NCLEX: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: THE INTRAPARTUM EXPERIENCE

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

VI. DISORDERS AFFECTING FLUID-GAS TRANSPORT: fetal

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Fetus in jeopardy—general aspects:

1. Pathophysiology—maternal hypoxemia, anemia, ketoacidosis, Rh isoimmunization, or decreased uteroplacental perfusion.

2. Etiology—maternal:

a. Preeclampsia/eclampsia, PIH.

b. Heart disease.

c. Diabetes.

d. Rh or ABO incompatibility.

e. Insufficient uteroplacental/cord circulation due to:

  • Maternal hypotension/hypertension.
  • Cord compression:

(a) Prolapsed.
(b) Knotted.
(c) Nuchal.

  • Hemorrhage; anemia.
  • Placental problem:

(a) Malformation of the placenta/cord.
(b) Premature “aging” of placenta.
(c) Placental infarcts.
(d) Abruptio placentae.
(e) Placenta previa.

  • Post-term gestation.
  • Maternal infection.
  • Polyhydramnios.
  • Hypertonic uterine contractions.

f. Premature rupture of membranes (PROM) with chorioamnionitis.

g. Dystocia (e.g., from CPD).

3. Assessment—intrapartum:

a. Amniotic fluid examination—at or after rupture of membranes. Signs of fetal distress: meconium stained, vertex presentation—due to relaxation of fetal anal sphincter secondary to hypoxia/anoxia. Note: Fetus “gasps” in utero—may aspirate meconium and amniotic fluid.

b. Fetal activity:

  • Hyperactivity—due to hypoxemia, elevated [latex] CO_2 [\latex].
  • Cessation—possible fetal death.

c. Methods of monitoring FHR:

  • Fetoscope.
  • Phonocardiography with microphone application.
  • Internal fetal electrode—attached directly to fetus through dilated cervix after membranes ruptured.
  • Doppler probe using ultrasound flow.
  • Cardiotocograph—transducer on maternal abdomen transmits sound.

d. Abnormal FHR patterns.

  • Persistent arrhythmia.
  • Persistent tachycardia of 160 or more beats/min.
  • Persistent bradycardia of 100 or fewer beats/min.
  • Early deceleration—due to vagal response to head compression.
  • Late deceleration—due to uteroplacental insufficiency.
  • Variable deceleration—due to cord compression.
  • Decreased or loss of variability in FHR pattern.

e. Medical evaluation—procedures: fetal blood gases, pH (rarely performed).

  • Purpose—to identify fetal acid-base status.
  • Requirements for:

(a) Ruptured membranes.
(b) Cervical dilation.
(c) Engaged head.

  • Procedure—under sterile condition, sample of fetal scalp blood obtained for analysis.
  • Signs of fetal distress:

(a) pH less than 7.20 (normal range is 7.3–7.4).
(b) Increased [latex] CO_2 [\latex] (c) Decreased [latex] PO_2 [\latex]

4. Analysis/nursing diagnosis:

a. Impaired gas exchange, fetal, related to decreased placental perfusion/insufficient cord circulation.

b. Altered tissue perfusion related to hemolytic anemia.

c. High risk for fetal injury related to hypoxia.

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

B. Prolapsed umbilical cord

1. Pathophysiology—cord descent in advance of presenting part; compression interrupts blood flow, exchange of fetal/maternal gases → fetal hypoxia, anoxia, death (if unrelieved).

2. Etiology:

a. Spontaneous or artificial rupture of membranes before presenting part is engaged.

b. Excessive force of escaping fluid, as in polyhydramnios.

c. Malposition—breech, compound presentation, transverse lie.

d. Preterm or fetus who is SGA—allows space for cord descent.

3. Assessment:

a. Visualization of cord outside (or inside) vagina.

b. Palpation of pulsating mass on vaginal examination.

c. Fetal distress—variable deceleration and persistent bradycardia.

4. Analysis/nursing diagnosis:

a. Impaired gas exchange, fetal, related to interruption of blood flow from placenta/fetus.

b. Anxiety/fear, maternal, related to knowledge of fetal jeopardy.

5. Nursing care plan/implementation:

a. Goal: reduce pressure on cord.

  • Position: knee to chest; lateral modified Sims’ with hips elevated; modified Trendelenburg.
  • With gloved hand, support fetal presenting part.

b. Goal: increase maternal/fetal oxygenation: oxygen per mask (8–10 L/min).

c. Goal: protect exposed cord: continuous pressure on the presenting part to keep pressure off cord.

d. Goal: identify fetal response to above measures, reduce threat to fetal survival: monitor FHR continuously.

e. Goal: expedite termination of threat to fetus: prepare for immediate cesarean birth.

f. Goal: support mother and significant other by staying with them and explaining.

6. Evaluation/outcome criteria:

a. FHR returns to normal rate and pattern.

b. Uncomplicated birth of viable infant.

VII. SUMMARY OF DANGER SIGNS DURING LABOR

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Contractions—strong, every 2 minutes or less, lasting 90 seconds or more; poor relaxation between contractions.

B. Sudden sharp abdominal pain followed by board-like abdomen and shock—abruptio placentae or uterine rupture.

C. Marked vaginal bleeding.

D. FHR periodic pattern decelerations—late; variable; absent variability.

E. Baseline.

  1. Bradycardia (<100 beats/min).
  2. Tachycardia (>160 beats/min).

F. Amniotic fluid.

  1. Amount: excessive; diminished.
  2. Odor.
  3. Color: meconium stained; port-wine; yellow.
  4. 24 hours or more since rupture of membranes.

G. Maternal hypotension, or hypertension.

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Health Promotion and Maintenance; Nursing Care of the Childbearing Family: THE POSTPARTUM PERIOD

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

General overview: This review of the normal physiological and psychological changes occurring during the postpartum period (birth to 6 weeks after) provides the database necessary for assessing the woman’s progress through involution, planning and implementing care, anticipatory guidance, health teaching, and evaluating the results. Emerging problems are identified by comparing the woman’s status against established standards.

I. BIOLOGICAL FOUNDATIONS OF THE POSTPARTUM PERIOD

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Uterine involution—integrated processes by which the uterus returns to nonpregnant size, shape, and consistency.

1. Assessment:

a. Contractions (“after-pains”)—shorten muscles, close venous sinuses, restore normal tone.

  • Frequency, intensity, and discomfort decrease after first 24 hours.
  • More common in multiparas and after birth of a large baby; primiparous uterus remains contracted.
  • Increased by breastfeeding.

b. Autolysis—breakdown and excretion of muscle protein (decreasing size of myometrial cells). Lochia—sloughing of decidua and
blood.

c. Formation of new endometrium—4 to 6 weeks until placental site healed.

d. Cervix

  • Immediately following birth—bruised, small tears; admits one hand.
  • Eighteen hours after birth—becomes shorter, firmer; regains normal shape.
  • One week postpartum—admits two fingers.
  • Never returns fully to prepregnant state.

(a) Parous os is wider and not perfectly round.
(b) Lacerations heal as scars radiating out from the os.

e. Fundal height and consistency

  • After birth—at umbilicus; size and consistency of firm grapefruit.
  • Day 1 (first 12 hours)—one finger above umbilicus.
  • Descends by one finger-breadth daily until day 10.
  • Day 10—behind symphysis pubis, nonpalpable.

f. Lochia

  • Character:

(a) Days 1 to 3: rubra (red).
(b) Days 3 to 7: serosa (pink to brown).
(c) Day 10: alba (creamy white).

  • Amount:

(a) Moderate: 4 to 8 pads/day (average 6 pads/day).
(b) Following cesarean birth: less lochia—due to manipulation during surgery.

  • Odor: normal lochia has characteristic “fleshy” odor; foul odor is characteristic of infection.
  • Clots: normal: a few small clots, most commonly on arising—due to pooling. Note: Large clots and heavy bleeding are associated with uterine atony, retained placental fragments.

B. Birth canal

1. Vagina—never returns fully to prepregnant state.

a. First few weeks postpartum—thin walled, due to lack of estrogen; few rugae.

b. Week 3: rugae may reappear.

2. Pelvic floor

a. Immediately after birth—infiltrated with blood, stretched, torn.

b. Month 6: considerable tone regained.

3. Perineum

a. Immediately following birth—edematous; may have episiotomy (or repaired lacerations); hemorrhoids.

b. Healing, incisional line clean; no separation.

c. Hematoma—blood in connective tissue beneath skin; complains of pain, unrelieved by mild analgesia or heat; perineal distention; painful, tense, fluctuant mass.

C. Abdominal wall

1. Overdistention during pregnancy may → rupture of elastic fibers, persistent striae, and diastasis of the rectus muscles.

2. Usually takes 6 to 8 weeks to retrogress, depending on previous muscle tone, obesity, and amount of distention during pregnancy.

3. Strenuous exercises discouraged until 8 weeks postpartum.

D. Cardiovascular system—characteristic changes:

1. Immediately after birth—increased cardiac load, due to:

a. Return of uterine blood flow to general circulation.

b. Diuresis of excess interstitial fluid.

2. Volume—returns to prepregnant state (4 L) in about 3 weeks. Major reduction—during first week, due to diuresis and diaphoresis.

3. Blood values.

a. High WBC during labor (25,000–30,000/ [latex] mm^3 [\latex]), drops to normal level in first few days.

b. Week 1—Hgb, RBC, Hct, elevated fibrinogen return to normal.

4. Blood coagulation

a. During labor: rapid consumption of clotting factors.

b. During postpartum: increased consumption of clotting factors. Hypercoagulability maintained during first few days postpartum; predisposes to thrombophlebitis, pulmonary embolism.

5. Assessment: potential complications—vital signs:

a. Temperature—elevated in:

  • Excessive blood loss, dehydration, exhaustion, infection.
  • Elevation: 100.4°F (38°C) after first day postpartum suggests puerperal infection.

b. Pulse—physiological bradycardia (50–70 beats/min) common through second day postpartum; may persist 7 to 10 days; etiology: unknown. Tachycardia—associated with: excessive blood loss, dehydration, exhaustion, infection.

c. Blood pressure—generally unchanged. Elevation—associated with: preeclampsia, essential hypertension.

E. Urinary tract—characteristic changes:

1. Output—increased due to: diuresis (12 hours to 5 days postpartum); daily output to 3000 mL.

2. Urine constituents:

a. Sugar—primarily lactose, usually not detected by conventional dipstick.

b. Acetonuria—after prolonged labor; dehydration.

c. Proteinuria—first 3 days in response to the catalytic process of involution ≤1+.

3. Dilation of ureters—subsides in first few weeks.

4. Assessment: potential complications—measure first few voidings, palpate bladder to determine emptying.

a. Edema, trauma, or anesthesia may → retention with overflow.

b. Over-distended bladder—common cause of excessive bleeding in immediate postpartum.

F. Integument (skin)—characteristic changes:

1. Striae—persist as silvery or brownish lines.

2. Diastasis recti abdominis—some midline separation may persist.

3. Diaphoresis—excessive perspiration for first few (approximately 5) days.

4. Breast changes (see II. A. 3. Breasts, below).

5. Linea nigra and darkened areolae fade.

G. Legs

1. Should have no redness, tenderness, local areas of increased skin temperature, or edema.

2. May have some soreness from birth position.

3. Homans’ sign should be negative (no calf pain when knee is extended and gentle pressure applied to dorsiflex the foot).

H.Weight—characteristic changes:

1. Initial weight loss—fetus, placenta, amniotic fluid, excess tissue fluid.

2. Weighs more than in prepregnant state (weight maintained in breasts).

3. Week 6—weight loss is individualized.

I. Menstruation and ovarian function—first menstrual cycle may be anovulatory.

1. Non-nursing—ovulation at 4 to 6 weeks; menstruation at 6 to 8 weeks.

2. Nursing—anovulatory period varies (39 days to 6 months or more); some for duration of lactation; contraceptive value: very unreliable.

II. NURSING MANAGEMENT DURING THE POSTPARTUM PERIOD

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assessment—minimum of twice daily.

1. Vital signs.

2. Emotional status, response to baby.

3. Breasts

a. Observe: size, symmetry, placement and condition of nipples, leakage of colostrum. Normal: although one breast is usually larger than the other, breasts are essentially symmetrical in shape; nipples: in breast mid-line, erectile, intact (no signs of fissure); bilateral leakage of colostrum is common.

b. Note: reddened areas, elevations, supernumerary nipples, inverted nipples, cracks.

c. Observe for signs of (normal) engorgement (i.e., tenderness, distention, prominent veins). Transient; normally occurs shortly before lactation is established—due to venous and lymphatic stasis.

d. Palpate for: local heat, edema, tenderness, swelling (signs of localized infection).

4. Fundus, lochia, perineum.

5. Voiding and bowel function.

6. Legs.

7. Signs of complications.

B. Analysis/nursing diagnosis.

C. Nursing care plan/implementation:

1. Goal: comfort measures.

a. Perineal care—to promote healing, prevent infection.

b. Sitz baths—to promote healing.

c. Apply topical anesthetics, witch hazel to episiotomy area, hemorrhoids.

d. Administer mild analgesia, as ordered.

e. Instruct in tensing buttocks on position change—to reduce stress on suture line, discomfort.

f. Breast care: mother who is bottle-feeding.

  • Wash daily with clear water and mild soap.
  • Support with well-fitting brassiere.
  • For engorgement:

(a) Prevent with tight binder.
(b) Treat with ice pack and mild analgesic.
(c) Avoid nipple stimulation.

2. Goal: encourage normal bowel function. (Normal to take 1 to 3 days for function to resume.)

a. Administer stool softeners, as ordered.

b. Encourage ambulation.

c. Increase dietary fiber (salads, fresh fruit, vegetables, bran cereals).

d. Provide adequate fluid intake.

3. Goal: health teaching and discharge planning.

a. Reinforce appropriate perineal self-care.

b. Reinforce hand washing.

c. Infant care

  • Bathing, cord care, circumcision care, diapering.
  • Feeding, burping, scheduling.
  • Assessment—temperature, skin color, newborn rash, jaundice.
  • Normal stool cycle and voiding pattern.
  • Common sleep/activity patterns.
  • Signs to report immediately:

(a) Fever, vomiting, diarrhea.
(b) Signs of inflammation or infection at cord stump.
(c) Bleeding from circumcision site.
(d) Lethargy, irritability.

d. Self-care

  • Adequate rest, nutrition, hydration.
  • Breast self-examination; wear bra to support breasts and promote comfort.
  • Normal process of involution; lochial patterns.

e. Resumption of intercourse approximately

4 weeks postpartum (wait until lochia stops).

  • Explain that time interval varies as to first postpartum ovulation.
  • Family planning options may resume if desired:

(a) If not breastfeeding, oral contraceptives (estrogen and progesterone); low-dose progesterone given to mothers who are breastfeeding.
(b) Long-acting progestins (subcutaneous implants or injectable). Safe to use during lactation.
(c) Use of IUD or diaphragm decided at postpartum checkup.
(d) Emphasize need to recheck size and fit of diaphragm.
(e) Other options: condom plus spermicides.

f. Exercises—to restore muscle tone, relieve tension.

  • Mild exercise during first few weeks.

(a) Deep abdominal breathing.
(b) Supine head-raising.
(c) Stretching from head to toe.
(d) Pelvic tilt.
(e) Kegel—to regain perineal muscle tone.

  • Strenuous exercises (sit-ups, leg lifts)— deferred until later in postpartum.

g. Maternal signs to report immediately:

  • Prolonged lochia rubra.
  • Cramping.
  • Signs of infection.
  • Excessive fatigue, depression.
  • Dysuria.

4. Goal: anticipatory guidance—discharge planning: mothers are discharged earlier in their postpartum recovery today—(6–48 hours after birth if asymptomatic).

a. Discuss, assist in organizing time schedule. Nap, when possible, when infant asleep—to minimize fatigue.

b. Common maternal emotional/behavior changes, feelings:

  • Jealous of infant; guilt feelings.
  • “Baby blues”—due to hormonal fluctuations, fatigue, change of lifestyle.
  • Feelings of inadequacy.

c. Discuss support groups, aid in identifying supportive people.

D. Evaluation/outcome criteria:

1. Woman experiences normal, uncomplicated postpartum period. All assessment findings within normal limits.

2. Woman returns demonstrations of appropriate self-care measures/techniques:

a. Perineal care, pad change, hand washing.

b. Breast care, breast self-examination.

3. Woman verbalizes understanding of:

a. Need for adequate rest and diversion.

b. Appropriate time for resumption of intercourse and exercise.

c. Appropriate nutritional intake to meet needs (own and, if breastfeeding, infant’s).

d. Signs to be reported immediately.

e. Returns demonstration of appropriate infant care measures.

f. Evidences beginning comfort and increasing confidence in parenting role.

E. Postpartum assessment—6 or less weeks after birth:

1. Weight, vital signs, urine for protein, complete blood count (CBC).

2. Breast examination lactating or not.

3. Pelvic examination—involution and position of uterus; perineal healing; tone of pelvic floor.

4. Desire for selection of method of contraception.

III. PSYCHOLOGICAL/BEHAVIORAL CHANGES. Achievement of developmental tasks—progress in assuming maternal role.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assessment:

1. Taking-in phase—1 to 3 days following birth.

a. Talkative; verbally relives labor/birth experience.

b. Passive, dependent, concerned with own needs (eating, sleeping, elimination).

2. Taking-hold phase—day 3 to 2 weeks.

a. Impatient to control own bodily functions, care for self.

b. Expresses interest/concern in learning how to care for baby (desire to assume “mothering” role).

c. Responds to positive reinforcement.

3. Letting-go phase—mother “lets go” of former self-concept, role, lifestyle; begins to integrate new role and self-concept as “mother.”

a. Feelings of insecurity, inadequacy.

b. Hesitancy in approaching infant care tasks.

4. “Baby blues”—may appear on day 4 or 5. Note: Often, father/partner experiences same feelings.

a. Thought to result from fatigue (sleep deprivation), realization of need for role change, recognition of new responsibilities, hormonal change.

b. Mild depression, cries without provocation.

c. Frightened—intimidated by own perceptions of responsibilities, hormonal changes.

5. Lag in experiencing “maternal feelings”—usually resolved within 6 weeks.

a. May contribute to “baby blues.”

b. Guilt regarding lack of “maternal feelings.”

c. Diminished by prompt bonding experience.

B. Analysis/nursing diagnosis:

1. Ineffective family coping: compromised, related to achieving developmental tasks.

2. Situational low self-esteem related to perceived inadequacy in acceptance of maternal role.

3. Ineffective individual coping related to “baby blues,” lag in experiencing maternal feelings.

C. Nursing care plan/implementation:

1. Taking-in. Goal: emotional support.

a. Encourage verbalization of labor/birth experiences; compliment parents on “how well” they did.

b. Explore feelings of disappointment, if any.

c. Meet dependency needs; comment on appearance, hair, personal gowns.

d. Encourage rooming in.

2. Taking-hold. Goal: health teaching.

a. Discuss self-care, postpartum physiological/psychological changes.

b. Demonstrate infant care; mother returns demonstration.

D. Evaluation/outcome criteria:

1. Woman demonstrates beginning comfort in maternal role.

2. Woman develops confidence and competence in infant care.

3. Woman expresses satisfaction with self, infant; eager to return home.

4. Woman succeeds in breastfeeding. (Tension inhibits let-down reflex; baby nurses poorly.)

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IV. BREASTFEEDING AND LACTATION

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Biological foundations:

1. Antepartal alterations:

a. High estrogen/progesterone levels—stimulate proliferation and development of breast ducts.

b. High progesterone levels—also → development of mammary lobules and alveoli.

2. Postpartum alterations:

a. Rapid drop in estrogen/progesterone levels.

b. Increased secretion of prolactin—stimulates alveolar cells → milk.

c. Suckling—stimulates release of oxytocin → contraction of ducts → milk ejection (let-down reflex).

d. Engorgement—due to venous and lymphatic stasis.

  • Immediately precedes lactation.
  • Lasts about 24 hours.
  • Frequent feeding reduces engorgement.

B. Assessment:

1. Colostrum (yellowish fluid)—continues for first 2 to 3 days; has some antibiotic, immunologic, and nutritive value.

2. Milk (bluish-white, thin)—secreted on about third day.

C. Analysis/nursing diagnosis:

1. Knowledge deficit related to breastfeeding techniques.

2. Pain related to engorgement.

3. Personal identity disturbance related to problems in breastfeeding.

4. Sleep pattern disturbance related to discomfort or infant care needs.

D. Nursing care plan/implementation:

1. Goal: promote successful breastfeeding.

a. Encourage first feeding within 1 hour after giving birth.

b. Encourage emptying both breasts at each feeding and before engorgement to stimulate milk production, prevent mastitis.

c. Encourage rest, relaxation, fluids.

d. Nutritional counseling.

  • Additional 500 calories daily—may be supplied by one extra pint of milk, one extra egg, and one extra serving of meat, citrus fruit, and vegetable.
  • Increase fluid intake to 3000 mL daily.

2. Goal: prevent or relieve engorgement.

a. Pain: relieved by warm packs, emptying breasts.

b. Wear good, supportive bra.

c. Administer analgesics, as ordered/necessary.

3. Goal: health teaching.

a. Instruct, demonstrate rooting reflex and putting infant to breast. Infant must grasp nipple and areola over location of milk sinuses.

b. Demonstrate burping techniques, what to do if infant chokes; removing infant from breast.

c. Instruct in basic nipple care.

  • Teach good hand washing.
  • Nurse on each breast, making sure areola is in mouth, alternating position of infant.
  • Alternate “beginning” breast.
  • Break suction before removing infant from breast.
  • Air-dry nipples after each feeding and apply lanolin if abraded. Note: Creams, lotions, or ointments block secretion of a natural bacteriostatic oil by Montgomery glands—and infant may refuse breast until it is washed. Instead: expressed milk may be massaged gently around nipple.
  • Teach daily hygiene of breasts.

d. Instruct in care of cracked or fissured nipples.

  • Encourage and support mothers.
  • Air-dry nipples after each feeding.
  • Use nipple shield if nipples extremely sore.
  • Discontinue nursing for 48 hours; maintain milk supply by expressing milk with pump.

e. Discuss avoiding use of any drugs except under medical supervision—may affect infant or suppress lactation.

f. Discuss possibility of sexual stimulation during breastfeeding.

  • Validate normalcy and acceptability.
  • Note: During orgasm, milk may squirt from nipples.

g. Explain that contraceptive value of nursing is unpredictable; the time that ovulation is inhibited varies widely.

h. Explain contraindications to breastfeeding:

  • Active tuberculosis.
  • Severe chronic maternal disease.
  • Mastitis (temporary interruption may be necessary).
  • Some therapeutic drugs.
  • Severe cleft lip or palate in newborn (may pump and give in special bottles).
  • HIV-positive status; AIDS.

E. Evaluation/outcome criteria:

1. Woman verbalizes understanding of breastfeeding techniques, nutritional requirements for successful lactation.

2. Woman successfully demonstrates breastfeeding; infant nurses well.

3. Woman demonstrates appropriate burping techniques; clears excessive mucus from infant’s mouth without incident.

4. Woman verbalizes understanding of basic breast care techniques:

a. Self-examination.

b. Clear water bath.

c. Drying nipples after bathing, feeding.

d. Care of cracked or irritated nipples.

e. Correct infant positioning for feeding.

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