NUR 2633 Maternal Child Health Nursing

Maternal Newborn Exam 2

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What causes urinary retention after birth?

- Temporary nerve damage, caused by edema from labor

Common side effects of antibiotics

- Gi effects (nausea, vomiting, diarrhea, bloating, indigestion, abdominal pain,

loss of appetite)

Common sites for infection following birth?

- Reproductive tract

Nursing care for postpartum preeclampsia

- Bedrest, seizures - give mag sulfate and antihypertensive med, assess for

edema, measure i and o

Postpartum preeclampsia

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- Headache

sob

blurred vision

nausea

vomiting

edema

seizure, other neuro deficit

epigastric pain 

Mastitis

- Infection

common causative factor: organism is the hemolytic staphylococcus aureus,

introduced from the infant's mouth through a fissure in the nipple.

May progress to a breast abscess if not effectively managed.

Mastitis management

- Antibiotic therapy

application of heat or cold to the breast

hydration

analgesics/Nsaids

maintain lactation: empty the breast every 2-4 hours by breastfeeding,

manual expression, or breast pump

Fundal assessment

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- @ delivery - midline, midway between umbilicus and symphysis pubis

1 hour - at the level of umbilicus

24 hour - 1 cm below umbilicus

2 days - 2 cm below umbilicus

3 days - 3 cm below umbilicus

7 days - palpable at the symphysis pubis

9-10 days - not palpable

Manifestations of withdrawal in a newborn

- Irritability

disturbed sleep pattern

constant moving, possibly leading to abrasions on the elbows, knees, or nose.

Tremors

frequent sneezing

shill, high-pitched cry

possible hyperreflexia and clonus (neuro irritability)

convulsions

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tachypnea (rapid resp) possible leading to hyperventilation and alkalosis

vomiting and diarrhea, leading to large amounts of fluid loss and secondary

dehydration 

Newborn vital signs:

- Hr.: 120-160 bpm

RR: 30-60/min

t: 36.5-37.4c

Apgar scale

- A standard measurement system that looks for a variety of indications of

good health in newborns

Appearance

- 0 - blue, pale

1 - pink body, blue extremities

2 - pink

Pulse

- 0 - absent

1 - below 100/min

2 - over 100/min

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Grimace (reflex irritability)

- 0 - floppy

1 - minimal response to stimulation

2 - prompt response to stimulation

Activity (muscle tone)

- 0 - absent

1 - flexed arms and legs

2 - active

Respirations

- 0 - absent

1 - slow and irregular

2 - vigorous cry 

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