NCLEX-RN: Maternal–Newborn Nursing

Maternal–Newborn Nursing: ANTEPARTUM PERIOD

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Antepartal Maternal Changes

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Physiological Changes

Focus topic: Maternal–Newborn Nursing

Reproductive Organs
A. Uterus—increases in weight from 57 g to about 907 g at the end of gestation and in size from five to six times larger.

  • Changes in tissue.
    a. Hypertrophy of muscle cells with limited development of new muscle cells.
    b. Development of connective and elastic tissue, which increases contractility.
    c. Increase in the size and number of blood vessels.
    d. Hypertrophy of the lymphatic system.
    e. Growth of the uterus is brought about by the influences of estrogen during the early months and the pressure of the fetus.
  • Other changes.
    a. Contractions occur throughout pregnancy, starting from very mild to increased strength.
    b. As the uterus grows, it rises out of the pelvis, displacing intestines, and may be palpated above the symphysis pubis.

B. Ligaments—broad ligaments in the pelvis become elongated and hypertrophied to help support and stabilize uterus during pregnancy.
C. Cervix.

  • Becomes shorter, more elastic, and larger in diameter.
  • Marked thickening of mucous lining and increased blood supply.
  • Edema and hyperplasia of the cervical glands and increased glandular secretions.
  • Mucous plug expelled from cervix as cervix begins to dilate at onset of labor.
  • Increased vascularity, deepening of color to dark red or purple—Chadwick’s sign––found in both vagina and cervix.

D. Vagina.

  • Hypertrophy and thickening of muscle and mucosa.
  • Loosening of connective tissue.
  • Increased vaginal discharge.
  • High pH secretions, less acidic (4.0–6.0 pH).

E. Perineum.

  • Increased vascularity.
  • Hypertrophy of muscles.
  • Loosening of connective tissue.

F. Ovaries and tubes.

  • Usually one large corpus luteum present in one ovary. Produces hormones (estrogen and progesterone) until week 10–12.
  • Ovulation does not take place.

Breast
A. Changes in tissue.

  • Extensive growth of alveolar tissue, necessary for lactation.
  • Montgomery’s glands—enlargement of sebaceous glands of primary areola.

B. Other changes.

  • Breast increases in size and firmness and becomes nodular.
  • Nipples become more prominent and areola deepens in color.
  • Superficial veins grow more prominent.
  • At the end of third month, colostrum appears.
  • After delivery, anterior pituitary stimulates production and secretion of milk.

Abdomen
A. Contour changes as the enlarging uterus extends into the abdominal cavity.
B. Striae gravidarum usually appear on the abdomen as pregnancy progresses.

Skin
A. Pigmentation increases in certain areas of the body.

  • Breast—primary areola deepens in color.
  • Abdomen—linea nigra, dark streak down the midline of abdomen, especially prominent in brunettes.
  • Face—chloasma, the “mask of pregnancy” pigmentation distributed over the face. Usually disappears after pregnancy.
  • Face and upper trunk—occasionally spider nevi or palmar erythema develops with the increase in estrogen.

B. Increased sebaceous and sweat gland activity.
C. Pigmented areas on abdomen and breast usually do not completely disappear after delivery.

Circulatory System
A. Considerable increase (up to 50%) in volume as a result of

  • Increased metabolic demands of new tissue.
  • Expansion of vascular system, especially in the reproductive organs.
  • Retention of sodium and water.

B. Increase in plasma volume is greater than increase in red blood cells (RBCs) and hemoglobin (Hgb).

  • Decline in hemoglobin due to hemodilution referred to as “pseudoanemia.”
  • Low hemoglobin in pregnancy, below 11.5%, usually caused by iron-deficiency anemia.

C. Folic acid (folate) and iron requirements are increased to meet demands of increased blood supply and growing fetus (need cannot be met by diet alone; supplement usually given).
D. Heart increases in size. Cardiac output is increased (25–50%); after 28 weeks reaches maximum volume.
E. Blood pressure (BP) should not rise during pregnancy. Slight decline is normal in second trimester.
F. Fibrinogen concentration increases to term.
G. Palpitations may be experienced during pregnancy due to sympathetic nervous disturbance and intraabdominal pressure caused by enlarging uterus.

Respiratory System
A. Thoracic cage is pushed upward and diaphragm is elevated as uterus enlarges.
B. Thoracic cage widens to compensate, so vital capacity remains the same or is increased.
C. Oxygen consumption is increased 15% to support fetus and tissue.
D. Shortness of breath may be experienced in latter part of pregnancy due to pressure on diaphragm caused by enlarging uterus and decreased CO2 levels.

Digestive System
A. Nausea, vomiting, and poor appetite are present in early pregnancy because of decreased gastric motility and acidity; due to effects of progesterone.
B. Constipation is due to a decrease in gastrointestinal (GI) motility, reduced peristaltic activity, increased water absorption, the pressure of the uterus, and displacement of intra-abdominal organs; it may be present in latter half of pregnancy.
C. Flatulence and heartburn may be present due to decreased gastric secretion of HCl and pepsin and decreased motility of the gastrointestinal tract; results in delayed gastric emptying time.
D. Cardiac sphincter relaxes.

Urinary System
A. Kidneys.

  • Kidney and renal function increase.
  • Renal blood flow and glomerular filtration increase 50%.
  • Renal threshold for sugar is reduced in some women. Glycosuria is an indication of the need to further test for gestational diabetes.

B. Bladder and ureters.

  • Blood supply to the bladder and pelvic organs is increased.
  • Pressure of the uterus on the bladder causes frequent urination in early and late pregnancy.
  • Relaxation of smooth muscles during pregnancy leads to dilatation of ureters and renal pelvis, and may cause urine stasis.
  • A decrease in bladder tone is caused by hormonal influences, and a decrease in bladder capacity occurs because of crowding; may lead to complications during pregnancy and in the postpartum period (urinary tract infection [UTI], urinary retention).

Joints, Bones, Teeth, and Gums
A. Softening of pelvic cartilages occurs, probably due to the hormone relaxin, progesterone, and estrogen.
B. Posture changes as upper spine is thrown forward to compensate for increased abdominal size (lordosis).
C. Demineralization of teeth does not occur as a result of normal pregnancy but may be related to poor dental hygiene.
D. Increased vascularity of gums due to hormonal changes with tendency to bleed easily.

Endocrine System
A. Placenta produces the hormones HCG and HPL.

  • Production of estrogen and progesterone is taken over from the ovaries by the placenta/ fetal unit after the second month.
  • Normal cycle of production of estrogen and progesterone by ovaries is suspended until after delivery.

B. Anterior lobe of pituitary gland enlarges slightly during pregnancy.
C. Adrenal cortex enlarges slightly.
D. Thyroid enlarges slightly and thyroid activity increases.
E. Aldosterone levels gradually increase beginning about the fifteenth week.

Metabolism
A. Weight gain

  • Progressive gain to ensure fetal growth and development and stores for successful lactation.
    a. Pattern of weight gain important.
    b. Second and third trimester: 0.4 kg (0.88 lb)/week (normal weight); 0.5 kg/ (1.1 lbs) week (underweight); 0.3 kg (0.66 lb)/week (overweight).
  • Recommendation determined by prepregnancy weight for height; normal: 11.5–16 kg (25.3–35.2 pounds).
  • Weight gain should be from balance of foods; see MyPlate (2011 revision).

B. Some of the weight gain is caused by retention of fluid and by deposits of fatty tissue.

C. Water metabolism.

  • Tendency to retain fluid in body tissues, especially in the last trimester.
  • Reversal of fluid retention usually takes place in the form of diuresis in the first 24 hours postpartum.

D. Metabolic rate increases 20%.
E. Carbohydrate metabolism.

  • Increased need to spare protein stores.
  • First half: Glucose readily passes across placenta to meet rapid growth needs of fetus; may experience hypoglycemia and faintness.
  • Second half: Increased production of HPL (insulin antagonist properties) produces a normal maternal hyperglycemia; implications for gestational diabetes or preexisting diabetes.

Maternal–Newborn Nursing: Psychosocial Changes

Focus topic: Maternal–Newborn Nursing

Altered Emotional Characteristics
A. Pregnancy may be viewed as a developmental process involving endocrine, somatic, and psychological changes, as a period of increased susceptibility to a maturational crisis.
B. Emotional reactions to pregnancy may vary from early rejection to elation.
C. Mother may be puzzled by changes in her feelings.
D. Mother may have fears and worries about the baby and herself.
E. Quick mood changes are common; some emotional instability usually occurs.
F. Mother may experience dependency–independency conflict.

Socialization for Parental Role
A. Pregnant woman may fantasize or daydream to experience the role of mother before the actual birth.
B. Takes on adaptive behaviors that are best suited to her own personality and situation.
C. Experiences a “letting go” of her former role (e.g., as a career woman).

  • May experience ambivalence about letting go of her old role to take on the new one.
  • Desire to have a baby influences adjustment.

D. Concerns.

  • First and second trimester—concerns about body changes, fear of labor and delivery; beginning conceptualization of fetus as separate individual.
  • Third trimester—emotionally labile, becomes more concerned about labor and delivery; shows readiness to assume care of infant; incorporation of concept of fetus as a separate individual should be complete.

E. Father may also experience ambivalence at taking on new role, assuming increased financial responsibility, and sharing wife’s attention with child.
F. Father may experience physiologic changes, such as weight gain, nausea, and vomiting (couvades).

Maternal–Newborn Nursing: Signs of Pregnancy

Focus topic: Maternal–Newborn Nursing

Definition: The signs of pregnancy are divided into three groups: presumptive, probable, and positive. Positive signs cannot be detected until after the fourth month.

Presumptive Signs (Subjective Changes)

A. Amenorrhea (cessation of menstruation).
B. Breast changes: increased size and feeling of fullness, nipples more pronounced, areola darker.
C. Nausea and vomiting (morning sickness): appears in about 50% of pregnant women and usually disappears at the end of the third month.
D. Frequent urination—frequent desire to void: usually occurs in the first 3 to 4 months. Pressure on the bladder from an enlarged uterus gives the sensation of a distended bladder.
E. Quickening—first perception of fetal movement: occurs between 16th and 18th week.
F. Fatigue: period of drowsiness and lassitude during first 3 months.
G. Chadwick’s sign: vaginal changes, discoloration and thickening of vaginal mucosa.

Probable Signs (Objective Changes)
A. Enlargement of the abdomen: usually occurs after the third month when the fetus rises out of the pelvis into the abdominal cavity.
B. Increased pigmentation of skin, chloasma, linea nigra, and striae gravidarum.
C. Changes in internal organs.

  • Change in shape, size, and consistency of the uterus.
  • Hegar’s sign—softening of the isthmus of the uterus: occurs about sixth week.
  • Goodell’s sign—softening of the cervix: occurs beginning of the second month.
  • Chadwick’s sign—vaginal changes, discoloration and thickening of vaginal mucosa.

D. Braxton Hicks contractions: usually not felt by the mother until seven months, but contractions begin in the early weeks of pregnancy and continue.
E. Ballottement—giving a sudden push to the fetus and feeling it rebound in a few seconds to the original position: usually possible in the fourth to fifth month.
F. Outline of the fetus by abdominal palpation (a probable sign, because a tumor may simulate fetal parts).

G. Pregnancy tests.

  • Positive test is based upon the secretion of chorionic gonadotropin in the urine; it is usually detectable 10 days after the first missed period. Test is 95% effective.
  • Radioimmunoassay (RIA) test.
    a. Test for Beta (B), the subunit of HCG: most sensitive but not readily available. Pregnancy can be detected before the first period. Test requires 24 hours to complete.
    b. 2-hour tube tests: first void specimen; quite reliable.
    c. 2-minute rapid-slide test: less sensitive and less reliable.
    d. False-positive readings: may be due to protein or blood in urine, neoplasms, ingestion of certain drugs (aspirin, methadone).

H. Amenorrhea by week 4.

OBSTETRICAL ASSESSMENT

Maternal–Newborn Nursing

OBSTETRICAL ASSESSMENT

Maternal–Newborn Nursing

Maternal–Newborn Nursing

Maternal–Newborn Nursing

Maternal–Newborn Nursing

Positive Signs
A. Apparent after eighteen to twenty week.
B. Auscultation of fetal heart rates (FHR) with stethoscope or ultrasonic equipment (rates: 120 to 160). With ultrasonic equipment, fetal heart rate may be heard at 10 to 12 weeks.
C. Active fetal movements are perceptible by the examiner.
D. Ultrasound examination, showing fetal outline. Transvaginal ultrasound allows identification of gestational sac by 5 weeks’ gestation.

Implementation

Physical Examination
A. Initial examination.

  • Record complete history: past obstetrical history, medical history, family history.
  • Assist with physical examination: pelvic, breast, chest, abdomen, complete blood count (CBC), Pap smear, rubella titer, slide for gonorrhea and chlamydia, serology for syphilis (Venereal Disease Research Laboratory; VDRL), human immunodeficiency virus (HIV), hepatitis.
  • Assess for risk factors: age, socioeconomic, ethnicity, previous pregnancy history, multiple pregnancy, late prenatal care, preexisting or coexisting medical problems, substance abuse.
  • Establish baseline blood pressure and weight.
  • Provide client with diet and health instructions.

B. Subsequent examinations: usually once a month until the last trimester, then more frequently. More frequent in high-risk pregnancy.

  • Assess weight, blood pressure, and urine for protein and sugar.
  • Assist with physical examination.
    a. Measure fundal height.
    b. Palpate abdomen.
    c. Auscultate fetal heart rate.
    d. Observe for signs of complications.
    e. Pap smear and smear for gonorrhea before delivery.
    f. Screening and treatment of beta-hemolytic group B streptococci (GBS) culture-positive women before delivery.

Client Instruction
A. Provide client with diet and health instructions.

  • It is important that mother maintain adequate nutrition and fluids.
  • Vitamin, folic acid, and iron supplements are usually prescribed.
  • All drugs can be expected to cross the placenta and affect the fetus.
  • Greatest danger is first trimester, especially when organs are developing.
  • Many other effects of drugs on the fetus are unknown and may not be evident for years.
  • Pregnant women should refrain from taking drugs during pregnancy, even commonly used drugs such as aspirin.
  • There is no “safe” level of alcohol consumption during pregnancy.
    a. It is recommended that women abstain from any alcohol during the first trimester.
    b. Alcohol passes the placental barrier within minutes of consumption.
    c. Effects of alcohol on the fetus varies according to the stage of fetal development.
  • Nicotine: current research indicates that smoking retards growth of the fetus.
    a. Vasoconstriction of mother’s vessels, resulting in decreased placental flow.
    b. Increase in carbon dioxide levels in mother’s blood and reduction of oxygencarrying capacity.
  • Caffeine: may cause malformations. Suggest limited intake or avoidance of sources of caffeine (e.g., coffee, cola, and chocolate).

B. Inform client regarding activities of daily living.

  • Exercise in moderation is beneficial but should never be carried on past the point of fatigue.
  • Sports may be participated in if they are part of the mother’s usual activity and there are no complications present.
  • Fatigue is common in early pregnancy.
  • Frequent rest periods, at 10–15-minute intervals, are helpful in avoiding needless fatigue.
  • Dental hygiene should be maintained daily and infections treated promptly.
  • Tub baths may be taken. Water enters vagina under pressure only. Baths are contraindicated after membranes have ruptured.
  • Travel.
    a. May travel with physician’s permission.
    b. Airlines discourage travel after the eighth month.
    c. When traveling, tell client to elevate feet and walk around periodically to decrease pedal edema.

C. Assess if client is employed and provide instructions as applicable.

  • May be continued as long as it does not cause over fatigue.
  • Have client avoid areas where chemicals or gases are used as these may cause congenital malformations in infant.
  • Have client avoid heavy lifting and individuals with contagious diseases.

D. Provide information to client regarding sexual intercourse.

  • May be carried on without fear unless bleeding or premature contractions develop.
  • May need to vary usual positions as pregnancy advances.

E. Provide information of danger signs during pregnancy and process to follow when labor begins.

Psychosocial Support
A. Reassure client that emotional changes and feelings are normal reactions and that the client need not feel guilty.
B. Provide supportive atmosphere allowing the client to express fears and concerns regarding self, baby, changes in family relationship, etc.
C. Inform client’s mate that changes in attitudes, feelings, sexuality, and emotions are temporary and are related to pregnancy.
D. Screen for abusive relationship.

MAJOR DISCOMFORTS AND RELIEF MEASURES

Maternal–Newborn Nursing

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Maternal–Newborn Nursing: Childbirth Education and Preparation

Focus topic: Maternal–Newborn Nursing

A. Theories of childbirth.

  • Each method varies somewhat, but basic underlying concepts are similar. Birth is viewed as a natural occurrence. Knowledge about the birth experience dispels fear, tension, and distraction. Concentration during labor and delivery modifies the pain experience.
  • Purpose: to promote relaxation enabling the mother to work with the labor process. Allows parents to take an active part in the birth process, thereby increasing self-esteem and satisfaction.

B. Factors that influence pain in labor.

  • Preconditioning: by “old wives’ tales,” fantasies, and fears. Accurate information about the childbirth process can often alleviate effects of preconditioning.
  • Pain produces stress, which in turn affects the body’s functioning. Interpretations of and reactions to pain can be altered by a refocusing of attention and by conditioning.
  • Feelings of isolation. Social expectations and tension may also include feelings of pain.
  • Expectations for mastery and control.

C. Goals accomplished by means of

  • Education: anatomy and physiology of reproductive system, and the labor and delivery process; replacement of misinformation and superstition with facts. May include classes on nutrition, discomforts of pregnancy, breastfeeding, infant care, etc.
  • Training: controlled breathing and neuromuscular exercises.
  • Presence of father or significant other in labor and delivery rooms to serve as coach and lend support.

D. Common methods presently available.

  • Lamaze method.
  • Bradley method.
  • Scientific relaxation for childbirth.
  • Read method (natural childbirth): introduced by Grantly Dick-Read in England. Believed pain in childbirth was psychological rather than physiological. Pain brought about by fear and tension. (This theory not subscribed to today.)

E. Other: water birth, LeBoyer Birth Method (introduced in the 1970s to reduce the stress to the infant from birth by providing a quiet, warm environment, soft lights, and a warm bath immediately after birth).
F. Instruction for parents on delivery by C-section (cesarean).

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