability to process & respond to
environment
Behavioral responses - Motor maturity - -evaluation of posture, tone, coordination,
movements
Behavioral responses - Self-quieting ability - -newborns' ability to quiet & console
themselves
Behavioral responses - Social behaviors - -the degree to which newborn nestles into
arms
First period of reactivity - -■ Begins at birth & lasts from 30 minutes up to 2 hours
■ The newborn is alert, moving, may appear hungry
■ Period of alertness allows parents to interact w/ their newborn & to
enjoy close contact w/ their baby
■ The appearance of sucking & rooting from a newborn provides good opportunity for
initiating breastfeeding
Period of decreased responsiveness - -30-120 minutes of age, the newborn enters the
2nd stage known as the sleep
period or decrease inactivity
■ heart &respiratory rates decline along w/ muscles relaxed & responsiveness to
outside stimuli diminishes
■it's difficult to interact w/ a newborn during this phase
■ this can be a quiet time for both mother & baby to rest afterbirthing experience
NUR 327
signs of respiratory distress in newborn - -Cyanosis, tachypnea, expiratory grunting,
sternal retractions, nasal flaring
Newborn Hemoglobin - -17-23 g/dL
Newborn Hematocrit - -46-68%
Newborn Platelets - -150,000-350,000/ uL
Newborn RBC - -4.5-7.0 (1,000,000/ uL)
Newborn WBC - -10-30,000/mm
Newborn Glucose - -40-60 mg/dL -first day
then 50-90 mg/dL
Newborn Hepatic System - -■ At birth, the liver assumes the functions that the placenta
handled during fetal life
■ Blood coagulation
■ Iron storage
■ Carbohydrate metabolism -the main source of energy for 1st several hours
■ Conjugation of bilirubin - when unconjugated bilirubin pigment is deposited in
skin, jaundice occurs
first stool of the newborn - -meconium - greenish/black tarry consistency
Milk stool - -BF- yellow gold, loose, sour smelling
Formula- vary based on type, yellow-green, loose, unpleasant odor
Newborn Jaundice - -RBC die off in large numbers after birth
phorphyrin rings (bilirubin) will overwhelm the immature liver causing it to process slowly
Build up of bilirubin/biliberin in tissues
treatment = UV light (phototherphy)
Vitamin K - -■ Fat soluble vitamin that promotes blood clotting by increasing synthesis
of prothrombin
by the liver
NUR 327
NUR 327
■ Deficiency of this vitamin K delays clotting time therefore leading to hemorrhage
■ Takes about a week for the newborn to produce enough vitamin K to prevent bleeding
■ Administer 0.5-1 mg IM into the vastus lateralis 1 hour after birth
■ DO NOT administer in the same leg as hep B
Umbilical Cord Care - -■ Begins within hours of birth and is shriveled and blackened by
the 2nd or 3rd day
■ Sloughs off between 7-10 days
■ Do not submerge baby in water until the umbilical cord falls off (Sponge baths)
■ Fold diapers below the level of the cord
■ Frequent assessments to detect signs of bleeding and drainage
Cord infection manifestations - -■ Moist
■ Red
■ Foul odor
■ Purulent drainage
■ Notify DR. Immediately
Circumcision Care - -■ NOT done immediately after birth due to low vitamin K levels
■ Heals in 7-10 days
■ If bleeding occurs, then apply pressure
■ Use petroleum jelly w/ gauze to cover the incision
■ Change diapers frequently
■ Yellow exudate forms in 2-3 days
Circumcision contraindications - -■ Hypospadias (abnormal positioning of urethra)
■ Epispadias (urethra on top of head of penis)
■ Family history of bleeding disorders
■ Parents decline vitamin K for infant
NUR 327
NUR 327
NUR 327
Bowel elimination (mother) - -■ Proper bowel function - IMPORTANT after delivery
■Use the following to assist w/ proper GI motility & prevent constipation
■ Progressive exercise - walking
■ Dietary fiber - found in whole grain breads/cereals & unpeeled fruits & vegetables
■ Extra water & fluid - 6-8 glasses per day
Colostrum - -■ thin, milky fluid secreted by the breast during pregnancy and during the
first days after birth before lactation begins
■ delivers essential nutrients and antibodies in a form that the newborn can digest
Newborn safety - discharge - -■ Make sure ID bands match
■ Properly installed car seat
■ Babies should sleep on their backs
■ Protect from excessive sunlight
■ Provide a smoke-free environment
■ Learn CPR
Signs of infection in infant - -■ green, watery stools
■ fever
■ vomiting
■ loss of appetite
■ very lethargic
■ labored breathing
■ drainage from umbilical cord site & eyes
Newborn Meconium Aspiration - -Occurs when a newborn breathes a mixture of
meconium & amniotic fluid into the lungs around the time of delivery
Newborn Meconium Aspiration Symptoms - -■ Bluish skin color in the infant
■ Breathing problems
■ Dark, greenish staining or streaking of the amniotic fluid or the obvious presence
of meconium in the amniotic fluid
■ Limpness in infant at birth
Newborn Meconium Treatment Symptoms - -■ Suction mouth immediately following
birth
■ Antibiotics
NUR 327
■ Breathing machine to keep lungs inflated
■ Baby warmer for temp. regulation
■ Chest tapping to loosen secretions
Hyperbilirubinemia - -excessive level of bilirubin (bile pigment) in the blood
Hyperbilirubinemia symptoms - -
■ Jaundice appearance
■ Poor feeding
■ Lack of energy
Hyperbilirubinemia treatment - -Phototherapy - used to lower increased levels of
bilirubin (used if increased hydration does NOT work)
■ Exposing the newborn to UV light converts unconjugated bilirubin into
products that can be excreted through feces and urine
■ Most common treatment for hyperalbuminemia
Heel Stick Procedure - -■ Newborns need to ingest enough breastmilk to elevate
phenylalanine levels to identify
PKU accurately
■ Requires a few drops of blood taken from the newborn's heel
■ Blood is then replaced on the blood specimen card for screening
■ Performed before discharge
NUR 327
Vista previa del contenido
NUR 327
NUR 327 Chamberlain Advanced Study
Guide Exam 3 2026
Normal fetal HR - -110-160 beat/min
Accelerations in FHR - -
■ Temporary increase -
■ Reassuring - no interventions
Early decelerations - -
■ Normal - no interventions, expected finding
■ Cause: compression of head on the pelvis
Late deceleration: response after contraction - -
■Non-reassuring - needs intervention
■ Interventions: side-lying position, fluids, d/c oxytocin, O2, notify the provider, palpate
uterus for tachysystole
■ Cause: uteroplacental insufficiency
Variable decelerations - -
■ Requires intervention
■ Intervention: knee to chest position or side-side reposition, d/c oxytocin, O2,
notify provider
■ Cause: cord compression
VEAL CHOP MINE - -Menomic for decelerations
■ Variable Cord compression Move the patient
■ Early Head compression Identify labor progress
■ Accelearate Okay No action
■ Late Placental insufficiency Execute "STOP"
(stop
Pitocin, turn patient on side, O2 via face mask, plain IV fluid increased)
Fetal bradycardia - -FHR drops below 110 for at least 10 minutes
Fetal Bradycardia - Cause & Intervention - -
■ Causes: uteroplacental insufficiency, umbilical cord prolapses, maternal
hypotension, anesthetic meds mom received
NUR 327
,NUR 327
■ Interventions: stop oxytocin, left side position, O2, notify provider
Fetal tachycardia - -FHR increases above 160 for over 10 minutes
Fetal tachycardia - Cause & Intervention - -■ Causes: infection, cocaine use,
dehydration
■ Interventions: antipyretics, oxygen, IV fluid bolus
(B)UBBLE - -Breasts
(size, contour, asymmetry, engorgement, redness, nipples: cracking, inverted,
bleeding)
B(U)BBLE - -Uterus
(Fundal Height, Uterine Placement, and Consistency)
■ 2 hrs after birth- Fundus is between the umbilicus and the symphysis pubis
■ 6-12 hrs after birth the fundus usually is at the level of the umbilicus
■ The fundus progresses downward at a rate of 1 fingerbreadth (or 1 cm) per day
after childbirth
■ If the fundus is not firm gently message the uterus using a circular motion until it
becomes firm
BUB(B)LE - -Bladder
■ Assess the bladder for distention and adequate emptying after efforts to void
■ Note the location and condition of the fundus , a full bladder tends to displace
the uterus up and to the right
■ Be alert for signs of infection, including infrequent or insufficient voiding (less
than 200 ml)
BU(B)BLE - -Bowels and GI function
■ Spontaneous bowel movements may NOT occur for 2-3 days after giving birth b/c
of a decrease in muscle tone in the intestines during labor
■ Normal patterns of bowel elimination usually return within 8-14 days after birth
■ Inspect the woman's abdomen for distention, auscultate for bowel sounds in all 4
quadrants, & palpate for tenderness
■ Ask the woman if she has had a bowel movement or has passed gas since giving
birth
Lochia rubra - -Rubra- red 1-3 days
Reddish or red-brown vaginal discharge that occurs immediately after childbirth;
composed mostly of blood.
NUR 327
, NUR 327
(COAT)
Lochia serosa - -Serosa- pink 3-10 days
Lochia alba - -Alba- white 10-14 days
Lochia Scant - -The amount of lochia on the perineal pad is described as follows:
Scant: 1-2-inch lochia stain or approx. a 10 mL loss
Lochia light - -The amount of lochia on perineal pad is described as follows:
Light or small: an approx. 4-inch stain or a 10-25 mL loss
Lochia moderate - -The amount of lochia on the perineal pad is described as follows:
Moderate: a 4-6-inch stain w/ an estimated loss of 25-50 mL
Lochia large or heavy - -The amount of lochia on the perineal pad is described as
follows:
Large or heavy: a pad is saturated within 1 hour after changing it
BUBB(L)E - -Lochia
■ the postpartum vaginal discharge that typically continues for 4-6 weeks after childbirth
■Report any abnormal findings, such as heavy, bright-red lochia w/ large tissue
fragments or a foul odor to the physician
■ Teach patient about frequent changing of perineal pads, continuous use of the
peribottle, and proper handwashing before & after changing the pad
BUBBL(E) - -Episiotomy/Perineum:
■ Inspect the episiotomy for irritation, ecchymosis, tenderness, hematomas
■ Assess for hemorrhoids
■ Redness, swelling , increased discomfort, or purulent drainage may indicate
infection
■ Ice can be applied to decrease comfort and reduce edema; sitz baths can also
promote comfort and perineal healing
NUR 327