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Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Chapter 15 Caring for the Postpartum Woman and Her Family Fourth Trimester Begins immediately after childbirth Puerperium—first 6 weeks after birth Close observation—identify hemorrhage and complications during first critical hour Ongoing education and support Safety for Mother and Infant Key Patient Safety Concerns: Prevent infant abductions Check ID bands Educate mother about safety measures #1 risk on postpartum is Falls Postpartum Psychological Adaptation Reva Rubin Taking in: Mom wants to talk about her experience of labor & birth, preoccupied with her own needs Taking hold: More ready to resume control of her body, baby & taking on mothering role. Needs reassurance if inexperienced. Letting-go: by 5th week, total abandon to NB Bonding: en face position, engrossement. Encourage through early interaction & breastfeeding (within 1/2 hr of birth is best). Maternal Responses to Newborn Reva Rubin Touch- progresses from fingertips → palming →cuddling → Voice- high-pitched & babies respond Odor- mom’s respond to baby’s unique smell Eye contact- en face position delay eye ointment & bright lights Nurse role- be able to answer ? About baby Postpartum/baby blues: Blues vs Depression transient depression in first few days: weepiness mood swings anorexia difficulty sleeping feeling of letdown Postpartum Depression *If persists past 2 weeks, or worsens Symptoms: very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping. Not be able to concentrate. Not feel hungry and may lose weight. (But some women feel more hungry and gain weight) Postpartum Psychosis Onset within first 8 weeks after childbirth Distinguishing signs: hallucinations, agitation, confusion, suicidal/homicidal thoughts, delusions, sleep disturbances, loss of touch with reality Requires hospitalization & treatment Postpartum Nursing for Vulnerable Populations Victims of abuse History of depression/ mental illness Special needs population- support Adolescents- Teen support groups Undocumented immigrants Limited Access to care/homelessness Endocrine Adaptations Hormones: -drop after delivery of placenta. hCG & hPL gone by 24 hours Estrogen & progesterone drop within 1 wk FSH remains low for 12 days, then rises to begin new cycle Sex is ok once lochia is alba. Menstrual period in 6-10 wks. Contraception necessary. Early Maternal Assessment Vital signs Fundus Immediate postpartum—halfway between the symphysis pubis and the umbilicus 1 hour postpartum—level of the umbilicus or one fingerbreadth above Then, descends one fingerbreadth each day Lochia Rubra, serosa, alba Postpartum Assessment Guide BUBBLE-HE Breasts Uterus Bladder Bowel Lochia Episiotomy Homan’s sign Emotions & bonding Afterpains Occur during process of involution Assess pain More pronounced in multipara Nursing care Explain cause Prone position with abdominal pillow Sitz baths Encourage ambulation Administer mild analgesics Cardiovascular System Delivery of the baby, expulsion of the placenta, and loss of amniotic fluid can create cardiovascular instability Cardiac output remains elevated Physiological diuresis Hematological System Decrease in blood volume Blood loss Diuresis White blood count increased x 5 to 6 days Fibrinogen increased Returns to normal by third to fourth week Deep Vein Thrombosis Homans’ sign Clinical assessment Erythema, unequal calf circumference, heat Clinical signs are NOT reliable Hormonal Levels Estrogen and progesterone decrease Anterior pituitary—prolactin Placental lactogen, cortisol, growth hormone, and insulinase levels decrease Insulin needs decrease—“Honeymoon phase” Neurological System Altered sleep patterns—maternal fatigue Numbness in legs, dizziness Safety for infant and mother Headaches Assess quality and location, and carefully monitor vital signs Implement environmental interventions Immune System Rho (D) immune globulin (RhoGAM) Rubella vaccination Nonimmune status Signed consent form Avoid pregnancy for 1 month Flu-type symptoms may occur Menstruation & Ovulation Nonlactating women Menstruation returns in 6 to 8 weeks First cycle may be anovulatory Lactating women Delayed ovulation and menstruation Educate—ovulation can precede menstruation, need contraception Gastrointestinal System Decreased gastric motility Decreased muscle tone in abdominal wall Constipation Stool softeners Musculoskeletal System Laxity of pelvic joints and ligaments Relaxation of soft tissues Muscle fatigue Body aches Rectus abdominis diastasis Correct posture Modified sit-ups Postpartum Complications Postpartum Hemorrhage CAUSES: Uterine atony, lacerations, retained placental fragments Risk factors: ↑ uterine distension: multiples, polyhydramnios, macrosomia, fibroids Trauma: rapid or operative birth Placental problems: previa, accreta, abruptio, retained placental fragments Atonic uterus: prolonged pitocin, magnesium sulfate or labor; ↑ maternal age or parity; uterine scar; chorioamnionitis; anemia; prior history Inadequate blood coagulation: fetal death or DIC Hemorrhage Interventions: Fundal massage, ensure bladder emptying. If uterus is firm but bleeding persists, suspect laceration. Administer oxtocics (pitocin, methergine, hemabate, prostaglandins), blood replacement. Frequent assessment of bleeding, vital signs. MD: Bimanual massage, manual exploration of uterus, uterine packing, D & C, hysterectomy. Postpartum Hemorrhage Definition Accurately estimating blood loss Hypovolemic shock DIC Early vs. late LARRY 4 “T’s” Postpartum Hemorrhage Uterine atony Hallmark—soft uterus filled with clots and blood Genital tract trauma- lacerations Uterus firm Tissue trauma- hematoma Thrombin Postpartum Hemorrhage Late postpartum hemorrhage Retained placental fragments Ergonovine medication- Methergine antibiotics possible D&C Collaborative Management Frequent vital signs and fundal massage Note patient’s behavior- PTSD noted Medical management depends on cause Administer oxygen Obtain laboratory tests Accurate I/O Hematomas Cause: Trauma Puerperal hematomas occur in 1:300 to 1:1500 deliveries Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams, preeclampsia, prolonged second stage of labor, multifetal pregnancy, vulvar varicosities, or clotting disorders Assessment: location, size, vital signs, pain, H&H Treatment: evacuation and repair of bleeding source by MD Definition Puerperal Infections Types of puerperal infections Endometritis Mastitis Operative wound Urinary tract Careful and thorough assessment Postpartum Infection Puerperal Infection: Endometritis infection of reproductive tract within 6 wks of childbirth Increased risk with: C-section Prolonged ROM, chorioamnionitis Retained placental fragments Preexisting anemia Prolonged/difficult birth, instrumental birth Internal fetal monitoring or IUPC Uterus explored after birth/manual removal of placenta Preexisting vaginal infection (BV or chlamydia) Postpartum Infection Endometritis: infection of endometrium Associated with chorioamnionitis & Csection Signs & Symptoms Can progress to pelvic cellulitis or peritonitis. Endometritis Ttreatments: antibiotics oxytocics such as methergine, ↑ fluid intake pain relief diet Nursing considerations: Fowler’s position or walking encourages drainage by gravity, gloves, strict handwashing Usual course is 7-10 days May result in tubal scarring & interfere with future fertility Post op C/Section Complications 1. Paralytic Ileus 2. Wound Dehiscence 3. Wound infection Cultural Sensitivity Conduct cultural assessments Expand knowledge and understanding Culturally influenced beliefs Common health care practices Customs and rituals Discharge Planning and Teaching Fundus and lochia Hygiene Abdominal incision Body temperature Elimination Nutrition Discharge Planning and Teaching Fatigue Weight loss Exercise Pain management Mood Sexual activity and contraception Community Resources Support groups Home visits Telephone follow-up Outpatient clinics Critical Thinking 1. A mother is experiencing shaking chills during the hour following birth. What is the nurse’s initial action? A. B. C. D. Take a rectal temperature Notify the physician or nurse-midwife Cover the woman with warmed blankets Review the order sheet for antibiotic orders Critical Thinking \ The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right. What is the appropriate nursing action? A. Encourage the client to breastfeed B. Assist the client to empty her bladder C. Massage the fundus D. Assist the client to a prone position and place a small pillow under her abdomen 3. A nurse is caring for a client who is 2 hours postpartum who complains of severe, unremitting vaginal pain and inability to void. The fundus is firm at the umbilicus with moderate lochia rubra, and the perineum appears edematous with significant bruising. The nurse suspects the client may have: A. A fourth-degree episiotomy. B. Distended bladder. C. Hematoma. D. Endometritis. 4. A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage. What should be the nurse’s correct initial response? A. Instruct the client to take her pain medication as prescribed B. Notify the physician or nurse-midwife C. Instruct the client to increase rest and seek assistance with household tasks D. Instruct the client to call the physician or nurse-midwife if her temperature reaches 100.8. 5. A 6-day postpartum client complains of fatigue and episodes of crying during the past two days. Which of the following statements is a correct response by the nurse? A. “This must be very difficult for you.” B. “This sounds like postpartum blues. It is a normal response to birth.” C. “You sound exhausted. Try and sleep when the baby sleeps.” D. “This sounds like postpartum depression; you should contact your health care provider for referral to a counselor.” 6. A nurse is caring for a client with a superficial thrombophlebitis. Which of the following is the most appropriate nursing action? A. Administer anticoagulants per order B. Elevate the affected limb C. Apply ice packs to the affected limb D. Administer antibiotics per order Infant Feeding Choices Breastfeeding Bottle feeding Educate Support Breastfeeding Promotion WHO promotes Breastfeeding around the world Healthy People 2020 APA advocates breastfeeding for 12 months Baby Friendly initiatives in hospitals ↑breastfeeding rates and duration 11753398 Breastfeeding Initiation Prolactin produced (stimulates milk production) when progesterone levels fall after placenta is delivered Colostrum- First milk produced: thick, creamy, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins and maternal antibodies--digestible. Has laxative effect to aid baby to excrete meconium. Milk flows from lactiferous sinuses Fore milk- constantly formed milk. Low in fat. As infant sucks, oxytocin is released from the posterior pituitary. Produces let-down reflex Let-down reflex- stimulation of baby at breast, sound of baby. Hind milk ejected. Hind milk is formed after the let-down reflex. Higher in fat and calories. Infant Advantages in Breastfeeding Less infection: mom’s antibodies passed, breast milk has elements that prevent absorption of viruses & bacteria from GI tract and that kill/inhibit bacteria & viruses - ↓ gastroenteritis and ↓ ear infections Ideal composition for human baby: electrolytes, minerals, linoleic acid, trace elements, hypoallergenic-reduces allergies Easy to digest Reduces obesity, diabetes later in life Maternal Advantages of Breastfeeding Protective function in breast cancer prevention Release of oxytocin from the posterior pituitary gland aids in uterine involution Empowerment effect Reduces economic costs Bonding Breast milk contains lysozymes that are involved in destroying bad bacteria Breast Feeding and Jaundice Pregnanediol (breakdown product of progesterone) depresses an enzyme that converts indirect bilirubin to direct bilirubin (accumulation of indirect bilirubin) Encourage frequent feedings because colostrum is a natural laxative and helps promote passage of meconium and bile Don’t need to bottlefeed- although frequently done Baby who is feeding well--”getting enough” Breastfeeding Teaching Every 2-3 hours in first weeks Promote adequate sucking Provide support Techniques for burping Multiple infants Engorgement Breastfeeding Problems Sore nipples– poor latch-on Supplemental feedings Working outside of the home Weaning Engorgement Mastitis -Signs & symptoms -Interventions -Collaborative Treatment The Amazing Newborn The First Breath Internal stimuli Chemical factors External stimuli Sensory factors Thermal factors Mechanical factors Respiratory Breathing is a result of replacement of air for fluid Big Squeeze with vaginal birth Cardiopulmonary Adaptation Increased aortic pressure and decreased venous pressure Increased systemic pressure and decreased pulmonary pressure Closure of foramen ovale, ductus arteriosus, and ductus venosus Cardiopulmonary Transitions Increased pulmonary blood volume Conversion from fetal to neonatal circulation Immediate assessment necessary Skin color Respiratory rate; breathing pattern Common to have acrocyanosis, investigate central cyanosis (look at mucous membranes) Cyanosis in the Newborn Acrocynanosis Cyanosis Respiration problems: Predisposing Factors Cord prolapse Low APGAR Meconium staining Prematurity Postmaturity Small for gestational age Breech birth Chest, heart or respiratory tract anomalies Maternal history of diabetes Premature rupture of membranes Maternal use of barbiturates or narcotics close to birth Non-reassuring fetal monitoring strip C-section birth Respiratory Distress: Newborn Assessment 5 symptoms of respiratory distress Tachypnea Cyanosis Nasal flaring Expiratory grunting Retractions Transition period (1-2 hrs post birth) vs signs of respiratory distress that persist Thermogenic Adaptation Newborns are homeothermic Neutral thermal environment Cold stress Large body area Limited subcutaneous fat Limited ability to shiver Thin skin and blood vessels close to surface Mechanisms of Heat Loss Can be unstable. Guard against loss due to: Convection Conduction Radiation Evaporation Dry immediately with warm blankets Adaptations: Increase Heat Production Increased BMR and muscle activity Peripheral vasoconstriction Nonshivering thermogenesis Brown adipose tissue Hematopoietic Adaptation Blood volume Blood components Erythrocytes and hemoglobin Hematocrit Leukocytes Platelets Hepatic Adaptation Glycogen and blood glucose maintenance Iron storage Conjugation of bilirubin Coagulation of blood Gastrointestinal Adaptation Stomach and digestive enzymes Bacterial colonization once starts eating • Vitamin K produced Intestinal peristalsis • Meconium Meconium Ileus- Cystitic Fibrosis Genitourinary Adaptation Kidney function Bladder capacity 6 to 44 mL Fluid requirements—60 to 80 mL/kg Urine output 1 to 3 mL/kg/hour Nursing assessments Careful monitoring of I/O Assess appearance of urine Signs dehydration or ↑ ICP Immunological Adaptation Active acquired immunity Passive acquired immunity Immunoglobulins Psychosocial Adaptation Early stages of activity First period of reactivity Period of inactivity and sleep Second period of reactivity Behavioral States Sleep Deep, quiet; REM Alert Drowsy/semidozing Wide awake Active awake Crying The 5 Senses Hearing- yes Vision- “light” and “dark” in the first months. Approx 18” range. Touch- well-developed Taste- can discriminate Smell- well-developed Integumentary System Smooth and soft Postterm infants—tough, leathery skin Pustular melanosis Milia Erythema toxicum Pigmentation—Mongolian spots, café-aulait marks Integumentary System Skin: Color should be pink Cyanosis: mottling, acrocyanosis normal. Investigate central cyanosis. Look at mucus membranes Hyperbilirubinemia: yellow tone to skin, sclera Pallor: usually caused by anemia: blood loss?, blood incompatibility?, internal bleeding? Harlequin sign: normal, immature circulatory system. Dependent side red, upper side pale. Appearance of a Newborn Skin Birthmarks Hemangiomas: vascular tumors of skin Erythema toxicum: innocuous, pink, papular neonatal rash Milia: unopened sebaceous glands--tiny, white, pinpoint papules on nose, etc. Erythema toxicum-newborn rash Birthmarks Mongolian Spots: hyperpigmentation (usually disappear by school age) Assessment Infant’s Head Symmetry Eye shape, size, placement, and coordinated lid movement, red reflex, gross vision Ears: shape, size, placement, hearing Movement, color of the lips Chin—appropriate size Head Fontanels Estimate size Fullness without bulging—normal Bulging and tense with large head circumference—increased intracranial pressure Sunken—dehydration Head Caput Succedaneum Diffuse edema, crosses suture lines, disappears in few days Cephalhematoma Subperiosteal hemorrhage Does not cross suture lines Persists for weeks Respiratory System Assessment Symmetry in chest movement Auscultate lungs anterior and posterior Nasal patency Respiration rate, pattern, and use of accessory muscles Abnormal: Sx RDS Asymmetry: Pneumothorax, Diaphragmatic hernia Cardiovascular System Assessment Inspection and auscultation Point of maximum impulse Heart rate Capillary refill Peripheral pulses Auscultate all areas—murmurs Gastrointestinal System Assessment Abdominal inspection, including umbilical cord Auscultate bowel sounds, upper abdomen for gastric bubble, and heart sounds of the abdominal aorta Palpation Conditions That Warrant Further Assessment Abdominal distention Absence of bowel sounds Discharge from umbilical cord/site Abdominal mass Genitourinary System Assessment Hips abducted Palpate and inspect scrotum, testes, and penis Male—check meatus location Palpate and inspect female genitalia Anus and anal wink reflex Common Findings Male Infants Scrotal swelling Smegma Hypospadius Epispadius Common Findings Female Infants Hymenal tags Vernix caseosa on labia Pseudomenstruation Conditions That Warrant Further Assessment Undescended testicles Micropenis Ambiguous genitalia Imperforate hymen Imperforate anus Musculoskeletal System Assessment Observe infant’s movements in crib Inspect for differences in extremity length and size Assess muscle tone and symmetry Gentle passive ROM to assess joint rotation Assess head lag Skin folds on thighs ASSESS change in tone & movement Musculoskeletal System Assessment Common Findings Torticollis Developmental dysplasia of the hip Asymmetry of hip folds Barlow maneuver Ortolani maneuver Crepitus Unusual positions of foot Musculoskeletal System Assessment Conditions That May Warrant Further Assessment Fractured clavicle Sacral dimple, spinal bifida, or scoliosis Polydactyly Syndactyly Simian crease Newborn and Family: Initial feeding Bathing Sleeping pattern Diaper area care Hearing Screen Newborn Screening Test (PKU) Test for metabolic disorders (inborn errors of metabolism) Done 24 hrs after first feeding Discharge Teaching: Newborn Care Temperature assessment Bathing Nail Care and umbilical cord care Clothing & Diapering Attachment Boys- Circumcision Girls- Vaginal bleeding Feeding frequency & duration Child care Circumcision Care Surgical Removal of Foreskin Site covered with sterile petroleum Assess bleeding q 15 mins. for 1st hour, then q hour for 24 hr Note first voiding Apply diapers loosely to prevent irritation Teach parents to keep area clean & check diaper q 4 hours Notify provider for redness, discharge, swelling, strong odor, tenderness, decrease in urination or excessive crying of infant. Yellowish mucus “crust” may form over glans--normal, don’t wash off Circumcision Care Heals in a couple of weeks Monitor for complications: hemorrhage, cold stress/hypoglycemia, infection, urethral fistula, delayed healing and scarring, fibrous bands. Discharge instructions & signs of danger Avoid premoistened towlettes--use only water to wash Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Susan Ward Shelton Hisley Chapter 19 Caring for the Newborn at Risk Risk Factors for Newborns Intrauterine development -prematurity, IUGR, hypoxia Intrapartum development -birth injury, hypoxia Extrauterine development -cold stress, infection, jaundice Classification of High-Risk Newborns Gestational Age (GA) Preterm (born before 37 weeks) Late Preterm (born 37-39 weeks) Term (born between 38 and 42 weeks) Postterm (born after 42 weeks) Birth Weight Low birth weight (LBW) (<2500 g) Very low birth weight (VLBW) (<1500 g) Extremely low birth weight (ELBW) (<1000 g) Intrauterine Growth Restriction (IGUR) A term used to denote a lack of intrauterine fetal growth that usually results in an SGA newborn At risk for hypoglycemia Small-for-Gestational-Age Infants (SGA) Infants born at any gestational age who have a birth weight that falls below the 10th percentile on the growth charts Hypothermia Pain Hypoglycemia Polycythemia Large-for-Gestational- Age Infants (LGA) Infants born who are over the 90th percentile on the growth chart Chronic hyperglycemic state Transient tachypnea of the newborn Hypoglycemia Hypocalcemia Hypomagnesemia Birth injuries Brachial plexus injuries Fractures Hyperbilirubinemia Physiologic jaundice appears 24 to 48 hours after birth; transient Pathologic jaundice present at birth or within 24 hours Breastfeeding jaundice—2 to 4 days Breast milk jaundice—7 days; peaks at 10 days Hyperbilirubinemia Hyperbilirubinemia: results from destruction of red blood cells Physiologic jaundice Normal physiologic process Peaks ≤ 12 mg/dl Does not occur in first 24 hours of life Home care Pathologic jaundice Abnormal destruction of RBCs Occurs in first 24 hours of life or persists after 1 week Causes: hemolytic disease of newborn: Rh or ABO blood incompatibility (mom Rh - or type O) Physiological Jaundice 2nd or 3rd day of life. Breakdown of fetal red blood cells. Heme and globin realeased. Heme breaks down into protoporphyrin which breaks down into indirect bilirubin & is excreted by liver in feces Baby’s liver is immature Before 24 hours or persistent after day 7 Pathologic Jaundice Bilirubin increases more than 0.5 mg/dl/hr, peaks at greater than 13 mg/dl or associated with anemia and hepatosplenomegaly Rh incompatibility/isoimmunization, infection, RBC disorder. ABO incompatibility: positive coombs test (test babies when mom O−/O+) Kernicterus (bilirubin encephalopathy) can result from untreated hypergbilirubinemia with bilirubin levels at or higher than 20 mg/dl → mental retardation Hyperbilirubinemia: Risk Factors ↑ RBC breakdown cephalohematoma, extensive bruising from birth trauma Rh or ABO incompatibility Ineffective breastfeeding & dehydration Certain medications (aspirin, tranquilizers, and sulfonamides) Maternal enzymes in breast milk- fairly uncommon Hypoglycemia Hypothermia Decreased liver function Anoxia Hyperbilirubinemia: Nursing Assessments Yellowish tint to skin, sclera and mucus membranes--observe by window Note time of jaundice physiologic > 24 hours pathologic ≤ 24 hours Treatments: early feedings, phototherapy, exchange transfusion if very high levels Hyperbilirubinemia: Lab Testing Elevated serum bilirubin (direct and indirect) Blood type H&H Direct Coomb’s test--reveals presence of antibodycoated (sensitized) Rh-positive RBCs in the newborn Electrolyte levels for dehydration from phototherapy (treatment of hyperbilirubinemia) Hyperbilirubinemia Graph Well Baby > 36 weeks gestation The Premature Newborn Severe prematurity 23 to 26 weeks Moderate prematurity 26 to 30 weeks Long-term health problems Neonatal Complications Pathophysiology: RDS Atelectasis with congestion and edema in lung spaces Underdeveloped alveoli Low-level or absent surfactant Inspiratory effort to inflate alveoli remains high Pulmonary resistance prevents fetal shunts from closing Lungs are poorly perfused and tissue hypoxia occurs with resultant acidosis Surfactant not formed until week 34 Neonates at Risk for Respiratory Distress Syndrome (RDS) Preterm infants Infants of diabetic mothers Infants born by cesarean Perinatal asphyxia Decreased O2 tension in the lungs (one cause is meconium aspiration) Maternal factors: PROM, barbiturate/narcotic use, hypotension, bleeding Collaborative Management RDS Assist with endotracheal intubation (ET) Administer surfactant through ET tube Oxygen administration (CPAP or assisted ventilation with PEEP) Maintain mechanical ventilation Indomethacin or ibuprofen to close patent ductus arteriosus Wean ASAP to prevent complications Retinopathy of Prematurity Pathology: Result of immature retinal vasculature followed by hypoxia Inversely related to gestational age Risk factors Diagnosis –– 5 stages Nursing Care: Maintain lowest O2 levels possible Fluctuations in concentrations of oxygen must be prevented Wean off oxygen ASAP Decrease constant bright lights Encourage routine examinations Anemia of Prematurity Hemoglobin below 35% and 45% Nursing Care: Administer recombinant human erythropoieten SC Sudden Infant Death Syndrome (SIDS) “Back to Sleep” Educate parents about prevention Gastrointestinal Conditions of Prematurity Necrotizing Enterocolitis Ischemic episode of the bowel; can produce septicemia Nursing Care: Ensure that oral feedings are stopped Discuss possible surgery Colon resection Short gut syndrome Neurological Conditions of Prematurity Intraventricular and Periventricular Hemorrhage [categorized by extent and involvement (grades)] Nursing Care: Recognize seizures Administer antiseizure medications Prevent cerebral damage Maintain adequate oxygenation Educate parents The Postterm Newborn Newborns in utero after the optimal growth time (42 weeks) Skin is parchment-like Fingers are long and peeling Muscle wasting is present Conditions Affecting the Postterm Newborn Meconium Aspiration Pneumonia — meconium aspirated at birth Meconium-stained skin, nails, and umbilical cord Initial respiratory distress Rales and rhonchi on auscultation Nursing Care: Give chest physiotherapy (CPT) Monitor mechanical ventilation Administer medications Persistent Pulmonary Hypertension of the Newborn Vascular resistance in pulmonary system Meconium-stained amniotic fluid Brief respiratory distress at birth, then resolves and returns about 12 hours later Centrally cyanotic and tachypenic Audible murmur Nursing Care: Extracorporeal membrane oxygenation (ECMO) See Chapter 19 Nursing Care Plan Neonatal Abstinence Syndrome Drug-abusing mother Irritability Withdrawal process Refer to Table 19-6 for drugs that cause withdrawal symptoms Nursing Care: Do Not administer Narcan Toxicology screen Use neonatal abstinence scoring tool every 3 hours Social Services referral CASE STUDY: BABY BOY QUINCY Baby boy Quincy is a neonate who was born at 37 weeks of gestation via a normal spontaneous vaginal birth 4 hours ago. Baby Quincy’s mother is a 17-year-old G1 P1, whose prenatal course was complicated by pregnancy-induced hypertension. Baby Quincy’s weight is 2400 g (5 lbs 4.6 oz); his length is 18 inches (45.72 cm). He has just returned from a rooming-in session with his mother. The infant’s vital signs are axillary temperature 97.2°F (36.2°C); apical pulse 172 beats/minute; respiratory rate 62 breaths/minute with occasional periods of apnea lasting 15 to 20 seconds; BP 60/40 mm Hg. Baby Quincy’s skin has a mottled appearance; his hands and feet have a bluish tinge and are cool to the touch. Critical Thinking Questions 1. What is the priority nursing diagnosis at this time? 2. What is the expected outcome associated with this diagnosis? 3. Describe the teaching/learning needs related to the scenario that corresponds to the priority nursing diagnosis. 4. List nursing interventions with rationales that correspond to the priority nursing diagnosis.