nursing 3 Flashcards

Terms Definitions
A-appearanceP-PulseG-Grimace(reflex irritability)A-Activity(muscle tone)R-Respiratory Effort2 pts for each=10 total
Phenergan, Largon, Vistaril
screening for gestational diabetes;blood glucose monitoring or fasting blood sugar 24-28 wks.
3 types of contractions
heartburn;esophageal reflux; avoid eating & reclining/elevate HOB; small freq meals/low fat; avoid caffeine
1-3 days after birthRed
Breastfeeding Positions
Side-lying, Football, Cradle
G-inc. current (sometimes total)F-full term pregnanciesP-premature >20 wks, A-abortions/ miscarriage L-living children
antepartal to prenatal
conception to labor
from corpus luteum/placenta; prevents uterine contractions; relaxation of pelvic bones for delivery
Vaginal discharge during the prerperium consisting of blood, tissue & mucus. There are 3 kinds
Breech Presentation
Feet and/or buttocks first
Psychosocial Considerations - Includes: perceptions/expectations (anxiety, fatigue, pain intolerance, cultural knowledge, educational preparation (prenatal classes), support (coach, doula)
Pain Relief Measures
Relaxation,, effleurage, counterpressure, massage, touch, music, water, aromatherapy, biofeedback, heat/cold
"Caines" (i.e. Novacaine), Fentanyl, Morphine
control the development of female secondary sex characteristics: breast dev, widening of hips, deposits of fat tissue; amt. greatest furing proliferative phase of menstrual cycle
greatest amts during secretory phase of menstrual cycle; Hormone of pregnancy because effects on uterus allow pregnancy to be maintained; cervix secretes thick, viscous mucus, breast tissue increases in size and breasts prepare for lactation
pelvic outlet assessment
biischial diameter(between ischial tuberosities);external exam;IF >8cm, outlet considered OK;transverse dim of outlet
inc saliva; astringent mouth, chew gum, support
strength during acme; measure manually for ex. mild feels like chin; moderate feels like bridge of nose; strong feels like forehead
prostaglandin theory
formed by uterine decidua(esterogen stimulates this); stim uterine contractions(we use prostaglandins to induce labor & ripen cervix)
ultrasoundgroup B strepalphafetoprotein
6-10 weeks35-37 wks16-20 wks
Erythema Toxicum
Transient rash. Lesions appear suddenly & anywhere. Thought to be an inflammatory response. AKA flea bite dermatitis. Appears within 24 to 48 hrs after birth & resolves spontaneously. Some say no known cause
Cyclic changes that occur with established regularity; such as sleeping & eating patterns
Oxytocin (pitocin)
Strenghtens & coordinates uterine contractions
Lactating suppressant used years ago that was found to cause reprodutive cancers in the offspring of mothers who took it
Passageway, Information about the passageway include: smallest diameter at ischial spines, fetus must pass beneath pubic arch, hormones soften cartilage and ligaments
Cesarean Assessments
Incision care, Peri-care, Ambulation, Breast Care, Assess gas
Placenta Delivry
Separates from uterus, contractions cause the site to shrink, gush of blood, check for intact placenta, no retained pieces, leads to hemorrhage.
The uterus drops, promotes easier breathing and causes frequent urination
post partum
delivery of placenta to 6 weeks
perinatal to intrapartal
onset of labor to delivery
first stage of labor
*latent phase(0-3cm of dilation;*active phase(4-7cm of dilation);*transition phase(8-10cm of dilation)
true conjugate
Post aspect of symphysisto estimate true conjugate, subtract 1.5-2cm from diagonal conjugate;EX. 11.5-2=9.5(true conjugate)
anterior fontanelposterior fontanel
lg diamond shape(bregma)~~closes 18 mo.smaller, triangle shape(occiput is beneath post fontanel~~closes 3 mo.
for production of milk in acini cells(anterior pituitary)
funic souffle(fetus(f))
soft blowing sound heard over umbilical cord & synchronous with fetal heartbeat
Luteal phase
days 15-28; uterine lining prepares for pregnancy, blood supply inc due to hormone production
Normal platelet count ranges
150,000 to 300,000 mm
Swelling of the breasts, occuring as colostrum. Occurs about 72 to 96 hours after birth
Process by which parents, over time, form an emotional relationship with their baby
Brown Fat
Is unique to newborns; nonshivering thermogenosis is accomplished & it increases metabolic activity in brain, heart & liver. More rich vascular & nerve supply than ordinary fat. Located: interscapula region, axillae, vertebrae, kidney & thoracis inlet
Uterine Atomy
Relaxation of the uterus muscles, leads to postpartum hemorrhage
Growth Spurts
Times of increased neonatal growth. Occurs at 10 days, 3 weeks, 6 weeks, 3 months and 6 months
Infant responds to familiar sounds by moving their body in time to the rhythm to sounds, but don't respond to random. Baby gets excited to parents voice
Medical treatment for Postpartum depression
Individual psychotherapy, antidepressants, lithium, group therapy, antipsychotics
Opening of the cervix, expressed as 0cm-10cm
Passenger = Fetus, Factors include: head, lie & attitude, presentation, position
External opening to vagina: tears, abrasions, hematomas, estrogen resp flex
An enduring two way bond or relationship affection between persons
Fetal Status Assessment
Fetal position, heart rate, gestational date
fetal attitude
relation of fetal parts to one another; flexion--head is flexed forward w/chin almost resting on chest w/ arms & legs flexed.
umbilical cord
2 arteries (carry blood to chorionic villi from embryo); 1 vein (returns blood to embryo)
follicular phase
days 1-14; lining is repaired & epithelial tissue builds up; under influence of FSH and LH
fetal lie
way the baby is lying in mom;relationship of fetal back to maternal back (longitudinal or transverse)
Apgar Score
Numeric expression of the condition of a newborn obtained by rapid assessment at 1 to 5 minutes of age.
The return of the uterus to a nonpregnant state
Time right after the 3rd stage of labor, this lasts until invoultion of the uterus takes place lasting about 3 to 6 weeks. Also referred to as the 4th trimester of pregnancy
Period from birth thru first 28 days of life.
This protein lines the alveoli of an infants lungs and it reduces surface tension
Congenital Heart Block
Persistent bradycardia (less than 120 bpm)
Epidural Info
Not given until active phase, IV fluids must be maintained, BP must be monitored, Empty bladder
Internal monitor
Requires: ROM, 2cm dilated, 0 station. Spiral electrode (invasive) directly to babies scalp, IUPC - reads intrauterine pressure, duration, and frequency, passes beside fetus
Care of the Newborn
Airway-suction mouth & nose, Warmth-dry and wrap, cover head, APGAR (0-10): heart rate, resp, tone, reflex, color @ 1 & 5 Min, ID
Rupture of Membranes
May occur spontaneously or done artificially (amniotomy). May be done if: fetus is engaged, to prevent prolapse of cord, used to stimulate labor. Asses fetal heart rate and observe color, and consistency of fluid.
Mutual Regulation
Behaviors in which mother and baby modify their relationship in an attempt to make it as enjoyable as possible (non-verbal)
O Station
Fetus is engaged, even with ischial spines
Vital Sign Assessment
Increased temp (100.4) after delivery, after 24 hours increased temp = infection.BP decrease for labor or normal, sudden decrease=hemorrhage, increase BP & headache= PIHPulse=brady 1-6 days PPResp=norm
progesterone deprivation theory
causes of onset of labor; progesterone secreted by corpus luteum, then by placenta; maintains preg; prog dec, estro inc (at end of preg)
Cold Stress
Excessive loss of heat that results in increased resperiations & nonshivering thermogensis to maintain core body temperature. Basal metabolic rate increases.
Becoming a Mother
Transformation & growth of the mother identity
Do formula fed infants void more of less than breatfed babies
void less
Afterbirth Pains (After Pains)
Painful uterine cramps that occur intermittently for approximately 2 or 3 days after birth. Result from uterus returning to normal invoulted condition. May be the cause of big baby, multiple fetuses or polyhydramnios.
Let Down Reflex
Release of milk in response to oxytocin
Sleep Wake States
Variations on the state of c nsciousness of infants. From deep sleep to extreme irritation
Supply meets demand system
Physiologic basis for determining milk production the volume of milk produced equals the amount removed from the breast
Rubin's early maternal responses (early 60's)
Taking-in (touching baby, embracing and talking about L&D), Taking-hold (a week later, how to take care of baby), Letting-go (looking for resources)
Fetal Heart Rate
Baseline: avg rate in 10 min (110-160bpm)
Maternal role attainment
Process by which a woman learns mothering behaviors and becomes comfortable with her identity as a mother
Cephalic Presentation (Vertex)
Crown first, chin well flexed on chest
Cephalic Presentation (Face or Brow)
Chin is extended, diameter larger
Duration of contraction
The amount of time the contraction lasts
Breast fed infants should have how many stools per 24 hrs after 3 or 4 days when the mothers milk comes in?
3 stools per day
What is the bilirubin level that denote jaundice?
5 to 7 mg/dl
Diastasis Recti Abdominis
The separation of large abdminal wall wall, can be the result of large baby or multiple fetuses
Cardinal Movements (Baby mechanism of labor)
Engagement (o station), Descent (downward), Flexion (chin tucked on chest), Internal rotation (head rotates after entering inlet sideways to exit outlets as it hits pelvic floor), Extension (baby stretches neck), External rotation (restitution), Explusion
2nd degree episiotomy or laceration
Subcutaneous tissue of the perineal body
Maternal Responses to labor
BP rises during contractions, drops if aorta vena cava are compressed by uterine weight, O2 consumption up, possible resp. alkalosis, bladder (blocks babies descent if full), may have protein in urine (overworked muscles), Digestion slows, Pass stool
cycle of menses
day 1-7 is high amts of FSH---FSH stim ovarian follicles to prod estrogen---inc estrogen causes ant pit gland to prod LH---LH causes ovulation (ovulation cannot occur w/o LH)---ovulation causes corpus luteum to prod huge amts of progesterone; if implantation does not occur w/in 7-10 days, corpus luteum stops prod progesterone
Fourth Stage of Labor
The first 1 or 2 hours after childbirth
After the 4th day, all newborns void ______per 24 hrs
6 to 8 times
Stage 1 of Labor, Phase 2
Active: 4-7cm dilated, Contraction 3-5 min apart, mod to strong, lasting 40-70 sec, +1 to +2 station, Epidural may occur here. Mom working hard, may fatigue, serious, focuses, internalizes
Stage 2 of Labor
Birth, pushing baby to +5 station. Lasts minutes or 2-3 hours
Normal heart rate for infants
100 to 160 beats per minute; their color is pink
Stage 3 of Labor
Delivery of placenta. Lasts 2 min to 1 hours
antepartal visit schedule (office)
Q month (4 wks) -1st 28 weeksQ 2 wks until 36 weeksQ wk after 36 weeks until deliveryPt. education is an integral part of each visit
What and when does Lochia Rubra occur?
It is bright, red, distinctly blood tinged vaginal flow that follows birth and lasts 2 to 4 days
RhoGam given when and why...
Rh- mother and Rh+ babyGiven at 28 wks and within 72 hours after delivery
transverse measurement
mutually rewarding interaction
Shoulder Presentation
Transverse lie
cephalic(head)vertex(normal, but could be face/brow)breech(full, frank, footling)shoulder(transverse lie)
bloody show
blood-tinged vaginal discharge~~usually means mucous plug has passed
Beginning of milk production
Mixed narcotic agonist-antagonist
Stadol, Nubain
normal hematocrit=38-47
pregnancy hematocrit=33-34;hgb 1st tri=11.6;hgb 3rd tri=12.5
uterine contr. involuntary, occur intermittently; uterus needs relaxation for recovery from bl supply;upper seg contracts(fundus)Lower seg relaxesMaternal bearing down
Elevation of unconjugated serum bilirubin concentrations
A parent's absorption, preoccupation, & interest in their infant.
Psychologic & physiologic phenomenon wherby the response to a constant or repeated stimulus is decreased
Narcotics and (Narcotic Antagonist)
Demerol, Fentanly(Narcan)
External monitor
Non-invasive, ultrasound transducer, usually on fetal back, toco-transducer, over fundus, measures duration, frequency, NOT intensity
After Pain
Contracting down of uterus
10-20 days after birthWhite, Creamy
excessive profuse flow during menses; may be ca or tumors~~~NSAIDS are used to treat this because they inc vasoconstriction; do not use aspirin because use will inc bleeding; need endometrial bx
stim uterine contractions and "letdown reflex" (posterior pituitary)
mucous discharge that forms mucous plug- prevents ascending infections~~~do not douche
late deceleration
caused by uteroplacental insufficiency resulting from dec bl flow & oxygen transfer to fetus during uterine cont; onset of deceleration occurs after onset of the uterine cont; uniform shape, requires nursing intervention
5 P's
powers, passenger, passageway, psyche, position
(16-18 wks) passive fetal movement elicited when the examiner inserts two gloved fingers into vagina & pushes back cervix~examiner feels rebound of fetal body
stages of labor
dilation-cervix dialates 1-10 cmexpulsion-from complete dilation to birth of infantplacental-from birth of infant to del. of placentafirst 4 hrs. after feeding(breastfeeding)
Greenish black viscous first stool formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin) and cells (shed from the mucosa
Vernix Caseosa
Protective gray-white fatty substance of cheesy consistancy covering the fetus skin
Stork bites, angel kisses, usually pink and easily blanched. Usually on face or head, fade by 2nd year of life, no clinical significance
Small white sebaceous glands that appear as tiny white pinpoint papules on the forehead, nose, cheeks and chin of the neonate
The self destruction of excess hypertrophied tissue (additional cells laid down during pregnency).
Powers: Primary-involuntary uterine contractions & Secondary-voluntary abdominal muscles and diaphragm (bearing down)
variable deceleration
occur when umbilical cord becomes compressed, thus reducing bl flow between placenta & fetus; onset varies in timing with onset of uterine cont & variable in shape; requires nursing intervention
"mask of pregnancy"; worse in sun, mask will fade after delivery
vertex presentation
chin to chestocciput is presenting partsuboccipitobragmatic presents to maternal pelvis
pelvic inlet assessment
via diagonal conjugate(an external exam)measures dist between sacral prominitory & lower margin of symphysisIf >11.5 cm, inlet assumed OK
beginning of contra to beginning of next contra
early deceleration
fetal head compressed, cerebral bl flow dec=vagal stimulation; onset occurs before onset of uterine contraction; NO intervention
Excision of the prepuce (foreskin) of the penis, exposes the glans
Use of lights to reduce serum bilirubin levels by oxidation of bilirubin into water soluble compounds that are processed in the liver and excreted in bile & urine
Claiming Process
Process by which parents identify their new baby in terms of likeness to other family members, differences & uniqueness
Normal Leukocytes (WBC) counts
9,000 to 30,000 mm
Mongolian Spots
Bluish gray or dark nonelvated pigmented areas usually found over the lower back & buttocks present at birth in some infants, primarily nonwhite; usually fade by school age
Infant body movement or behaviors that provides the observer with clues
Blood clot obstruction a blood vessel that remains at the place where the placenta was formed
Visceral Pain
Cervical changes and uterine ischemia, secondary to contractions, lower abdomen, back and thighs
Somatic Pain
Perineal stretching, pressure on other structures
Used for several concerns: PROM, PID, inadequate labor progression, postterm dates
Labor Status Assessment
Contraction history, cervical changes, membranes, and bloody show
Factors that promote involution
Breastfeeding, Voiding, Fundal massage, oxytoxic medications
from start of contr to end of contra(same)
Goodell's sign
softening of uterus (probable S/S of pregnancy)
ductus venosus
shunts most blood into inferior vena cava; empties directly into fetal vena cava
Infection in a breast, usually a milk duct
Opthalmia Neonatorum
Infectiin in the infants eyes. usually from gonorrheal, chlamydial or orther infection contracted when the fetus passes thru the birth canal
Caput Succedaneum
Swelling of the tissue over the presenting part of the fetal head caused by pressure during labor
Physiologic Jaundice
Yellow tinge to skin & mucous membranes in response to increased serum levels of unconjugated bilirubin; not usually apparent until after 24 hrs; also called neonatal jaundice, physiological hyperbilirubinemia
Creation of production of heat in the body
Demand Feeding
Feeding baby by cues they exhibit indicating hunger
Position of mom - Tactics include squatting (gravity helps fetal descent), all fours (relieves backache), lateral (may help rotation of fetal head, turn mom to relieve pressure on cord, NO LYING FLAT
Measure of the degree of descent of the fetus through the birth canal
Hegar's sign
softening of the isthmus of the uterus (lower uterine segment) using a vaginal exam
danger signs of pregnancy
*visual changes; *sudden, severe cont headaches; *edema(non-dependent); *rapid wt gain; *ab or epigastric pain;*S/S of infection; *vag bleeding/drainage; *persistant vomiting; *musc. irritability/seizures; *absence or dec in fetal movements
En Face
Face to face position in which the parent & infant faces are approximately 20 cm (8 inches) apart and on the same plane
How many times will the newborn void during the 2nd day
2 times
Couplet Care
One nurse, educated in both mother & infant care, functions as the primary nurse for both. Also known as mother-baby care or single-room maternity care
Failure of the uterus to reduce to its normal size and condtion after pregnancy
Warm Line
A help line for families to access after hospital discharge. Offers support of newborn care & postpartum care
Precipitous Labor
Less than 3 hours from onset of contractions to birth. Maternal complications: ruptured uterus, placental hemorrhage, lacerations, amniotic fluid embolism. Fetal complications: hypoxia, intracranial hemorrhage
Menstruation & Ovulation resumes when...
6-24 weeks before menstruation returns, but no ovulation.
Fetal Presentation
Fetal part that is down and out first
Intensity of contraction
The strength of the contracation, how tight
Minus # Stations
Baby is higher up within the pelvis
Factors influencing process of labor and birth (5 P's)
Passenger, Passageway, Powers, Position of Mom, Psychological Aspects
3 trimesters
week 1-13 1st trimesterweek 14-26 2nd trimesterweek 27-40 3rd trimester
How many times will a newborn void in the 1st 24 hours
1 time
Signs of infant respiratory distress
Nose flaring, retractions, grunting & seesaw respirations
Moro Reflex
Infants fingers fan out and form a "C" with index finger and thumb
Stage 1 of Labor, Phase 1
Latent: 0-3cm dilated, Contractions 5-30 min apart, mild to moderate, lasting 30-45 sec, 0 to -2 station. Mom alert, excited, walking, fluid intake
Stage 1 of Labor, Phase 3
Transtion: 8-10 cm dilated, Contractions 2-3 min apart, strong to very strong, lasting 60-90 sec, +2 to +3 station. Mom irritable, tired, trouble following directions, hurting if no epidural, may fall asleep btwn contrax, awakes in pain, shakes and vomit
Ferguson Reflex
The urge to push when the baby's head presses on receptors. Urge may be absent with epidural anesthesia.
average weight gain
1st tri 3-5 lbs.2nd tri 12-15 lbs.3rd tri 12-15 lbs.
Name the 4 types of heat loss
Convection, radiation, evaporation & conduction
3rd degree episiotomy of laceration
Involves fibers of the external rectal sphincter
1st degree episiotomy or laceration
Vaginal mucous membrane and skin of perineum
Name the 3 kinds of lochia
Lochia rubra, locha serosa & locha alba
What and when does Lochia Alba occur?
Thin, yellowish to white vaginal discharge that follows lochia serous on about the tenth day after birth and may last for 10 to 14 days
Postpartum Depression (lasts weeks or months, 15-20% of new moms)
Never gets over blues, happy about baby but have flat affect or show forced emotions. Personality changes, compulsive thoughts, feelings of inadequacy, inability to care for infant and/or self, suicidal thoughts, fears of hurting self/baby
To decrease milk in non-lactating mothers...
Wear a supportive bra 24/7No nipple stimulation, do not express milkIce packs/analgesics for engorgementGreen cabbage leaves in the bra
What and when does Lochia Serosa occur?
It consists of old blood, serum, leukocytes and tissue debris. The duration is 22 to 27 days. This follows Lochia rubia
Sexual activity should not be resumed until...
The perineum is completely healed (2-4 weeks). External may heal in 2 weeks, but internal needs at least 4 weeks.
Normal respirations of infants
30 to 60 - count for 1 minute as they are irregular
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