Exam 1 Flashcards
an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof
sentinel event
- leaving a foreign body in a client (sponge, 4x4, forceps)
- falls
- maternal death related to the birth process
- wrong milk to wrong baby
- birth injury
gestation
how long a woman is pregnant (40 weeks)
term
37 - 42 weeks
preterm
20 - 36.6 weeks
abortion (weeks)
less than 20 weeks
gravida
number of times a woman is pregnant
para
the number of times she has “emptied the uterus” delivered
GT
gravida & para
pregnancies and deliveries
GTPAL
Gravida (pregnancies) Term deliveries (37-42 weeks) Preterm deliveries (20-36.6 weeks) Abortions (less than 20 weeks) Living Children
GTPALM
Gravida (pregnancies) Term deliveries (37-42 weeks) Preterm deliveries (20-36.6 weeks) Abortions (less than 20 weeks) Living children Multiples (e.g., twins)
viability weeks
20 weeks
ability to live outside womb
organization that works closely with organizations to address sentinel events and to prevent these types of events from occurring in the first place
joint commission
common risks to women
Age
Adolescent (teen pregnancy)
Young/middle adulthood
Parenthood after age 35
Late reproductive age
Social, Cultural, Economic, & Genetic factors
- diseases among ethnic groups
Socioeconomic
- affects birth outcomes
- cycle
Substance abuse & Alcohol
Obesity
- BMI > 30
- risk for HTN, diabetes, post-term deliveries, IUGR, IFD
Eating Disorders
- anorexia nervosa
- bulimia
- binge-eating disorder
STDs
Lack of exercise, Stress, Depression, Anxiety/other mental health conditions, Sleep Disorders, Environmental/Workplace hazards, Sexual practices, Medical conditions, Female genital mutilation, Violence against women
common disease among ethnic groups
sickle cell - African Americans
Tay-Sachs - Jews
adult lactase deficiency - Chinese
beta thalassemia - Mediterranean
cystic fibrosis - Northern European
alcohol risks
low birth weight babies
fetal alcohol syndrome
intellectual disabilities
behavior problems
learning and physical problems
caffeine risks
coffee, tea, and soft drinks
Heart Dysrhythmias
prescription drug use risks
check to see if it crosses the placenta (most do)
illicit drug use risks
can cause birth defects
Check for drug use:
SROM
vaginal bleeding of unknown origin
FAS
fetal alcohol syndrome
severe facial deformity that can occur if fetus is exposed after 20 weeks
SROM
spontaneous rupture of membrane
IUGR
intrauterine growth restriction
IFD
intrauterine fetal demise/death
doxycycline and pregnancy (chlamydia)
pregnant women shouldn’t take doxycycline because it crosses the placenta and will make the baby’s teeth turn yellow when they are developed
genital warts (HPV)
pregnant women shouldn’t use podofilox because it can cause the lesions to proliferate and become friable (use cryotherapy to burn them off)
RPR (rapid plasma reagent)
performed on pregnant women to test for syphilis
PID
pelvic inflammatory disease
(infection that can be caused by gonorrhea, chlamydia, trachomatous)
increases risk for ectopic pregnancy, infertility, and/or chronic pelvic pain
if a mom is HIV positive
it does not mean the baby will have it
low blood levels of ovarian hormones stimulate the hypothalamus to secrete ______, which stimulates anterior pituitary secretions of FSH
GnRH (Gonadotropin-releasing hormone)
stimulates development of ovarian Graafian follicles and their production of estrogen
follicle stimulating hormone (FSH)
a marked _____ and a smaller peak of estrogen precede the expulsion of the ovum from the Graafian follicle by about 24-36 hours
luteinizing hormone (LH)
LH peaks about day __ or __ of a 28 day cycle
13 or 14
if fertilization has not occurred when LH peaks, regression of the _____ ______ follows
corpus luteum
then menstruation will occur
if there is no fertilization, estrogen levels begin to ______ and hypothalamic GnRH triggers the anterior pituitary to release LH
decrease
if fertilization occurs, no menstruation occurs and the corpus luteum continues to secrete _____ &____ for the first few months
progesterone & estrogen
produced by the ovarian corpus luteum and is necessary to mature and maintain the uterine lining
progesterone (pro-life)
a thin uterine lining is unable to nourish the implanted blastocyte
- Affect smooth muscle contractility
- Influences the production of progesterone and estrogen by the corpus luteum
prostaglandins
if they do not rise with LH, the ovum remains trapped in the graffin follicle
most common STD in the US
chlamydia
most prevalent in adolescents
- inflammation of cervix with mucopurulent discharge
- may be asymptomatic
- untreated may lead to urethritis, tubal occlusion, PID, and infertility
chlamydia clinical manifestations
screening/diagnosis of chlamydia
- screen 1st trimester or when enter healthcare
- by culture or DNA probe or enzyme immunoassay (CDC recommends nucleic acid amplification test [NAAT] or urinary, vaginal, or endocervical areas)
- retest 3rd trimester if multiple sex partners or under the age of 25
- test for gonorrhea
treatment/management of chlamydia
- azithromycin 1g PO single dose
or - doxycycline 100mg BID for 7 days
*pregnant women should not be given doxycycline because it will discolor baby’s teeth when they are developed - erythromycin ophthalmic ointment NBs conjunctival sac 1 hour after birth
chlamydia: pregnancy/fetal/neonatal effects
Pregnancy: increased incidence of PROM, PTL, PID, ectopic pregnancy
Newborn may be asymptomatic
conjunctivitis > scarring > blindness
respiratory problems may result in pneumonia
often asymptomatic
complaint of mucoid or mucopurulent vagina/endocervical discharge, dysuria, and swollen/reddened labia
pelvic, lower abdominal or rectal pain
vulvovaginal inflammation progresses to yellow-green vaginal discharge
may ascend to involve pelvic structures > PID
gonorrhea clinical manifestations
gonorrhea screening/diagnosis (aerobic gram-negative diplococcus)
gram stain culture of endocervical, vaginal, rectum, and possibly pharynx
chlamydia culture and serologic test for syphilis
screened at 1st prenatal visit (at risk clients screened again in 3rd trimester [36 weeks])
gonorrhea treatment/management
ceftriaxone (rocephin) 125 mg IM single dose
baby: erythromycin ophthalmic ointment within 1 hour of birth
gonorrhea: pregnancy/fetal/neonatal effects
Pregnancy: amnionitis, PTL, and postpartum salpingitis
Newborn: ophthalmia neoinatorum (gonococcal conjunctivitis)
- if untreated > blindness
because of the prevalence of chlamydia and gonorrhea, all states have a law requiring preventative treatment to newborns at birth
primary stage: ulcer (chancre) - condyloma - warts may be present on vulva, perineum, or anus (flatter than HPV genital warts)
secondary - maculopapular rash can be on hands and soles of the feet
this disease progresses to secondary and tertiary stages with varying characteristics
syphilis CM
syphilis screening/diagnosis
screened at first prenatal visit VDRL or RPR serology, again in 3rd trimester, and at time of birth if they are high risk
(if HIV or other STI, always check to see that RPR or VDRL was done too)
syphilis treatment/management
- penicillin G 2.4 million units single dose (if allergic to doxycycline or tetracycline - not to be used in pregnancy)
treatments by 18th gestation week prevents congenital syphilis in neonate (however, treat at time of diagnosis)
syphilis: pregnancy/fetal/neonatal effects
Pregnancy: may result in spontaneous abortion or PTL
- transmitted across placenta after approximately 18 weeks gestation
Newborn: congenital anomalies and/or congenital syphilis
- congenital syphilis: test on cord blood
- painful, red papules
- pustular vesicles that break and form wet ulcers that later crust
- low grade fever, chills, malaise, & severe dysuria
- dyspareunia (pain during intercourse)
herpes simplex virus type 2 (HSV)
medication is not a cure (acyclovir [zovirax] PO 7-10 days, suppressive treatment acyclovir/36 weeks decreases viral shedding during delivery, counseled cesarean birth may be indicated if active lesions present)
crosses placenta as well as acquired during direct contact during birth
screening by history and exam for lesions, new cases by culture from active lesions, multinucleate giant cells in microscopic exam of lesion exudates
condyloma acuminata (genital warts) that spread, enlarge during pregnancy (small, soft papillary swellings in the genital and anorectal regions)
human papilloma virus (HPV)
associated with cervical cancer later in life
speculum exam, Pap test (papanicolaou), history, SNS
trichloroacetic acid, laser treatment, cyocautery
vaginal discharge: thin, grayish with fish-like odor
intense pruritus
bacterial vaginosis (gardnerella)
wet-mount slide positive for clue cells
topical metronidazole (flagyl)
associated with PTL
thick, white, pruritic vaginal discharge
common in pregnancy r/t changes in vaginal with antibiotic tx and w DM or HIV infection
candidiasis (yeast infection)
wet-mount slide
monistat (antifungal) vaginal cream, diflucan (oral)
candida infection (oral thrush) if baby in direct contact with organism in birth canal
frothy, odorous vaginal discharge
trichomoniasis (protozoan)
flagellated trichomonads visible on microscopic exam of wet-mount slide
metronidazole (flagyl) for sexual partners is usual treatment (NO flagyl given to pregnant patients in 1st trimester)
clotrimazole (gyne-trimin) topical antifungal
group B streptococcus
asymptomatic, UTI
screening at 35-38 weeks gestation is recommended for all pregnant women
penicillin (ampicillin) broad spectrum
intra-amniotic infection
jaundice, fever, painful joints
transmitted through blood, saliva, vaginal secretions, semen, and breast milk
hep B
- HBsAG test (acute and chronic)
- IgM antibody (acute or recent)
- identify carriers at prenatal screening
- screened again 3rd trimester to allow tx during delivery and neonate at birth
- HB vaccine for unvaccinated pregnant clients
- series of HBsAG recommended for all newborns (1st injected given within 24hr/birth)
- infants of mothers positive for HBsAg need hep B immune globulin and vaccine at birth
maternal: prematurity, LBW
all pregnant women should be screened for
HIV Hep B Syphilis Chlamydia Gonorrhea (1st trimester)
women at risk screening
(multiple sex partners, drug abuse)
prescreened 3rd trimester
Hep C
anemia in pregnancy
iron deficiency
folic acid
sickle cell
total iron requirement for a pregnancy
1000 mg
(diet rarely meets pregnancy needs)
2nd & 3rd trimesters:
hgb = < 11 mg/dL
hct = <33
iron deficiency anemia maternal symptoms
pallor fatigue lethargy HA pica for various substances microcytic, hypochromic rbc's
iron deficiency anemia fetal effects
receives adequate iron at cost to mother
- in presences of severe maternal anemia, reduced hgb and O2 > compromised baby
iron deficiency anemia therapeutic management
elemental iron 200 mg (at least 3 months after correction of anemia)
- absorption decreased with milk, tea, and coffee
- absorption increased in presence of vitamin c (melon, strawberries)
adult female: 15 mg
pregnancy: 30 mg
parenteral: z track method
folic acid
essential for formation of rbc cell duplication and placental/fetal growth
maternal needs 2x during pregnancy r/t need for more erythrocytes, plus placental and fetal growth
folic acid deficiency anemia
caused by nutritional deficiencies (folate), hemolytic anemias, malabsorption, and specific medications
folic acid deficiency maternal symptoms
presence of megaloblasts (large, immature erythrocytes)
increased risk of spontaneous abortion, abruptio placentae, and fetal anomalies
folic acid anemia fetal effects
neural tube defects
folic acid anemia therapeutic management
folate supplement
adult female: 180
pregnancy: 400
lactation: 280
dietary
sickle cell anemia
autosomal recessive disorder
causes erythrocytes to assume an S shape
- they tend to clump together and occlude small by’s
characterized by chronic anemia, susceptibility to infection, and recurring episodes of sickle cell crisis
sickle cell anemia maternal symptoms
pregnancy may precipitate sickle crisis
sickle crisis associated with:
- jaundice r/t decreased bone marrow function and massive erythrocyte destruction
- pain r/t major infarcts in joints and all major organs
sickle cell fetal effects
prematurity
IUGR
fetal death during a sickle crisis
sickle cell therapeutic management
adequate hydration adequate nutrition folate supplement rest periods prompt tx of illness/infection
TORCH infections
a group of congenital infections that are passed from mother to child at some point during pregnancy, during delivery, or after birth
Toxoplasma gondii Other agents Rubella Cytomegalovirus (CMV) Herpes simplex virus (HSV)
Toxoplasmosis (protozoan) transmission
- raw meat
- infected animal (cat) feces
- transplacental
toxoplasmosis maternal effects
- influenza-like aching
- lymphadenopathy
- spontaneous abortion
toxoplasmosis fetal/neonatal effects
- congenital toxoplasmosis, LBW
- hepatosplenomegaly with jaundice, anemia
toxoplasmosis management
Avoid: eating uncooked meat, exposure to litter used by infected cats.
Titer checks during pregnancy
Elective ab may be discussed if titer is high during early pregnancy
varicella zoster (chicken pox) transmission
usually included as “other”, but could be many others
- direct contact
2. respiratory droplets
varicella zoster (chicken pox) maternal effects
preterm labor
encephalitis
varicella pneumonia
varicella zoster (chicken pox) fetal/neonatal effects
congenital varicella syndrome with limb hypoplasia, cataracts, microcephaly, and symmetric IUGR during 1st trimester
varicella zoster (chicken pox) management
varicella immune globulin for susceptible clients exposed during pregnancy
neonate born to mother with an active infection is given immune globulin within 72 hours
strict isolation for both mother and neonate
rubella (German measles) transmission
- transplacental
- direct contact
- respiratory droplets
rubella (German measles) maternal effects
rash
fever
malaise
spontaneous abortion during 1st trimester of pregnancy
rubella (German measles) fetal/neonatal effects
deafness MR IUGR cardiac defects microcephaly
rubella (German measles) management
prevent by rubella vaccinations in childhood
rubella titer is 1:8 is evidence of immunity
if vaccinated in adulthood, document understanding of pregnancy prevention for 3 months post vaccination
a herpes virus that becomes latent after primary infection
periodic reactivation and shedding
cytomegalovirus (CMV)
cytomegalovirus (CMV) transmission
- transplacental
2. body fluids
cytomegalovirus (CMV) maternal effects
flu-like symptoms
cervical discharge
cytomegalovirus (CMV) fetal/neonatal effects
fetal or neonatal death; severe generalized disease with hemolytic anemia, jaundice, hydrocephaly, or microcephaly
cytomegalovirus (CMV) management
no effective tx.
therapeutic ab considered if a primary infection occurs in 1st 20 weeks of pregnancy
hepatitis B transmission
- transplacental
- body fluids (blood, saliva, vaginal secretions, semen, breast milk)
- contaminated needles or blood transfusion
hepatitis B maternal effects
fever rash arthralgia abdominal pain enlarged and tender liver
hepatitis B fetal/neonatal effects
prematurity
LBW
development of acute infection at birth
possible neonatal death
hepatitis B management
all pregnant women are screened for HbsAG
at risk clients prescreened in 3rd trimester
newborn given immune globulin at birth to prevent infection from skin surface contamination
- repeated at 1 and 6 months of age
caused by retrovirus HIV
- depletes the body’s immune system (overwhelmed with opportunistic infections)
AIDS
AIDS transmission
- sexual exposure
- parenteral
- perinatal exposure of an infant to an infected mother
AIDS maternal effects
Antepartum: an increased incidence of other STDs
- offered the option of ZDV
Intrapartum: external EFM preferred
- avoid use of fetal scalp electrodes or blood sampling
Postpartum: breastfeeding contraindicated
- universal precautions for mom and baby
AIDS fetal/neonatal effects
if mother is HIV+, the newborn is given ELISA test for presence of HIV antibodies
- if positive but asymptomatic at birth, s/s usually become evident during 1st year of life
FTT, liver, and spleen involvement (bacterial infections most common)
AIDS management
prevention
safe sex practices, barrier contraceptives, Zidovudine (ZDV)
group B streptococcus (GBS) transmission
gram+ bacteria
- colonizes in the rectum, vagina, cervix, and urethra of women
- ascends after ROM or during birth
group B streptococcus (GBS) fetal/neonatal effects
- sepsis
- pneumonia or meningitis within 7 days of birth
(meningitis most common clinical symptom)
early (1st week of life) or late onset - may have permanent neurological deficits
group B streptococcus (GBS) management
IV antibiotics to mother in labor and/or to infant after birth
most common medical complication in pregnancy
hypertension
rate of hypertensive disorders has risen steadily since 1990 for all ages, races, and ethnic groups
significant contributor to maternal and perinatal morbidity and mortality
pre-eclampsia
potentially lethal complications during pregnancy
pre-eclampsi -> eclampsia
abruptio placentae
disseminated intravascular coagulation (DIC)
acute renal failure
adult respiratory distress syndrome (ARDS)
cerebral hemorrhage
HELLP syndrome
common types/classifications of hypertension
gestational
pre-eclampsia
eclampsia
chronic
preeclampsia superimposed on chronic hypertension
hypertension
a SBP >140 and a DBP >90 recorder on at least 2 separate occasions 4-6 hours apart within a maximum of 1 week
mean arterial pressure (MAP) > 105 mmHg
(sitting, right size cuff, no tobacco or caffeine 30 min prior)
onset of hypertension without proteinuria after 20 weeks gestation
gestational hypertension
recorded at least 2 separate occasions at least 4-6 hours apart but within 1 week
more frequent in multifetal pregnancies
usually develops at or after 37 weeks with no preexisting HTN
BPs return to normal within 1-12 weeks aft delivery
only 1 pressure has to be elevated
usually occurs 20 weeks after gestation in a previously normotensive pt AND has proteinuria
(may be mild or severe)
preeclampsia
- proteinuria at or above 30 mg (>/_ 1+ on a dipstick) or more in 2 random specimens at least 6 hours apart or >/_ 300 mg in 24 hours
mild: 140/90 x2 >4-6hrs apart (MAP >105, 24hr urine > 0.3g)
severe: >160/110 (MAP >105, 24hr urine >2g)
preeclampsia (2)
HTN and proteinuria developed after 2 weeks
elevated BP - often 1st sign
pathological edema
risk factors for preeclampsia
chronic renal disease chronic hon family hx of preeclampsia multiple gestation primigravidity or new partner maternal age diabetes rh incompatibility obesity
etiology of preeclampsia
disruption in placental perfusions and endothelial cell dysfunction
cause of preeclampsia is unknown - however, it is a condition unique to pregnancy and the only cure is delivery of the infant
why we look for blurred vision, headaches, liver functions, epigastric pain/RUQ pain, blood work
low platelets can be a precursor to HELLP, proteinuria
the major pathological factor in preeclampsia
poor perfusions as a result of vasospasm
- vasoconstriction results from sensitivity to vasopressors (like angiotensin II)
- arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP
- endothelial cell dysfunction as a result of vasospasm
effects of preeclampsia
placental: impaired perfusion leads to early aging of the placenta and IUGR of the fetus
renal: decreased GFR results in oliguria, increased excretion of protein (mainly albumin), decreased uric acid clearance, sodium and water retention
hepatic: decreased perfusion can result in hepatic edema and subcapsular hemorrhage as evidenced by the complaint of epigastric pain or RUQ pain (a sign of impending eclampsia)
- liver enzymes become elevated (AST, ALT, and LDH)
neurological: vasospasms and decreased perfusion can result in:
- cerebral edema (change in emotion, mood, and LOC)
- CNS irritability (H/A, hyperreflexia, +ankle clonus, and occasionally eclampsia)
- visual disturbances (scotomata and blurring)
lab values:
- decreased serum albumin (results in decreased plasma colloid osmotic pressure - fluid moves out of the intravascular resulting in hemoconcentration, increased viscosity, and tissue edema)
- increased Hit as a result of hemoconcentration
- increased BUN, serum creatinine, and serum uric acid as a result of degenerative glomerular change
the occurrence of seizures or coma in a woman with preeclampsia
eclampsia
HTN that occurs before pregnancy or dx before 20th week gestation
(also if it persists more than 6-12 weeks postpartum)
chronic hypertension
women with chronic HTN with new proteinuria or an exacerbation of HTN or proteinuria, thrombocytopenia, or increased hepatocellular enzymes
preeclampsia superimposed on chronic hypertension
proteinuria
- concentration at or above 30 mg/dL (>/_ 1+ on dipstick)
- in at least 2 urine specimens
- at least 6 hours apart
OR
- 24 hour specimen
- concentration at or above 300 mg/24hrs
- both in absence of UTI
eclampsia priorities
- keep the patient safe
- turn onto side
- suction
- oxygen
- IV mag sulfate
- monitor fetus
- uterine & cervical assessment
- document
following a seizure, a decision must be made regarding delivery
(may try to postpone delivery until antenatal gluticorticoids can be given and benefit received)
*document: time, duration, and any urinary or fecal incontinence
(seizure activity or coma in a woman with preeclampsia with no history of preexisting pathology that can result in seizure activity)
preeclampsia/hypertension assessment
History & S/S:
- the nurse should take a thorough history at the 1st prenatal visit to identify risk factors for the development of preeclampsia
- assess for s/s of preeclampsia at each subsequent prenatal visit
Blood Pressure:
- BP measured in a standardized manner
Edema:
- assess for distribution, degree, and pitting
- breath sounds are auscultated to assess crackles, which may indicate pulmonary edema (pulmonary edema is associated with severe preeclampsia)
*diuretics (lassie) are only used in preeclampsia when there is evidence of CHF or pulmonary edema
(diuretic therapy further reduces intervillous blood flow (placental perfusion), which may lead to serious fetal jeopardy) *daily weights
DTRs/Clonus:
- assess biceps & patellar reflexes as well as ankle clonus
- clonus: no rhythmic oscillations [negative beats of clonus]
+ clonus: presence of rhythmic oscillations [positive # of beats of clonus]
- hyperreflexia is a sign of CNS irritability (sign of impending eclampsia)
- absence of reflexes when a patient is being treated with magnesium sulfate is a sign of toxicity (Mg level >9mg/dL)