Provide attractive, small meals and remove dishes as soon as the client finished eating
Offer small feedings; dry food preferred. Offer liquids (herbal teas) between or after meals.
Administer antiemetics as ordered.
Provide rest, reduce stimuli and restrict visitors.
Monitor fetal heart tones.
2.1 Bleeding during the 1 st Trimester of Pregnancy
Abortion is the medical term for any interruption of a pregnancy before a fetus is viable.
Causes of Abortion
2. Chromosomal Aberration
3. Immune Response
4. Structural Malformation
Types of Abortion
1. Spontaneous- pregnancy ends because of natural causes.
2. Induced- therapeutic or elective reasons for terminating the pregnancy
Types of Spontaneous Abortion
1. Threatened - characterized by cramping and vaginal bleeding in early pregnancy with no cervical dilation.
2. Imminent or inevitable- characterized by bleeding, cramping and dilation. Termination cannot be prevented.
3. Incomplete- Characterized by expulsion of only parts of conception. Bleeding occurs with cervical dilation.
4. Complete- characterized by expulsion of all products of conception.
5. Missed- characterized by early fetus intrauterine death without expulsion of the product of conception. The cervix is closed and the client may report dark brown vaginal discharge.
6. Habitual- Spontaneous abortion of 3 or more pregnancy
1. Take and Record V/S
2. Monitor Blood loss (Pad counts); Note character and amount of blood.
3. Save all tissue and clots passed
4. Be sure that examination are done under aseptic technique.
5. Stay with the client and explain that the pain from contraction will cease when embryo and membrane are passed.
6. Teach controlled breathing and relaxation technique.
7. Allow woman and family time and opportunities to grieve
2.1.2 Ectopic Pregnancy
The implantation of the product of conception outside the uterine cavity. Usual implantation occurs at the distal third of the fallopian tube.
A Graphic Presentation of Ectopic Pregnancies
Adhesions on the fallopian tubes
Scars on the Uterus
Use of Intra Uterine Device
Common Sites of Implantation :
Fallopian tube- 95%
Others Site- 5%
Sharp, stabbing pain at Lower abdominal quadrant
Scant Vaginal Bleeding
Hemorrhage with Acute bleeding
Administration of Methotrexate, Leucovorin, Mifepristone
Surgery; Laparotomy and ligation of the other tube
1. Protect the patient from undue fatigue and infection.
2. Provide Emotional Support to patient and family
3. Facilitate Laboratory studies and Blood crossmatching
4. Continuously monitor v/s of patient and observed for shock
2.1.3 Hyatidiform Mole
A benign neoplasm of the chorion, in which chorionic villi degenerates, become filled with a clear viscous fluid and assume the appearance of grapelike clusters involving all or parts of the decidual lining of the uterus.
2 types of Molar Growth
1. Complete mole- Contains no genetic maternal material
2. Partial Mole- Contains 69 chromosomes
Rapid enlargement of the uterus
No Fetal Heart Tone
Positive Urine Human Chorionic Gonadotropine
Nausea and Vomiting
Intermittent brownish discharge after the 12th weeks
Oral Contraceptives for 12 months
Observe for uterine hemorrhage.
Provide emotional Support
Encourage client to have follow up treatment.
Have Client avoid pregnancy for one year from Negative Test.
Bleeding during the 2 nd and 3 rd Trimester of pregnancy
A condition in which the ovum implants low in the uterus towards the cervix, and the placenta develops so that it partially of completely covers the internal os.
3 degrees of Placenta Previa
1. Low Lying/ Marginal
3. Totalis/ Complete
1. Increasing Parity
2. Advance Maternal Age
3. Past cesarian Section
4. Past Uterine Curettage
5. Multiple gestation
Painless, bright red vaginal bleeding
Increase Uterine tone and contractility
1. Maintain client on bed rest.
2. Provide a quiet, restful atmosphere.
3. Place patient in side lying position.
4. Count perineal pads and measure blood amounts on beddings
5. Give emotional support
6. DO NOT Perform Vaginal Examination. Maybe done but prepare a double set-up.
7. Carefully monitor fetal heart tone thru external Monitors
8. Fetus of less than 34 weeks AOG should receive Betamethasone.
Premature separation of the placenta
A condition that occurs when the placenta separates from a normal implantation site in the upper segment of uterus before birth of baby
Advance Maternal Age
Short Umbilical Cord
Chronic Hypertensive Disease
Cocaine use and Smoking
3 types of Separation
1. Complete- Placenta becomes completely detached
2. Partial- Portion of placenta becomes detached from uterine wall
3. Central- Placenta separates centrally and blood is trapped between placenta and uterine wall
2 types of hemorrhage
1. External- Blood escape from vagina
2. Concealed- Blood is retained in uterine cavity
1. Painful, dark red vaginal bleeding
2. Couvelaire Uterus
3. Lack of alternate contraction
4. Assess for fetal heart tone
5. Assess for signs of shock.
1. Keep client on bed rest.
2. Observe for signs of shock.
3. Carefully monitor contraction.
4. If bleeding is severe, begin the administration of Intravenous Fluids.
5. Facilitate Laboratory work outs includes
6. Monitor Central Venous Pressure.
7. Record I&O, Observe for anuria and Oliguria
8. Observe for hemorrhage after delivery
9. Observe for Disseminated Intravascular Coagulation.
Pregnancy Induced Hypertension
A condition in which vasospasm occurs during pregnancy in both small and large arteries.
Predisposing/ Risk Factors:
1. Multiple Pregnancy
3. Less than 20 & Over 40 years of age.
5. With underlying disease condition
Triad Signs of PIH
2. Generalized Edema
Classification of PIH
1. Gestational Hypertension- BP: 140/90 mmHg, No Proteinuria
2. Mild Pre-eclampsia-
BP: >/ 140/90 mmHg,
+ 1, +2 Proteinuria,
> 2 lbs/ week weight gain in 2nd Trimester
> 1 lbs/ week weight gain in 3rd Trimester
3. Severe Pre-eclampsia-
BP:160/110 mmHg +3, +4 Proteinuria,
5 g or more in 24 hrs.
Severe Epigastric pain,
Nausea and Vomiting
Blurred Vision, severe headache
Spots before Eye,
Marked Hypereflexia Oliguria
4. Eclampsia- + Signs and symptoms Severe Pre-eclampsia + Seizures or Coma
Roll over test
1. Complete Bed rest.
3. Daily Weight
4. Magnesium Sulfate
1. Maintain client on bed rest
2. Monitor for MgSO4 Toxicity
Assessment PRIOR TO Administration
1. Urine Output
2. Respiratory Rate
3. Positive Patellar Reflex
Toxicity Signs and Symptoms
2. Respiratory failure
3. Monitor fetal Heart Tone and Observed for signs of Labor
4. Record I&O;
5. Check daily weight.
6. Check the Retina daily
7. Limit Visitors in Sever Cases.
8. Final Resolution of PIH is Delivery/ Early Termination of Pregnancy.
9. Maintain on Seizure Precaution
Implementation for Eclampsia
1. Provide quiet, darkened room.
2. Check Frequently for edema.
3. Maintained Seizure Precaution.
4. Keep client on NPO
5. Check V/S and Lab results.
6. Monitor FHT and Contraction
7. Observed 24 Hours postpartum for the Following:
d. Blurred Vision
8. Observed for HELLP Syndrome ( Hemolysis Elevated Liver Enzymes and Low Platelet Count)
Medical Diseases Complicating High Risk Pregnancy
Classification of Heart Disease
Class I- Uncompromised
Class II- Slightly compromised
Class III- Markedly Compromised
Class IV- Severely Compromised.
A. Observed for signs of cardiac Decompensation: 2nd Trimester
2. Evaluate for signs of Infection
3. Activity Restriction
4. Low Salt Diet
1. Educate the client about the classification and effects of pregnancy before conception.
2. Educate client about special needs and danger signal during pregnancy and postpartum.
3. Care for Client during Labor:
4. Counsel the client during postpartum
A chronic metabolic disease caused by the inability to metabolize glucose properly
Abnormalities disappear after pregnancy
Symptoms of Hyperglycemia are mild but maybe risky for fetus
Diet is cornerstone of intervention
Maternal Glucose crosses the placenta but insulin does not.
Pregnant mothers should be Screened for glucose level.
Implication of Diabetes in Pregnancy
1. Diabetes is more difficult to control.
2. There is a tendency for client to develop Acidosis
3. Client is more prone to infection
4. PIH, Hemorrhage and Polyhydramnios are more likely to develop.
5. Gestational Diabetes may develop to full blown diabetes.
6. Insulin requirements needs to be increased.
7. Premature delivery is more frequent.
8. Infant maybe overweight but have functions related to gestational age rather that size.
9. Infant is subject to Hypoglycemia, hyperbilirubinemia, Respiratory distress syndrome and congenital anomalies.
10. Stillborn and neonatal mortality is high.
1. Glucose Tolerance test
2. Positive signs of Hyperglycemia/Hypoglycemia
3. Assess for major signs and Symptoms of Diabetes
A. Educate the client on the effect of diabetes on her and the fetus during pregnancy and the reasons for adhering to therapy protocol.
B. Proper care if client is hospitalized.
C. Care of Client in Labor
d. Provide Postpartum care
5. Multiple Pregnancy
1. Faster rate of Increase size of the uterus
2. Increase Alpha-Feto protein level
3. Report flurries of action at different portion of abdomen
4. Multiple sets of Fetal Heart Sound
5. Assess for: Digestion difficulties
1. Encourage the woman to keep appointment for more frequent check up
2. Counsel the woman to rest frequently during day in the 3rd trimester.
3. Teach the mother the reportable signs and Symptoms of premature labor:
4. Advocate increase protein, iron and calcium in diet.
5. Monitor for Hypertension
6. monitor the woman for postpartum hemorrhage
4. Advocate increase protein, iron and calcium in diet.
5. Monitor for Hypertension disorder
6. Following delivery, monitor the woman for postpartum hemorrhage
7. Counsel the woman to rest frequently
8. Encourage pelvic rocking and or legs elevated when sitting to help relieve backache.
9. Small frequent meal is encourage.
Premature Rupture of Membrane
is rupture of fetal membrane with loss of Amniotic fluids during pregnancy before 37 weeks.
Maternal and Fetal Infections
Increase pressure on the Umbilical Cord
Potter Like Syndrome
Use of Nitrazine Paper
Observed for signs of Infections
Observed for signs of Labor
Observed for Amniotic fluid for foul odor
Complete Bed rest
Monitor for signs of Contractions
Monitor Fetal Heart Tone
Give Emotional Support
Refrain from Tub Bathing, Douching, Coitus and Enema
Monitor and Record Vital Signs
Dystocia (Dysfunctional Labor)
Occurs with prolonged and difficult labor and delivery. Labor is considered prolonged when it extends for 24 hours or more after the onset of regular contractions.
Types of Dystocia
Dysfunctional Uterine Contractions
Uterine contraction is ineffecient; Hence cervical dilatation, effacement and descend fails to occur.
Cause: False Labor
Oversedation/ Excessive Anesthesia
Abnormal Presentation and Malposition
Occiput Posterior Position
Breech Presentation, Face presentation
Cephalo-Pelvic Disproportion- Disproportion between the size of the fetus and the size of the pelvis.
Maternal Diabetes Mellitus
Large Baby, Head is larger
1. Observed rate of progress as well as overall length of labor:
Latent Phase :
Parous Women: 14 hours or longer
Nulliparous : 20 hours or Longer
Parous Women: Dilatation;slower than 1.5 cm/hour
Descent ;slower than 5 cm/hour
Nulliparous : Dilatation; Slower than 1.8 cm/hour
Descent ; Slower than 1cm/hour
2. Assess for Maternal Exhaustion
3. Assess for Fetal Distress
Monitor Vital Signs
Monitor Fetal Heart Tone
Encourage client to void at least every 2 hours and check for bladder Distention
Give client a back rub
Give client reassurance and support
Prepare for Cesarian Section as necessary
Occurs after the 20 th weeks but before the 37 th weeks AOG.
Occurs after 20 th weeks but before 37 th week AOG
Persistent Uterine contractions (4 times every 20 minutes)
Has 80% effacement and Dilatation of 1 cm.
Urinary Tract Infections
Persistent, dull, low back ache
Pelvic pressure: Abdominal Tightening
Menstrual Like cramping
Increasing Vaginal Discharges
Complete Bed Rest
Calcium Channel Blockers
( Nifedefine, Indomethacine)
Tocolytic Therapy: Beta 2 receptors Antagonist
Ritodrine Hydrochloride (Yutopar)
Isoxsuprine Hydrochloride (Vasodilan)
Complication: Risk for Prolapsed Cord
Maintain bed rest
Continuously monitor contractions
Administer medications as ordered
Keep client informed and provide emotional support
Carefully observed for signs of complication
Consideration in Terbutaline Therapy
Contraindicated for patient with Thyroid functions and Diabetes Mellitus
Obtain Baseline Blood data:
Mix terbutaline with Ringer's Lactate, and on piggy back infusion
Assess for Side effects
Induction of Labor Artificial initiation of Labor
Criteria for Induction
Fetus is in danger
Labor does not occur spontaneously
Fetus is at term
Presence of Maternal diseases
Condition before Induction
Fetus is in Longitudinal lie
Cervix is ripe or ready for birth
Presenting part is engaged
Fetus is mature
Ways of Induction of Labor
Patient should be on bedrest
Monitor for Side effects
Oxytocin. Cautiously use for patient with Asthma, renal failure and glaucoma.
Given intravenously, with Ringers Lactate
Management of Oxytocin
Cautiously monitor FHR and Uterine Contraction
Monitor Blood pressure
Monitor for Headache and Vomitting
Keep accurate I&O and test for specific gravity.
Monitor for Uterine Contraction
Rapid or sudden labor of less than 3 hours duration from onset of cervical changes to delivery of infant
Induction of labor by Oxytocin
Obtain a quick history by asking focused question
a. Do you want to push?
b. Have your membrane ruptured?
c. Are you bleeding?
d. Have you had baby born quickly before?
Assess for signs of impending delivery
Desire to push
b. Frequency of strong contractions
c. Heavy Bloody show
d. Membrane ruptured
e. bulging rectum
f. presenting part visible
g. severe anxiety
Premature separation of the placenta
Subdural hemorrhage for the fetus
Assisting with the delivery
a. Never leave the client unattended during this time
Never hold baby back
Ask another employee to notify the physician
Bring emergency delivery pack to room
Have client pant rather than push
b. reassure that you will remain with her and provide care until the physician arrive
c. Put on sterile gloves
d. Break membrane immediately
e. with a clean or sterile towel (if available) support baby's head with one hand, applying gentle pressure to the head
f. if cord is draped around the neck, with free hand gently slip it over the head.
g. if you have bulb syringe, gently suction baby's mouth and wipe blood and mucus from mouth and nose with a towel, if available.
h. Shoulders are usually born spontaneously after external rotation. If shoulders do not deliver spontaneously, ask client to bear down to deliver them.
i . Support the baby's body as it is delivered
j. Hold infant level with placenta until cord clamp is done.
k. All manipulation should be gentle to avoid injury to mother and baby.
Care after Delivery
A. After the delivery, hold the baby securely over hand and arm with the head in a dependent position
B. If baby does not cry spontaneously, gently rub baby's back or the sole of baby's feet.
c. Place the baby on the mother's abdomen to provide warmth.
d . Palpate mothers abdomen to make sure uterus is contracting
e. Watch for signs of placental separation
f. Support placenta in your hands after it expelled.
g. Clamp the cord after it stops pulsating if clamp or ties are available.
h. Wrap the baby in a blanket
i. Put the baby to the mothers Breast.
j. Check the uterus after the delivery of the placenta.
k. keep an accurate record of the time of birth and other pertinent data.
l. Comfort mother.
M. If baby is delivered unassisted, in bed, before the nurse arrives (precipitate delivery)
THE NURSE SHOULD IMMEDIATELY
1. Check the baby to make sure breathing is established.
2. Check the mother for excessive bleeding.
An excessive amount of amniotic fluid
Excessive Uterine Enlargement
Difficulty finding a comfortable position during sleeping
Pain in abdomen, back and thigh due to increasing pressure
Nausea and Vomiting
FHT maybe difficult to locate and Palpate
a. Assess for signs of Hemorrhage
b. Assess for signs of infections
c. Assess for premature labor
d. Instruct the mother to void prior the procedures
e . Provide privacy
f. Place a folded towel under the client's right buttocks
g . Take baseline maternal and Fetal V/S
h . Attached fetal monitor.
i. Instruct the patient to take deep breath during insertion
- Small amount of amniotic fluids associated with fetal renal agenesis and post maturity.
Small uterine size
Labor maybe premature
Uterine contraction maybe ineffective and labor maybe prolonged
Fetal hypoxia because of cord compression
Monitor fetal status carefully during pregnancy and labor
Monitor the woman for labor complications
a spontaneous or traumatic rupture of uterus
Unwise use of Oxytocin
Traumatic maneuver of Forceps or Traction
Excessive Fundal pushing
Scar from previous Cesarian Section
Sudden, sharp abdominal pain during contractions
Cessation of Contractions
Bleeding into abdominal Cavity and some into the vagina
Fetus easily palpated; No FHT
Signs of Shock
Develop over a period of a few hours
abdominal pain during contraction
Contraction continue but no Cervical Dilatation
Increasing Pulse Rate and Skin pallor
Loss of FHT
Administer IV Fluids and blood as ordered
Prepare the woman for surgery
Monitor Maternal and Fetal Vital Signs
Uterus maybe repaired but if extensive, Hysterectomy is necessary
Keep the woman informed about the procedure.
Prolapsed Umbilical Cord
Prolapse in front of or along side the fetal presenting part
Premature Rupture of Membrane
Cord maybe seen protruding from vagina
Cord maybe palpated in vaginal canal or cervix
FHT maybe irregular with periodic fetal Bradycardia
Reflex constriction on the umbilical cord
Place the woman in deep trendelenburg position
Administer Oxygen by mask
Place sterile gloved hand in vagina and push the infant head upward
Prepare immediate vaginal delivery if cervix is dilated or if not Cesarian Section
For home situation, cover protruding cord with clean, wet dressing, elevate the woman hip and transport to hospital immediately
Have woman hear FHT.
Amniotic Fluid Embolism
The escape of amniotic fluid into the maternal circulation. It is usually fatal to the mother. High maternal mortality rate of 85%.
1. Premature Rupture of Membrane
2. Tumultuos Labor
Observe for Acute Dyspnea
Assess for sudden chest pain
Check for Cyanosis
Observe for Pulmonary edema
Check for Vital signs that may indicate Shock
Digitalis for failing cardiac function
Fibrinogen to replaced depleted reserves
Heparin to combat fibrinogenemia
Institute efficiency measure to maintain life.
If clients survive, provide intensive care treatment
Keep family informed and provide emotional support.
Post Natal Period
Relaxation of the uterus and is the most common cause of Postpartal Hemorrhage
Factors that leads to Atony:
1. Conditions that distends the uterus beyong average capacity
2. Conditions that could have caused vaginal/Uterine laceration
3. Conditions with varied palcental sites/Attachement
Monitor Vital signs- Maybe an indicative of Shock
Facilitate Laboratory studies
Keep Accurate counts of Pads
Provide emotional Support
Keep the Client and family informed about the procedures
Involve a blood loss of 500 mL or more and occurs most frequently on the first hour following delivery.
Retained Placental Fragment
Laceration of the vagina, cervix of perineum
a . Observed for Uterine Atony
b . Check for lacerations
c . Checked for retained placental tissue
d .Evaluate signs and symptoms of shock
f. Evaluate laboratory results
Monitor V/S q 15 mins until stable
Prepare to administer IV fluids, blood and plasma expander as ordered.
Palpate the fundus every 15 mins. or PRN while bleeding continuous.
Gently massage the fundus
Administer Oxytocin or other uterine stimulants.
Have the physician Notified
Weight pads and linen.
Explain and provide warmth for client
Return client to DR or OR for removal of placental tissue or repair of laceration.
Localized collection of blood in loose connective tissue beneath the skin that covers the external genetalia, beneath the vaginal mucosa or in the broad ligaments .
Trauma during spontaneous delivery
Trauma during forcep application or delivery
Inadequate suturing of episiotomy
Ice and Hot compress
I&D and ligation of bleeder.
Keep the woman and family informed of changes in physiologic status and treatment plan.
Bacteria that are introduced from external sources
Normal bacterial organism in the generative tract.
Premature Rupture of Membrane
Infection elsewhere in the body
Fever: 38.0 C or above after the 24 hours after delivery
Endometritis Infections involving the endometrium
uterus usually larger than expected for post delivery day
Lochia may be profuse, bloody and foul smelling
Chills and fever
Infections of the pelvic connective tissue
Uterus maybe larger than expected
Uterus becomes fixed, the pelvic area warm
Chills, fever, tachycardia, severe unilateral or bilateral pain i
Incision and drainage is performed.
Inflammation of a vessel wall with clot formation
- Result from puerperial infections
Pelvic Thrombophlebitis -
*Begins on the 2 nd week from delivery
Severe chills and intermittent high fever 40.6 Celsius
* Pain and tenderness and turgidity of the calf
*Redness, increase skin temperature, edema of the calf and thigh
*Positive Homan's sign.
Severe Chills, fever, and rapid respiration
Pale skin: Fingers and lips maybe cyanotic
Lochial Discharges may increase and have foul odor.
a. Continue Monitoring V/S every 2-4 hours
b. Isolate woman
c. Maintain Fluids and electrolytes
d. Antibiotic Therapy is instituted
e. Monitor site for infections
g. Institute Comfort Measures.
Bladder Trauma during delivery
Urinary retention due to anesthesia, excessive IVF caising distended bladder
Increasing Temperature >/ 37.8 Celsius
Pain on Urination
Monitor V/S, degree and site of pain
Increase Fluid intake
Instruct the mother to empty the bladder completely each time she urinates.
Administer Antibiotics and Analgesics.
Encourage to rest.
Subinvolution of the Uterus
Slowing or halting of normal postpartum return of the reproductive organ to their pre-pregnancy state.
Retention of Placental Fragments
Uterus larger and softer than expected
Uterus still palpable after 4-6 weeks
Prolonged Lochial Discharges
Backache or sensation of weight in pelvis
Oral administration of Methergine Maleate
Prepare the woman for Uterine Curettage,
Administer prescribed antibiotics
Instruct the woman to report signs of infections, vaginal bleeding or any tissue passage vaginally.
Occuring with in 4-6 weeks after delivery
Clouding of consciousness and hallucinations
Fear and suspiciousness
Make referral to appropriate health team to increase resources
Encourage family support and presence
Administer psychotropic drugs
Encouraged the woman to touch and see the baby
Show and teach them some parenting skills
Do not leave the patient alone.
High Risk Infants
Care of Premature Infant
An infant born before the end of the 37 th week regardless of birth weight.
a. Assess digestive system
b. Assess CNS and Muscle tone
c. Assess for Respiratory System
d. Assess Intergumentary System
e. Assess immune system
f. Assess Hepatic System: Liver Immature
g. Assess for Circulatory system
h. Assess for Renal System
a. Provide Immediate care to infant
b. Evaluate Respiratory Status
c. Reposition every 2 hours
d. initiate feedings as ordered
e. provide for family's needs
f. Maintain I&O, and weight daily
g. Organize care to conserve energy
h. Measure head circumference and length
i. Check Heart Rate by apical pulse
j. Gently stroke and talk to baby when giving care
k. Hang colorful mobiles or other non-harmful objects in crib
l. Hold baby during feeding as soon as condition permits.
m. Encourage parents to hold, cuddle, feed and diaper as per baby
Respiratory Distress Syndrome
A group of clinical symptoms signifying that the infant is experiencing problems with the respiratory system- also called Hyaline Membrane Disease.
A. Symptoms are the result of a decrease in the amount of surfactant in the infant's lungs
B. Respiratory Distress syndrome is the most common cause of death in infant
A. assess for increased respiration
B. Assess for retractions sternal and intercostal.
C. Check for presence of cyanosis and expiratory grunting.
D. Assess for increased apical pulse.
E. Evaluate for nasal flaring and chin lag
F. Evaluate for lack of activity or movement.
G. Assess for inability to take in sufficient oxygen
H. Assess for Hypercarbia
I. Check for respiratory acidosis
J. Evaluate for decreased body temperature.
K. Check for metabolic acidosis due to increased production of Lactic Acid
A . Prevent Cold stress
B . Provide Nutrition and Hydration
C . Do careful monitoring of blood gases and electrolytes, color and activity.
D . Administer Oxygen for Hypoxemia
E . Surfactant replacement therapy
F. Care of Infant with Endotracheal Tube
G. Gently handle the infant with as little disturbance
H . Keep parents informed of infant's progress
I. Allow parents to visit infant as much as possible
J. Gently stroke and talk with infant while giving care.
Small for Gestational Age
Refers to infants who are significantly under size for gestational age. Also called as Intra-Uterine Growth Retardation.
Little Subcutaneous tissue
Loose, dry, scaling skin
Appears thin and wasted; old for size
Maybe meconeum staining of skin, nails
Sparse hair on head
Active, alert and seem hungry
Cord dries more rapidly
A. Assess for Hypoglycemia or poor glucose control
B. Assess for Hypothermia
C. Assess for Asphyxia
D. Assess for Polycythemi
A. provide care similar to Premature infants until stabilized.
B. Protect from cold stress; Keep warm; Usually in isolette
C. Perform test for glucose
D. Weigh daily and maintain I&O
Refers to an infant of over 42 weeks gestation
A. Assess that vernix and lanugo
B. Assess skin
C. Check fingernails and toenails
D. Assess size
E. Observe for Hypoglycemia
F. Observe for signs of birth injury
A. Similar to care given to preterm infants if premature characteristics are observed
B. Symptoms depends on conditions at birth.
C. Monitor for possible complication (Asphyxia, Polycythemia)
An abnormal elevation of bilirubin in the newborn (above 12.9 mg/100mL for fomula feed infants and above 15 mg/100 mL for breastfed infants and Prematures)
A. Observe for Jaundice, which progresses from head to extremities.
B. Observe for Pallor
C. Evaluate Activity Level
D. Assess if urine is concentrated and stools are light in color.
E. Assess progress of conditions
F. Evaluate Blood Tests.
A. Observe infant for signs of increase jaundice
B. Observe for and prevent acidosis
C. Maintain adequate hydration and offer fluids between feeding as ordered.
D. Using skin temperature probe
E. Prevent Infections
F . Provide Photo therapy
G . Meet infant's emotional needs
H. Reinforce Physician's teaching to parents and allow parents to express concerns and feelings
I. Monitor Exchange Transfusion;
J. Administer care after Transfusion
The destruction of Red Blood Cells that results from an Antigen-Antibody reaction and is characterized by Hemolytic Anemia and or Hyperbilirubenemia
Indirects Coombs' test
Directs Coombs' test
Spectrophotometric Analysis of Amniotic fluids
Assess for Jaundice
Administer immunization against hemolytic disease with RhoGAM as ordered
Monitor exchange transfusion after birth or Intrauterine transfusion.
Follow interventions for Hyperbilirubenemia.
Infants of Diabetic Mother
Infants with blood glucose level of less than 40 mg/dL. Most have been exposed to elevated maternal glucose level in utero.
A. Assess for excessive size and weight due to excess glycogen and fats in tissue.
B. Assess Appearance of Infants
C. Observed for signs and symptoms of Hypoglycemia
D. Observed for hypocalcemia
E. Observed for signs and symptoms of Respiratory Distress
A. Administer care similar to preterm infant
B. Caloric intake important
C. Be aware that any infant of a diabetic mother will be started on Hypoglycemia protocol regardless of weight.
There is a direct relationship between the duration of addiction, dosage and the severity of symptoms.
A. Heroin Addicted Mothers:
infants may appear normal at birth with low birth weight.
Onset of withdrawal begins within 72 hours.
Infants appears less ill than when mother is taking methadone
Heroin causes early maturation of the liver.
B. Mother on Methadone
Onset of withdrawal may be delayed; Most evident 48-72 hours and may last 6 days to 8 weeks.
Infant may appear to be very ill.
May develop jaundice due to prematurity
C. Mothers addicted to Cocaine
A stimulant; Maternal to fetal transfer of cocaine is swift, with the metabolites even more potent than the drugs.
A. Assess for irritability, tremors, hyperactivity, and hypertonicity
B. Assess for respiratory distress and ventilatory capacity
C. Observed for the following signs:
1. High pitched, shrill cry
4. Disruption of Normal sleeping pattern
5. Gastrointestinal Effects
c. Poor feeding
6. Excessive sweating
7. Extreme sucking of fist
A. Monitor respiratory and cardiac rates every 30 minutes and PRN
B. Take temperature every 4-8 hours and PRN
C. Reduce External stimuli and handle infant infrequently.
D. Pad sides of crib to protect the infant from injury
F. Suction if necessary
G. Provide careful skin care
H. Measure I&O
I. Keep mother informed of infants progress
J. Promote mother's Interest to infant
K. Administer Medication as ordered, usually, paregoric (Narcotic Opiates), phenobarbital, valium and tincture opium.
Fetal Alcohol Syndrome
a. Monitor for respiratory distress and apnea
b. Observe for cyanosis
c. Observe for seizures
d. check for major brain dysfunction symptoms
A. Position on side to facilitate drainage of secretions
B. Administer small, frequent feeding and burp well
C. Avoid Heat Loss
D. Reduce environmental stimuli.
Children with Neurological Disturbances
A conditions in which the normal circulation of the spinal fluid is altered, resulting in pressure on the brain, and the progressive enlargement of the head.
Types of Hydrocephalus
A. Assess for gradual enlargement of the head
B. Check for separation of skull
C. assess for sunset eyes
D. check for hyperactive reflexes
E. Evaluate presene of irritability, failure to thrive, and high pitched cry
F. Assess for presence of projectile vomiting
G. Prepare child and family for CT scan or MRI
A. Actions depends on the cause of increased pressure.
Removal of part of choroid plexus
Shunting of the fluid out of the brain to the heart or to the peritoneal cavity.
Removal of obstruction
B.Provide Preoperative Care (VP Shunting)
C. Postoperative Care
The failure of the posterior portion of the lamina of the bony spine to form, causing an opening in the spinal column, which may contain meninges and spinal fluid or meninges, spinal fluids and nerves.
A. Spina Bifida Occulta Type
B. Meningocele Type
C. Meningomyelocele Type
A. Assess for presence of Hydrocephalus
B. Assess neurological involvement
C. Check for Urulogical Involvement
D. Assess for Orthopedic Involvement
E. Evaluate bowel function
A. Neurological Intervention
Observe for Hydrocephalus as it is a frequent complications
Measure Head Circumference at least every 24 hours
Observe for signs of Increase Intracranial Pressure
B. Urulogical Interventions
1. use sterile technique
2. Keep careful record of Intake and Output
3. Teach parents crede method
4. Observe for signs of UTI
a. increase temperature
b. foul smelling urine
c. cloudy urine with possible mucus
A non-specific term used to describe a group of disorders characterized by motor and postural impairments due to abnormal muscle tone
Assess for Abnormal Movement
2. Athetoid (Dyskinetic)
Assess for seizures
heck for vision disturbance
Assess mental functioning
A. Each child requires an individualized program
B. Major focus of interventions is to:
Develop motor control
develop communication skills
Provide adequate nutrition
Prevent orthopedic complications
Acute encephalopathy with fatty degeneration resulting in marked cerebral edema and enlargement of the liver with marked fatty infiltration.
A. Usually follows a viral infection, especially Varicella and influenza B
B. Aspirin (because of links to develop of Reye's) is now contraindicated with influenza
A. Assess for Prodromal symptoms; Malaise, cough, rhinorrhea, sore throat