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Sphincter control for toileting: 18-24 months, girls are earlier Gravita: pregnant. Para: number of pregnancies that a woman has regardless of whether the newborn is born alive or dead o Primipara: given birth once after a pregnancy of at least 20 months o Multipara: more than one births o Nulli: no viable offspring G (gravida) T (term births) P (preterm births) A (abortions) L (living children) Erikson’s developmental level o Newborn: trust vs. mistrust o Toddler (1-3): autonomy vs. shame & doubt o Pres-school (3-6): initiative vs. guilt o School-age (6-12): industry vs. inferiority o Adolescent: identity vs. role confusion o Young Adult: Intimacy vs. Isolation o Middle adulthood (40-55): generativity vs. stagnation: create or nurture things, have success to feel useful o 55+: egointegrity vs. despair: reflect on life Risks for diabetic mothers: polyhydramnios, HTN, ketoacidosis, preterm labor, hypoglycemia, UTI, chronic monomial vaginitis, difficult labor, c-sec, post-partum hemorrhage, renal, cardiac, skeletal, and CNS systems malformateion. Newborn risks: cord prolapse, congenital anomaly, macrosomia, birth trauma from increased size, preterm birth, fetal asphyxia, intrauterine growth restriction, perinatal death, respiratory distress syndrome, polycythemia, hyperbilirubinemia, hypoglycemia (low temp, lethargy, low blood sugar), childhood obesity Treatment for diabetic mothers: tight glucose control and watch baby, determine insulin requirements from HbAIC (less than 7% indicates good control), fasting: less than 95 or 105 if diabetic, during labor: less than 110 with IV saline and blood glucose levels monitored q 2 hrs. Breastfeeding helps normalize blood glucose levels, focus on lifestyle education, if c-sec: give short-acting insulin or glucose based on levels and monitor hourly with ½ dextrose ready for baby. When does anterior fontanel close: 18 months, posterior: 8-12 weeks o Bulging: ICP o depressed: dehydration Ovulation occurs: 14 days before next menstruation Fertilization occurs 24 hours after ovulation Premature rupture of the membranes: water brakes before true labor. risk for infection, prolapsed cord, abruption placentae, and preterm birth. Management: no digital cervical exam, continuous electronic fetal heart rate, look for distress or hypoxia or meconium in amniotic fluid (fetal distress related to hypoxia), foul odor: infection Prolapsed cord: protrusion of cord alongside or ahead of the presenting part of the fetus. 50% perinatal mortality rate, fetal perfusion declines rapidly, prevention is key, more common in mal-presentation, growth restriction, premature, ruptured membranes with high station fetus, hydramnios, grandmultiparity, and multifetal gestation. Tx: sterile gloved hand into vagina and hold presenting part off cord, put women in trendelenburg or knee-chest position, monitor FHR, maintain bed rest and give oxygen, if not fully dilated do c-sec a.s.a.p. Post-partum blues (3-7 days) depression (beyond 6 weeks-mood and behavior changes) psychosis (3 weeks after: sleep distrubances, fatigue, depression, and hypomania, delirium and hallucination, anger, bizarre behavior, thoughts of violence, suicide is greatest hazard) o Caused by: prenatal anxiety, difficult labor or pregnancy, high-risk pregnancy or specialneeds infant, hormonal changes with decreased estrogen and progesterone Newborn VS o HR: 120-160 (180 when crying and 100 when sleeping) o RR: 30-60 o Temp: 36.5-67.5 Newborn reflexes: sucking, Moro (startled), stepping, tonic neck, rooting, Babinski (until 1 yr: toes fan out), palmar grasp, gag, cough Cervical cancer risk factors: HPV, early sex, lower socioeconomic status, promiscuous, unprotected sex, STDs, smoking, HIV, Oral contraceptive, PID Signs of adolescent depression: giving away things, writing letters, using drugs Jaundice: yellowish skin, mucous membranes, and sclera within first 3 days of life, blanced are a will appear yellow before cap refill, first 24 hours of life it is checked (12-15), lasts 5-7 days when using UV lights or phototherapy Secondary sex characteristics develop at age of 11-14 Fetal positions: L or R, presenting part: O, S, M, A, D(back), then location of presenting part: A, P, T. LOA is most common and most favorable, ROA 2nd. Pregnancy signs and symptoms o Presumptive: absence of menstruation, nausea, fatigue, breast tenderness. o Probable: Braxton hicks contractions, positive HCG test, abdominal enlargement, goodells (cervix), Hegar’s (uterine), Chadwick’s (blue-purple cervix) o Positive: FHR, palpate for movements, ultrasound o 1st trimester: urinary frequency, fatigue, N/V, breast tenderness, constipation, nasal stuffiness, bleeding gums, epistaxis, cravings, leucorrhea o 2nd trimester: backache, leg cramps, varicosities, hemorrhoids, flatulence with bloating o 3rd trimester: fatigue, urinary frequency, leucorrhea, constipation, dependent edema, SOB, dyspnea, heartburn and indigestion, contractions Fetal movement: 16-20 weeks, gross indicator of fetal well-being Breastfeeding: upright position, every 2-3 hours for 10-20 minutes, gives baby colostrum, transitional milk and then mature milk, decreases constipation for newborn, increases weight loss for mother, decreases infection, baby needs good suck and swallow reflexes, 4 positions: football, cradle, across-the-lap, side-lying. LATCH: Latch, Audible swallowing, type of nipple, comfort of nipple, hold or position (scored 0-2 pts each, score 8-10 best) Continuous internal fetal monitoring: spiral electrode into presenting part to assess FHR and pressure or contractions. Must have: ruptured membranes, cervical dilation of at least 2 cm, low presenting part, skilled person Fetal accelerations: increase in HR. Deceleration: decrease in HR from PNS stimulation. Early: lowest point at peak of contraction. Late: decline after contraction. Variable (most common). Repetitive late decelerations and late decelerations with decreasing baseline variability are nonreassuring signs. Caused by hypoxia. Tx: turn mom to left side, administer oxygen, increase IV fluids, tell doc, reduce oxytocin. Emergency c-sec possible Cesarean birth: classic or low transverse incision. Causes: shoulder dystocia, fetal distress, active gonorrhea, herpes 2, placenta previa, Hep B, fetal macrosomia, prolapsed cord, previous classic incision, HTN, diabetes, hydrocephalus, neural tube defects. Risks: infection, hemorrhage, aspiration, pulmonary embolism, urinary tract trauma, thrombophlebitis, paralytic ileus, atelectasis, newborn: fetal injury and transient tachypnea Perimenopause: around menopause: low estrogen Psychological pregnancy: 1st: denial, ambivalence. 2nd: excitement. 3rd: worry, bills, compassion Stages of labor o 1st: latent phase (0-3 cm) active (4-7 cm: increase contraction) transition (8-10: contraction 1-2 minutes, irritable and out of control, urge to bare down, most difficult but shortest, 1 hr in first birth and 30 minutes multi) o 2nd: complete dilation and effacement, fetus moves through birth canal: pelvic and perineal phase, increase in bloody show, crowning o 3rd: birth and ends with separation of placenta: uterus rises up, umbilical cord lengthens, sudden trickle of blood, uterus changes to globular, placental expulsion Therapeutic communication: listen and understand Ectopic pregnancy: not in uterus, pain, bleeding 4-6 weeks, solution: surgery Oral contraceptives: inhibits the release of follicular stimulating hormone. Side effects: nausea, vomiting, increased risk for infection and DVT Ultrasound: full bladder, earliest done at five weeks Contraction stress test: done at 28 weeks, give oxytocin and watch for fetal movements including late decelerations Newborn care at delivery: suction (aspiration of airway: mouth first), APGAR 1 and 5 minutes, ID band, warm, promote bonding Skin loses elasticity as part of aging Post-term: over 42 weeks, might see dry skin, bigger but less fat, hypoglycemia, long fingernails SGA: less than 10%. risks: heat loss, hypoglycemia. Keep warm, check temp. look for s/s: IUGR, head larger than body, poor muscle tone, hypoxia Lightening: fetal presenting part begins to descend into maternal pelvis. Impending sign of labor Chronological age is not predictor of physiological change Preconception counseling: smoking and alcohol cessation, prenatal vitamins, folic acid, exercise Preeclampsia: hypertension and proteinuria and edema during 20-40 week. Give Magnesium to prevent seizures and Procardia for BP. May have to deliver baby immediately. Prevent by diet Nagle’s rule: estimated date of delivery: -3 months + 7 days Fetal development: 4 weeks heartbeat, 8 weeks organ form, 12-18 weeks heartbeat with Doppler, 16 weeks sex, 20 weeks heart beat with stethoscope, 28 weeks eyes open and close, 32 weeks toe nails and other details Ovulation resides 12 weeks after delivery. Breastfeeding will delay Spontaneous abortion: before fetus is viable, bleeding and cramping. Look for clots and fetal tissue, encourage rest and no sex for 2 weeks. APGAR: Appearance (color), pulse (heart rate: 100>), grimace (reflexes: sneeze, cough, or cry), activity (muscles: tight flexion, good resistance), respiratory (regular, 30-60). 7-10 correct Bonding for premature: skin-skin but avoid over stimulation because you don’t want to burn precious calories Non stress test: done at 28 weeks. Test fetal movements after eating. FHR 15 increase for 15 seconds for 20 minute intervals. Done with Doppler. Vaginal infections during pregnancy (yeast infections): don’t douche, wear cotton underwear, increase air and keep it dry Chlamydia: most common STD, thick discharge, men have dysuria, must tell contact and report. Tx: azithromycin Contractions: from beginning of one to the beginning of the other in seconds Epidural anesthesia: monitor fetus BP and HR for hypo, give fluids and oxygen and turn to left side and call doctor Rhogam: given when RH + baby has RH – mom Pica: eat disgusting stuff, most often in rural areas and family history Labor: contractions that do not decrease with rest Postpartum infection symptoms: increase temperature (104), chills, tachycardia, foul odor Iron supplements: increase Hg for iron deficiency anemia, may cause constipation & dark stool Surfactant: increase opening of alveoli. Used for pre-mature or less than 2 LS ratio Postpartum care: check fundus, check discharge for hemorrhage and infection, VS, BUBBLE-EE (breasts, uterus, bladder, bowels, lochia, episiotomy/perineum, extremities, emotional), uterus: should be midline and firm at level of umbilicus. Lochia: rubra (deep-red, few clots, 3-4 days), Serosa (pinkish brown, 3-10 days, WBC and RBC), Alba (creamy white or light brown 10-14 days or up to 6 weeks). If Rubra after serosa: call doctor: may be subinvolution Oxytocin: increases contractions. Stop if decrease HR or sustained contractions that don’t relax Lamaze: labor and delivery method of relaxation and breathing, slow-paced, rhythmic Alpha-fetoprotein screening: done at 16-18 weeks, tests neural tube defects if elevated, may be used with biomarker screening for Down. Newborn with drug mom: high pitched cry, agitated, inconsolable, not coordinated. Give morphine Kohlberg: 4-10: preconventional: punishment vs obedience 7-10: Conventional: interpersonal beliefs (good-child, bad child) 10-12: rules to follow social order 13+: post conventional: question status quo Age Words Action newborn 12-36 months 200, two word Blocks, imitates adult, walking (toddler) sentences 36 months-5 years 1500, complete Run, jump, climb, brush teeth, (pre-school) sentences play with balls, skip 6 + (school-age) Interested in peers and family, role modeling Toy Mobile with contrast Household toys, tricycle, chalk, bucket, crayons Make figures,