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NUR 335 Maternal Health Exam 4 Study Guide verified by tutor
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lOMoAR cPSD| 22896205lOMoARcPSD|22 896205
NUR 335 Maternal Health Exam 4 Study Guide 2024-
2025 verified by tutor
Neonatal Period
● Transition to Extrauterine Life
○ Review signs/symptoms of abnormal findings.
○ What warrants escalation of care?
○ Interventions/Nursing actions for immediate resuscitation/care.
■ The Initial Assessment
● Apgar Scoring
○ Quick review of systems that are completed at 1 minute and 5 minutes of life to rule out
abnormalities.
○ Allows the nurse to rapidly assess extrauterine adaptation and intervene with appropriate nursing
actions.
■ 0-3 = severe distress
■ 4-6 = moderate difficulty
■ 7-10 = minimal or no difficulty adjusting to extrauterine life.
● Respiratory System
○ Establishment of respiratory function with the cutting of the umbilical cord is the most critical
extrauterine adjustment as air inflates the lungs with the first breath.
○ Assess for ease of breathing, nasal patency, and equality of bilateral breath sounds.
○ Abnormal Findings
■ Meconium staining (can indicate hypoxia)
■ Crackles and wheezing (normal for the 1st 2 minutes ONLY)
■ Periods apnea longer than 15 seconds
■ Grunting ■
Nasal Flaring ○
Complications:
■ Bradypnea (less than or equal to 30/min)
■ Tachypnea (greater than or equal to 60/min)
pg. 1
, NUR 335 OB EXAM 4 STUDY GUIDE 1
■ Abnormal breath sounds (expiratory grunting, crackles, wheezes)
■ Respiratory Distress (nasal flaring, retractions, grunting, gasping, and labored breathing)
■ Airway obstruction related to mucus
● Suction mouth first (prevents aspiration) and then nose with bulb syringe.
■ Inadequate oxygen supply
● Related to obstructed airway, poorly functioning cardiopulmonary system, or
hypothermia.
● Will have shallow respirations.
○ Monitor RR and for signs of cyanosis.
○ Stabilize the body temperature, administer oxygen, and if needed
prepare for resuscitation.
○ Nursing Care:
■ Stabilization & Resuscitation:
● The newborn is able to clear most secretions in the airway by the cough reflex.
● Routine suctioning of the mouth, then the nasal passages with bulb syringe is
done to remove excess mucus in the respiratory tract.
○ If bulb suction is unsuccessful, use mechanical suction for clearing
the airway. Institute emergency procedures if the airway does not
clear.
○ Bulb suction should always be kept with the newborn, and the
newborns family should be instructed on its use.
○ Family members should be asked to perform a demonstration to
show that they understand the proper technique.
■ 1: Compress the bulb
■ 2: Insert into the side of the mouth
■ 3: Avoid the center of the mouth to prevent stimulation of
gag reflex
■ 4: Aspirate mouth
■ 5: Aspirate one nostril
■ 6: Aspirate second nostril
● Newborns delivered by cesarean birth are more susceptible to fluid remaining
in the lungs than newborns who were delivered vaginally.
● Circulatory System
○ Circulatory changes occur due to the changes in pressure of the cardiovascular system related to the
cutting of the umbilical cord as the newborn begins breathing independently.
○ The three shunts functionally close during the newborn's transition to extrauterine life with the flow
of oxygenated blood in the lungs and readjustment of atrial blood pressure in the heart.
■ Ductus Arteriosus
■ Ductus Venosus
■ Foramen Ovale
pg. 2
, lOMoAR cPSD| 22896205
○ Auscultate the heart rate and quality of tones
○ Assess the umbilical cord for one vein and two arteries (AVA) and ensure the clamp is on properly.
○ Abnormal Findings
■ Murmurs (document and report all murmurs)
● The Thermoregulatory System
○ Thermoregulation provides a neutral thermal environment that helps a newborn maintain normal
core temperature with minimal oxygen consumption and caloric expenditure.
○ A newborn has a relatively large surface-to-weight ratio, reduced metabolism per unit area, blood
vessels close to the surface, and small amounts of insulation.
■ The newborn is at risk for hypothermia and hyperthermia until thermoregulation
stabilizes
■ Temperature stabilizes at 37 C within 12 hrs after birth if chilling is prevented.
■ The best method for promoting and maintaining the newborn's temperature is early skin-
to-skin contact with the parent.
○ The newborn keeps warm by metabolizing brown fat, which is unique to newborns but only has a
narrow temperature range.
■ Becoming chilled (cold stress) can increase the newborns oxygen demands and rapidly
use brown fat reserves.
○ Four Mechanisms of Heat Loss
■ Conduction
pg. 3
, NUR 335 OB EXAM 4 STUDY GUIDE 1
● Loss of body heat resulting from direct contact with a cooler surface.
● Preheat radiant warmer, warm a stethoscope & other instruments, and pad a
scale before weighing the newborn.
● Place the newborn on the client's chest, and cover with a warm blanket.
■ Convection
● Flow of heat from the body surface to cooler environmental air.
● Place the bassinet out of the direct line of the fan or air conditioning vent,
swaddle the newborn in a blanket, and keep the head covered.
● Any procedure where the newborn needs to be uncovered must be done under a
radiant warmer.
● Keep the temperature of the nursery and clients room at 22-36 C degrees (72-
78 F).
■ Evaporation
● Loss of heat as surface liquid is converted to vapor.
● Gently rub the newborn dry with a warm, sterile blanket (standard precautions)
immediately after delivery.
● If thermoregulation is unstable, postpone the initial bath until the newborn's
skin is 36.5 C.
● When bathing expose only one part of the body at a time, washing and drying
thoroughly
■ Radiation
● Loss of heat from the body surface to a cooler solid surface that is close to, but
not in direct contact.
● Keep the newborn and examining tables away from windows and air
conditioners.
○ Abnormal Findings
■ Cold stress
● Oxygen demands can increase and acidosis can occur.
● Newborns who have respiratory distress are at a higher risk of hypothermia.
● Nursing Actions:
○ Monitor for manifestations of cold stress (skin pallor with mottling,
and cyanotic trunk, tachypnea)
○ The newborn should be warmed slowly over a period of 2-4 hrs.
○ Correct hypoxia by administering oxygen.
○ Correct acidosis and hypoglycemia.
■ Hypothermia
● Monitor axillary temperature Q1 hr (should be between 36.5-37.5 C) ●
May appear cyanotic and have an increased respiratory rate.
● If temperature is unstable, place the newborn in a radiant warmer and maintain
skin temperature at approximately 36.5 C.
○ Ideal method for promoting warmth and maintaining neonates body
temperature is skin-to-skin contact with the parent.
● Perform all exams and assessments under the radiant warmer or during skin to
skin contact.
● The Metabolic System
○ Hypoglycemia
■ Frequently occurs in the first few hours of lids secondary to the use of energy to establish
respirations and maintain body heat.
■ Newborns of clients who have diabetes mellitus and are small or large for gestational
age; less than 34 weeks of gestation; or late preterm newborns are at an increased risk
of hypoglycemia.
■ Follow facility protocols regarding frequency of assessing blood glucose levels.
● Assess by heel stick ■ Nursing Actions:
● Monitor for jitteriness, twitching, weak abnormal cry, irregular respiratory
effort, cyanosis, lethargy, eye rolling, seizures, and blood glucose less than
40mg/dL.
● Have the parents breastfeed immediately or give donor breast milk or formula
to elevate blood glucose levels.
pg. 4
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