clinical prep Flashcards
IV mag sulfate daily assessments
Neuro check
Assess for s/s toxicity (deep tendon reflexes, respirations, LOC, proteinuria, headache, visual disturbances)
Draw labs/urine check for magnesium levels
Q15-30, BP, respiration rate
Continuous fetal heart rate and contraction monitoring
amniotic membranes ruptured (PPROM)
Greatest risk—Chorioamnionitis
Assess risk—risk factors are meconium-stained amniotic fluid, presence of certain genital tract pathogens, FHR and contraction monitoring
s/s pre-eclampsia
htn (>140/90)
proteinuria
thrombocytopenia: <100,000
impaired liver function: check liver enzymes
renal insufficiency: creatinine
pulmonary edema
cerebral or visual disturbances: new HA unresponsive to meds, no alternative diagnosis
mag toxicity antidote
IV calcium gluconate
nc for preexisting DM
Increased risk for gestational diabetes, high-risk pregnancies
With gestational diabetes, increased risk for preeclampsia, eclampsia, and polyhydramnios
Assess acute and chronic complications of DM, renal function
GBS transmission method
Birth canal
Occurs just before or during labor
GBS prophylaxis
during labor
placental abruption v. placenta previa
Previa = placenta is near or covers the cervical opening
Abruption = placenta detaches prematurely from uterus
cervical insufficiency
Passive and painless dilation of the cervix leading to recurrent preterm births during the second trimester
Often it is abnormally short
cerclage
Treatment for cervical insufficiency d/t cervical weakness
Keeps cervix closed during pregnancy (band or stitch)
non stress test with fetal monitoring
Check for fetal heart accelerations
Use Doppler and tocodynamometer
Reactive NST–HR accelerates to 15 bpm above baseline for 15 seconds in 20 minutes time if over 32 weeks gestation
If under 32 weeks, need above 10 bpm for 10 seconds
Nonreactive NST–accelerations not seen
How is continuous monitoring different from a non-stress test?
only lasts 30 min
Non-stress tests are for at risk fetuses, newborn complications in the past, or prior stillbirths
Necessary follow-up for abnormal findings of non stress test
Non reactive needs further testing: extend 20 min; still non reactive = CST or BPP
biophysical profile
breathing: at least 1 episode for at least 30s in 30 min
movement: at least 3 in 30 min
tone: at least one active extension-flexion
amniotic fluid: deepest vertical pocket >2cm
nonstress: reactive
necessary followup for abnormal findings of BPP
10-8: normal, repeat testing weekly to twice weekly intervals
6: suspect chronic asphyxia, consider proceeding to brith if pulmonary maturity; if not, repeat in 4-6 hr, deliver if oligohydramnios present
4: suspect chronic asphyxia, if >36 wk birth; if <32 wk repeat
0-2: strongly suspect chronic asphyxia extend test to 120 min, if persistent <4, proceed to birth
quad screen
Screen for trisomy chromosomes at 15 -21 weeks, measure levels of 4 maternal serum markers
Necessary follow up for abnormal findings for quad screen?
Genetic counseling and diagnostic testing of trisomy 21 or other chromosome abnormality diagnostics (NIPT)
pathophysiology of anemia during pregnancy
IDA–Excess plasma volume can make hgb look low
Sickle cell
Folic acid deficiency anemia–absence of folic acid so RBCs can’t dive (become enlarged and fewer in number)
s/s anemia
fatigue, pallor, tachy
Sickle cell anemia–sickle cell crisis
Folic acid deficiency–neural tube defect
treatment for anemia
Often don’t treat until iron is below 11
Ferrous sulfate
Sickle cell anemia–prevent crisis with IVF, abx, folic acid, analgesics
Folic acid deficiency anemia–all childbearing women take 400 mcg folic acid before pregnant then 1 mg after pregnant
freq of contraction
time from beginning of one to the beginning of next
contraction duration
time from start of contraction to end of same contraction
intensity of contraction
strength at peak
How is the assessment different when the client has an internal intrauterine pressure catheter (IUPC)?
It is in the uterus; toco is on the stomach
resting tone
Average is 10mmHg; palpate soft and easy
first stage of labor (latent and active)
Latent - cervix effaces, little increase in descent
Active - rapid dilation of the cervix and increased rate of descent of the presenting part
nc for first stage of labor
advocate and communicate her wishes, establish outcomes and expectations, protect modesty and dignity, positive reinforcement
Catheterization, IV, hygiene, intake
(longer table in google doc)
nc during second stage (latent)
Rest and calm
Rest is position of comfort, conserve energy, promote progress of fetal descent and onset of urge to bear down (encourage position changes, pelvic rock, ambulation, showering
nc for second stage active
woman has strong urges to bear down
1:1 nursing care–do NOT leave the woman alone
Help her change position
Help her to relax and conserve energy between contractions
Provide comfort and pain measures
Cleanse the perineum if fecal material is expelled
Coach her to pant during contractions and to gently push when the head is emerging
Provide emotional support, encouragement, positive reinforcement
Keep her informed about the progress
Offer a mirror to watch the birth
Created a calm and supportive environment
Encourage the woman to touch the fetal head when it is visible at the perineum
nc for third stage
Q15 minute assessment of maternal BP, pulse, and respirations
Assess for signs of placental separation and amount of bleeding
Assist with determination of APGAR score at 1 and 5 min of birth
Assess maternal and parter response to completion of birth process and their reaction to the newborn
Assist mom to bear down to expel separated placenta
Hygienic cleaning
Promote skin-to-skin contact with baby and delayed cord clamping
Provide private time for parents to bond with their baby; help them create memories
Massage the fundus
Give pitocin IV infusion after delivery of the placenta to decrease blood loss
dilation
when the cervix begins to open during labor. The cervix starts at 0 (not open) to 10 (complete or all the way dilated)
effacement
thinning of the cervix
The cervix should be 100% effaced before pushing begins
potential hazards when a patient pushes at 9 cm or less
Pain
Head crushed
Prolonged labor
Cervix swells
HR drops
engagement
when the widest part of the baby has passed through the pelvis
station
where the fetus is located in relation to ischial spines
If presenting part is 2 cm above the ischial spines, the fetus is at -2 station.
If presenting part is at the ischial spines, the fetus is at 0 station.
If presenting part is 1 cm below the ischial spines, the fetus is at +1 station
Normal baseline range of FHR
110 - 160
Variability
shows fetal oxygen status in absence of acidosis
Fetal tachycardia
baseline HR >160 bpm lasting >10 min
Fetal tachycardia - causes
interruption of fetal oxygenation, resulting in metabolic acidemia, fetal cardiac arrhythmias, maternal fever, infection (including chorioamnionitis), parasympatholytic drugs, beta-sympathomimetric drugs, maternal hyperthyroidism, fetal anemia, drugs (cocaine, caffeine)
Fetal tachycardia - nc
depends on cause; reduce maternal fever with antipyretics and cooling measures, carry out HCP orders
fetal brady
<110 beats/min lasting >10 min
fetal brady - causes
AV dissociation (heart block), structural defects, viral infections, meds, heart fail, maternal hypoglycemia, maternal hypothermia, interruption of fetal O2
fetal brady - nc
same as late decelerations
accelerations
indicate interruption of fetal oxygenation leading to fetal metabolic acidemia in not occurring at the time they are observed
accelerations - causes
spontaneous fetal movement, vaginal exam, electrode application, fetal scalp stim, fetal reaction to external sounds, breech, occiput posterior position, uterine contractions, fundal pressure, abd palpation
accelerations - nc
none
early decelerations
no known relationship to hypoxemia, clinically benign, not associated with poor outcome
early decelerations - causes
head compression: contractions, vaginal exam, fundal pressure, placement of internal mode of monitoring
early decelerations - nc
none
variable decelerations - causes
umbilical cord compression: maternal position with cord between fetus and maternal pelvis, cord around neck, arm, leg, or other body part, short cord, knot in cord, prolapsed cord
variable decelerations
usually little significance, pretty common
can indicate metabolic acidemia if they occur with rising baseline, absent or minimal baseline variability, absent accelerations, and slow return to baseline after decerlation
variable decelerations - nc
d/c oxytocin, change maternal position, notify hcp, vaginal exam to assess cord prolapse, amnioinfusion, birth
late decelerations
fetal response to transient or chronic uteroplacental insufficiency
metabolic acidemia if they occur with absent or minimal baseline variability, abnormal baseline rate, no accelerations
late decelerations - causes
disruption of oxygen transfer from env to fetus: uterine tachysystole, maternal supine hypoT, placenta previa, placental abruption, hypertensive disorders, possterm gestation, intrauterine growth restriction, DM, chorioamnionitis
late decelerations - nc
d/c oxytocin, lateral position, elevate legs to correct hypoT, increase rate if IV maintenance, palpate uterus (assess tachysystole), notify hcp, consider internal monitoring, birth
category I FHR tracings
baseline rate 110-160 beats/min
baseline variability: moderate
late or variable decel: absent
early decel: present or absent
accel: present or absent
category III FHR tracings
absent baseline variability and recurrent late decel, recurrent variable decel, or bradycardia
sinusoidal pattern
category II FHR tracings
baseline rate: brady w/o absent baseline variablity; tachy
baseline FHR variability: minimal baseline variability, absent baseline variability w/o recurrent decel, marked baseline variability
accel: none in response to fetal stim
periodic or episodic decel: recurrent variable decel with minimal or mod baseline variability, prolonged decel (>2 min but <10), variable decel with othe characteristics (slow return to baseline, overshoots, shoulders)
epidural anesthesia: preplacement
Assess for bacne
Monitor VS, level of mobility, LOC, pain and pain relief
epidural anesthesia: placement
Place patient sitting or lying on side with back curved
Support woman and encouraging breathing and relaxation
Pt must be still during injection
Stop if woman is giving birth
epidural anesthesia: post placement
Can’t stand up
Place upright
Probably need catheter
Watch for s/s anaphylaxis–SOB, wheeze, hypotension, hives, itching, flushing, swollen lips and tongue, vom
Monitor VS, level of mobility, LOC, pain and pain relief
Monitor fetus
Stop if woman is giving birth
spinning baby technique
the jiggle: vibrating the legs and buttocks
Betamethasone/Celestone
I: for risk of premature birth btw 23 -24 week, promote lung maturation and reduce respiratory difficulties
dose: 12 mg IM for 2 doses 24 hr apart
SE: Hypergly
Transient (72hr) increase in wbc and platelet count
Cervidil (Prostaglandin)
I: Preinduction cervical ripening before oxytocin and for induction of labor or abortion
dose: 0.3 mg/h over 12h; transvaginally into posterior fornix vagina and removed after 12h
SE: HA, N/V, diarrhea, fever, hypotension, uterine tachysystole w/ or w/o abnormal FHR and pattern, fetal passage of meconium
risk: A
Cytotec/Misoprostol
I: Preinduction cervical ripening before oxytocin and for induction of labor or abortion
Should not be used if hx of C/S or major uterine sx
dose: 100-200 mcg
Break tablet
Recommended initial dose of 25 mcg - intravaginal
SE: Uterine tachysystole with or without abn FHR
Higher dose = higher risk
risk:
Ferrous sulfate
I: low iron
dose: oral
SE: Constipation, black tarry stools
risk: A
Labetalol
I: hyperT
dose: 100 mg BID
SE: Hypotension
Tachycardia
The usual
risk:
mag sulfate
I: Prevention and tx of seizures for women with gestational hypertension and preeclampsia, low mag, (NOT BP)
dose: Loading dose 4-6g then maintenance dose 1-2g/h
SE: Warmth, flush, diaphoresis, Decreased reflexes, decreased respirations, change in LOC, high magnesium
risk: D?
suboxone
I: Opioid dependence outside of pregnancy
Lower incidence of NAS
dose:
SE: rebound effects
risk:
Oxytocin/Pitocin
I: Stim uterine contractions and lactation
dose: 0.5-1mU/min, increase by 1-2mU q15 - 60 min until contractions, then decrease
SE: Seizure, tetanic contractions, intracranial hemorrhage, abruptio placentae, decreased uterine blood flow, asphyxia, water intoxication of mom
risk:
breast care for breastfeeding women
No soap on nipple
Normal bathing routine
No regular breast cream use
Breast shield for inverted nipple (trains nipple to be more erect)
Wear bra without underwire
breast engorgement
increase in blood and lymphatic fluid as milk production increases, can happen in breast feeding and non breast feeding
breast engorgement - nc
apply ice packs or cabbage leaves, well fitting and supportive bra, anti-inflam meds
Breast feeding: feed often, pump/hand express often
non-pharmacologic interventions that assist with suppression of lactation
Avoid breast stimulation like suckling, expressing milk, or running warm water on breasts
Wear will fitted bra for at least 72h after giving birth
Meds are no longer prescribed
involution
Return of uterus to non preg state after birth, begins immediately after expulsion of placenta with contraction of uterine smooth muscle
subinvolution
Failure of uterus to return to non pregnant state as result of ineffective uterine contractions. Maybe retained placental fragments and infections
treat: ergonovine or methergine, dilation and curettage, abx
signs of excessive uterine bleeding
Perineal pad saturated in 15 minutes or less and pooling under buttocks
Respirations, pulse, skin condition, urinary output, LOC–indicators of hypovolemic shock
first intervention used to promote and maintain good uterine tone and boggy uterus (atone)
Fundal massage, stimulate uterine muscles
IV fluids and oxytocic meds
How does a distended bladder increase vaginal bleeding after delivery
Full bladder causes uterus to be displaced above the umbilicus and to one side of midline in the abdomen
3 ways that a postpartum nurse can promote appropriate parenting and bonding skills
Hold skin to skin, allow them to ask questions, rooming in, privacy, heighten awareness of infants responses and ability to communicate, bolster confidence and ego
help parents decrease sibling rivalry
Have sibling visit the birth facility and have your arms open wide to embrace the child when they walk in
Don’t force interactions between child and infant
Give the child a gift
Have another person at home ready to assist with child’s care
Give child small gifts to match infants
BUBBLE LE
Breasts - palpate, inspect; firm, heat, pain, engorgement
Uterus - inspect (midline, firm); palpate (soft, boggy, atony, distended bladder)
Bowel - auscultate (BM 2-3 days postpartum)
Bladder - percuss, void spontaneously, distended
Lochia - bleeding check quantity with number of pads used and color, few clots and fleshy odor is normal, foul odor and large amounts of clots are not
Episiotomy/Lacerations/Perineum/Hemorrhoids/Cesarean Incision
Legs - perform Homan’s sign (pain behind the knee after forced dorsiflexion of the foot), DTRs 1+, to 2+, assess with eyes for edema, redness, tenderness, pain
Emotional Status - excited, happy, interested or involved vs sad, tearful, disinterested in infant care: postpartum blues and depression
anterior and posterior fontanels
Anterior closes 12-18 months
Posterior closes 6-8 weeks
normal range: temp
Axillary 98.6
normal range: pulse
120-160 while awake, 80-100 while sleeping
normal range: RR
30 - 60
normal range: BP
Term - 60-80 SBP/40-50 DBP
normal range: glucose
55-60 between 30-90 minutes of birth
normal range: bilirubin level
Increase from 2 right after birth to 5-6 in 96 hours then 3 by 1 week of age
process of weight loss and gain in the newborn
Typically lose 5-7% during first week, then they gain, birth weight by 14 days
10% = call hcp
lanugo
(hair): absent = post mature; abundant = premature
vernix
(cheese): absent/minimal = postmature; abundant = preterm
formula
Begin with 15-30 mL formula per feeding for first day then gradually increase, feed q4 even through night
60-80 mL/kg for first 2 days then 100-150 mL/kg until day 8
Burp when sucking slows, several times during feeding
15-60 mL/kg/day, 2-6x/day for first 2 days then gradually increased
Yellow and soft, but formed; 1 stool per feeding
Emotional support, help getting resources, connect to social work if needed
breast feed
8-10 times in 24h around the clock
60-80 mL/kg for first 2 days then 100-150 mL/kg until day 8
Burp when sucking slows, several times during feeding
15-60 mL/kg/day, 2-6x/day for first 2 days then gradually increased
Meconium then greenish yellow and greener by days 3-5, yellow, soft, and seedy by end of week 1
Encourage stimulation of the nipple, nipple guard, establish feeding pattern
umbilical cord
2 arteries, 1 vein (thicker); demarcation, clamp in place for 24-48 hr
fall off 5-15 days, no tub baths until off, expose to air, keep outside diaper, clean with water
assess for edema, redness, drainage with each diaper change
respiratory distress/cold stress
Temp drops -> vasoconstriction -> pale, mottled, cool skin
If not corrected -> cold stress (RR increases, efforts shift to thermogenesis rather than brain and cardiac function and growth
newly circumcised penis - nc
Assess for bleeding q15-30 min for 1 hour, then q1 hr for 4-6 hrs; monitor urine output, pressure if bleeding
Educate parents: observe for bleeding or infection, lots of crying with diaper change, discomfort temporary, non pharm pain, keep area clean
Vitamin K: helps stop bleeding, if no Vit K, no circumcision
Physiological Jaundice
Usually resolves without treatment
Appears after 24 hrs of age
TSB levels progressively increase then decrease
pathological jaundice
Bilirubin accumulates
Unconjugated hyperbilirubinemia is either pathologic or severe enough to warrant eval and treatment
w/n 24 hrs of birth; increase >0.2mg/dL/hr
Usually indicative of hemolysis
PKU testing
Measure amount of Phe in a blood sample, lifelong diet - educate, special formula
tests mandated by the Health Resources and Services Administration
Sickle cell anemia, CF, hypothyroid, galactosemia, hearing
Rh incompatibility
Rh- mom has Rh+ fetus; usually okay with first fetus, problem with second
Fetal blood pass through placenta into mom, mom’s immune system makes antibodies = sensitization
ABO Incompatibility
Mom is O, fetus is A, B, or AB (coombs test)
First born infants can be affected, moms already have antibodies to attack, no sensitization needed, no preventative prenatal treatment
Hyperbili and anemia; hemolysis
choking or spitting up - nc
Don’t leave alone to feed, sit up, bulb syringe if choking, burp, modified heimlich
APGAR
appearance: pink, extremities blue, pale or blue
pulse: >100, <100, no pulse
grimace: cry and pull away, grimace or weak cry, no response
activity: active movement, arms and legs flexed, no movement
respiration: strong cry, slow and irregular, no breathing
<7 abnormal
interventions to help quiet an infant experiencing Neonatal Abstinence Syndrome
Medication
Swaddling, low light, quiet environment, minimal handling, pacifier use
Erythromycin ophthalmic ointment
Prevent gonorrhea - opthalmia neonatorum in newborns
1 cm ribbon to lower conjunctival sac
Chm conjunctivitis , blurry vision temporarily
Hemabate/Carboprost
Excessive postpartum bleeding/hemorrhage
1 mL IM
Bronchospasm, N/V/D, epigastric/ab pain
methergine
Treat subinvolution, contract uterus
0.2 mg q3-4 hr for 24-48 hr
hyperT
RhoGAM/Rhophylac
Rh incompatibility
post partum 1 vial 300 mcg IM
Additional doses may be needed
Antepartum: 1 vial IM at 24-26 weeks
Myalgia, lethargy, local tender and stiff, mild and transient fever, malaise, HA
Rubella Vax
Prevent rubella (with measles and mumps)
SQ injection postpartum before d/c
Fever, transient arthralgia, rash, lymphadenopathy
D
Vitamine K/Aquamephyton/Phytonadione
Provides Vit K bc newborn does not have it, promote clotting
IM - 0.5 mg if <1500g; 1 mg if >1500g
Edema, erythema, pain at site
Hemolysis, jaundice, hyperbilly
rooting
baby’s cheek or mouth is gently stroked, they should turn their head toward the hand, open their mouth, and begin sucking motions
palmar
fingers grasp an object placed in their palm
plantar
toes curl down
moro
startle, lift baby slightly by hands and let go, will slightly flail arms like they are startled, may cry
babinski
all toes hyperextend with big toe dorsiflexed
FDA - A
Controlled studies show no risk-Adequate, well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester of pregnancy.
FDA - B
No evidence of risk in humans-Adequate, well controlled studies in pregnant women have not shown increased risk of fetal abnormalities despite adverse findings in animals,
or
In the absence of adequate human studies, animal studies show no fetal risk. The chance of fetal harm is remote, but remains a possibility.
FDA - C
Risk cannot be ruled out- Adequate, well-controlled human studies are lacking, and animal studies have shown a risk to the fetus or are lacking as well.
There is a chance of fetal harm if the drug is administered during pregnancy; but the potential benefits may outweigh the potential risk.
FDA - D
Positive evidence of Risk-Studies in humans, or investigational or post marketing data, have demonstrated fetal risk. Nevertheless, potential benefits from the use of the drug may outweigh the potential risk. For example, the drug may be acceptable if needed in a life threatening situation or serious disease for which safer drugs cannot be used or are ineffective.
FDA - X
Contraindicated in Pregnancy- Studies in animals or humans, or investigational or post-marketing reports, have demonstrated positive evidence of fetal abnormalities or risk which clearly outweighs any possible benefit to the patient.
