Exam #2 Flashcards
What are the 2 sections in the first stage of labor called?
latent and active
What are characteristics of latent phase of labor?
-0-5 cm dilated
-regular, painful contractions that cause cervical change
What are characteristics of active labor?
-effacement 100%
-descent has begun
-contractions 1.5-5 mins apart last 40-90 secs and regular
When does stage 1 of labor end?
10 cm dilation
What are characteristics of stage 2 of labor?
-10 cm, 100% effaced
-ends with birth of baby
-50 mins for first time mom, 20 mins average if had kids before
-Contractions 2-3 mins apart lasting abt 90 secs
-pushing stage
When does stage 2 end?
baby delivery
Characteristics of stage 3 labor?
-ends with delivery of the placenta
-lasts 5-30 mins
What are reasons to do leopolds maneuver?
-fetal position
-where to put fhr monitor
-coming out feet or head first?
Instructions for Leopold’s maneuver?
-mom empty bladder
-fhr best heard on back
Steps of Leopold’s maneuver?
- Determine fetal lie; palpate fundus with finger tips, start at top. bottom=spony, head=firm
- Locate fetal back; run hands down each side. smooth curvature=back, knobby=legs,feet, knees
- Identify presentation; felt at mons pubis, true inlet of pelvis
- Determine attitude of head, outline head with fingertips and palms
Characteristics of true labor?
o REGULAR and predictable contractions
o Cervical CHANGE and dilation
o Felt in the lower back radiating to the lower portion of the abdomen.
What are numbers for moderate variability?
6-25 bpm over baseline
What are numbers for marked variability?
> or equal to 25 bpm
Characteristics of early decelerations?
-not pathological
-always occur with contraction
Causes of early decels?
-uterine contractions
-cephalopelvic disproportion
-persistent occiput posterior
Characteristics of late decels?
-uteroplacental deficiency
-always occur with contraction
Causes of late decels?
- hyperstimulation of the uterus from oxytocin augmentation
- supine hypotension syndrome
- hypertension – chronic or gestational; preeclampsia
- postmaturity (44-45 weeks)
- placental problems – abruptio, previa
*IUGR nadir occurs after peak of the contraction (nadir= lowest pulse rate from baby) - maternal disease – cardiac, anemia, diabetes w/vascular involvement
Characteristics of variable decels?
-umbilical chord compression
-transient and correctable
-periodic or episodic (not associated with contraction)
Causes of variable decels?
- maternal position – cord between fetus and pelvis
- nuchal cord
- short cord
- knot in cord
- prolapsed cord
What are actions to take for a prolapsed chord?
Apply firm upward pressure to raise head off cord
* Place client in knee-chest position and TURN/MOVE MOM
* O2, increase fluid intake
* Prepare for emergency CS
What is the nursing care during 1st stage of labor?
-Assess patient
-assess FHR
-manage pain
-emotional support
-encourage or assist in position changes
-assisting with interventions
-advocate for patient’s needs
Nursing care during 2nd stage of labor?
-coach for effective pushing
-assist with positioning
-offer reassurance and encouragement
-prepare for delivery
What is nursing care during 3rd stage?
-immediate infant care
-ID infant
-assign APGAR
-administer uterotonics
-emotional support
-assisting w/ interventions
Nursing care for 4th stage of labor?
-Assist with golden hour
-assist w/ feeding
-administer baby meds
-assess bp, hr, and fundus every 15 mins for first hour
-take temp every 4 hours two times and then every 8 hrs
-assess bladder
-assess lochia
-assess perineum
When is the APGAR score taken?
1 and 5 mins of life
What does the APGAR score tell you?
objective means for assessing newborn adaptation to extrauterine life
What does APGAR stand for?
Appearance
Pulse
Grimace
Activity
Respiration
What are the five processes labor affects?
- Passenger → fetus and placenta
- Passageway → birth canal
- Powers (Voluntary/ involuntary UC)
- Position of the mother
- Physiological responses & mother psychological response
What is the therapeutic range for mag sulfate?
4-7.5 meq/L
Nursing considerations for mag sulfate?
-limit fluid intake to 2500-3000 mL/day
* Be prepared to d/c if intolerable side effects occur
* Strict I&O
* Total IV intake at 125/hr
* Calcium gluconate/calcium chloride readily available to
reverse mag toxicity
What does terbutaline do?
inhibit uterine activity and stops preterm labor
Contraindications for terbutaline?
- HR > 130 beats/minute
- Heart Dx
- Severe Preeclampsia/Eclampsia
- Gestational Diabetes
- Hyperthyroidism
Contraindications
How to tell if terbutaline is working?
number and frequency of contractions decrease or stops altogether
What to assess for before/during pitocin?
-fetal presentation and descent
-FHR
-contraction pattern and intensity every 15 mins
Guidelines for pitocin?
The goal is to achieve a pattern of 3 contractions every 10 minutes that last around 40-60 seconds. The cervix should be dilating at a rate of 1 cm per hour, and the dose should be reduced once the cervix has dilated to 5-7cm. Pitocin is usually stopped once dilation reaches 7-8cm.
What is HELLP syndrome?
HELLP syndrome is a variant of preeclampsia that involves hepatic dysfunction, characterized by:
· H Hemolysis (Breakdown in RBC)
· EL Elevated Liver enzymes (liver isn’t getting rid of all the toxins)
· LP Low platelet count (normal platelet: (platelets arent coagulating enough)
How will a patient present with HELLP syndrome?
Can range from NO symptoms to N/V, epigastric pain, malaise, RUQ pain
What are nursing considerations for HELLP syndrome?
· Assess for signs of bleeding especially petechiae or bruising from BP cuff, these are signs she isn’t clotting well.
· Check IV sites and gums, if she’s bleeding, there is a problem.
· Tenderness in RUQ or if she tells you it feels like she has indigestion, this means liver involvement.
· Pt could start to look jaundice or yellow=monitor labs and if abnormal, CALL HCP!
· If mom is preggo and we see these signs, this is a precursor for mom to have a placenta that abrupts, which will kill the baby.
How is HELLP syndrome diagnosed?
lab work
What are possible complications of HELLP syndrome?
o Renal failure
o Pulmonary edema
o Ruptured Liver
o Hematoma
o DIC (mom bleeding out all the holes/ not coagulating) (Disseminated intravascular coagulation)
o Abrupt Placenta
What are warning signs for pre-eclampsia?
-Gestational HTN WITH protein in the urine!
-Usually 20 weeks after gestation.
- Indicators: blurred vision, N/V, RUQ pain (epigastric), abnormal liver functions
-You will see decreased serum albumin, increased Hct and BUN, creatinine and uric acid -concentration at or above 30mg/dL (>/=- 1+ on dipstick)
What are warning signs for HTN?
Onset of HTN WITHOUT protein in the urine and mother is past 20 weeks gestation. Mom is just pregnant with HTN. -recorder at least 2 separate occasions at least 4-6 hrs apart w/in 1 week and no sign of UTI -BP returns to normal w/in 1-12 weeks postpartum
140/90
What is a PP hemorrhage?
- the loss of 500mL or more of blood after vaginal birth or 1000mL after cesarean birth.”
- OR
- 10% change from admission hematocrit (HCT) to postpartum.
- OR
- The need for erythrocyte transfusion
- Remember 1gram = 1mL of blood – so weigh those pads dry and then wet.
What are causes of PP hemorrhage?
-uterine atony (muscles do not contract well enough after birth)
-parts of placenta stay attached to uterine wall
-if parts of reproductive organs damaged during delivery
-coagulation disorder
Interventions for PP hemorrhage?
-massage fundus
-pitocin admin
What are the cardinal mechanisms of labor?
· Engagement – BPD at pelvic inlet
· Descent – measured by station + numbers lower than ischial spines
Flexion – head flexes toward chest
· Internal rotation – head rotates to occiput anterior
Extension – occiput passes under symphysis pubis and head … first the occiput
· External rotation (restitution) – realignment of infant head to back/shoulders (back to original position)
· Expulsion (birth) – anterior shoulder under symphysis pubis à posterior shoulder and body completely emerges
What is teaching for kegel exercises?
- Make sure the bladder is empty
- Tighten the pelvic floor muscles. Hold tight and count 3-5 seconds
- Tighten like you are trying to hold it and you need to urinate badly, You should
feel your muscles tighten as you do this - Relax the muscles and count 3 to 5 seconds
- Repeat 10 times, 3 times a day (Morning, afternoon and at night)
- strengthens the muscle tone from stretched and/or torn pelvic tissue
- reduces urinary incontinence
What are insulin requirements during 1st trimester of preg?
Decreased need for insulin and N/V may increase risk for hypogly
What are insulin requirments during 2/3rd trimester?
insulin requirement increases almost 4 times more than normal
When does baby begin to produce own insulin?
week 10
Diabetes effects on baby?
-macrosmia (LGA)
-IUGR
-delayed lung maturity
-hypogly after birth
-neural tube and skeletal defects
Symptoms of hypogly?
- Nervousness
- HA
- Shaking/irritable
- Hunger
- Blurred vision
- Diaphoresis
Risk factors for GDM?
- Family history of diabetes
- Ethnic group at risk (example native American)
- Maternal obesity
- Previous LGA infant
- Previous unexplained stillbirth
Infant symptoms of hypogly?
Jittery
Apnea
Tachypnea
Cyanosis
Hypotonia
Unstable temperature
Symptoms of post-partum blues?
sadness/tearfulness
restlessness/insomnia
fatigue
anxiety
mood swings
depressed affect
Symptoms of PP depression?
intense fear, anxiety, anger
irritability
feelings of guilt
jealousy/rejection of infant
no interest in the baby
thoughts of harming self or
baby
Symptoms of PP psychosis?
auditory and/or visual
hallucinations (25%)
delusions (50%)
delirium/confusion
bizarre behavior
deficits in judgement
impulsiveness
Treatment for PP depression?
psychotherapy and antidepressants
Treatment for PP psychosis?
antipsychotics,
mood stabilizers, inpatient
psychiatric care
What is lochia rubra?
-day 1-3 PP
-bloody, small clots
-fleshy, earthy odor
-red or red-brown
What is lochia serosa?
-day 4-10 PP
-decreased amount
-sero-sanguinous
-pink or brown tinged
What is lochia alba?
-day 11-21 (may last until 6th week)
-white cream or light yellow
-decreasing amounts
What is the education for cerclage?
bed rest, pelvic rest, no sex
Criteria for polyhydramnios?
amniotic fluid index > 24 cm in all pools or more than 8 cm in deepest vertical pool
Weight of macrosomia baby?
greater than 4000 grams
What is an acceptable fetal blood sugar?
60-90
Diabetes in infants levels?
two elevations >140
What are reasons for earlier delivery/induction?
-poor metabolic control
-hypertensive disorder getting worse
-macrosomia
-IUGR
What would be the presentation of a patient with hyperemesis gravidum?
-Inability to retain even clear liquids
-Significant weight loss > 5%
-Symptoms of dehydration ( poor skin turgor, dry mucous membranes, decreased BP, increased pulse, concentrated urine, low output)
-Symptoms of starvation (Elevated BUN and ketonuria)
-Electrolyte imbalance of Na, Cl and K+
What are interventions for hyperemesis gravidum?
-Interventions: IV fluids, drugs that can be used are: Phenergan, Reglan, Zofran, Compazine.
-steroids, sometimes iv nutrition
-Once vomiting has stopped:bland diet recommended with small frequent meals instead of 3 large ones. Eating every 2-3 hours.
-Keep dry foods at the bedside. -Sometimes alternating wet to dry and foods should be bland.
-Herbal remedies include ginger, lemonade
-avoid high fat, greasy, or overseasoned foods
Fetal risk from hyperemesis gravidum?
-IUGR
-Abnormal development (anomalies)
-Preterm birth
-SGA
-Death from lack of nutrition, hypoxia or maternal ketoacidosis
What common OB medications can contribute to DKA?
terbutaline and corticosteroids
Placental effect of pre-eclampsia?
Impaired perfusion leads to early aging of the placenta and IUGR of the fetus
Renal effects of pre-eclampsia?
Decreased glomerular filtration rate (GFR) results in oliguria, increased excretion of protein (mainly albumin) decreased uric acid clearance. Sodium and water retention
Lab values of pre-eclampsia?
-↓ serum albumin-Results in ↓ plasma colloid osmotic pressure therefore,
fluid moves out of the intravascular resulting in hemoconcentration, ↑ blood
viscosity, and tissue edema.
-↑ Hct as a result of hemoconcentration
-↑BUN, serum creatinine, and serum uric acid as a result of degenerative
glomerular change
Nursing interventions for eclampsia?
Keep the patient safe
Turn onto side
Suction
Oxygen
IV Magnesium Sulfate
Monitor fetus
Uterine & Cervical Assessment
Document
Management of severe pre-eclampsia?
Hospital bed rest
Maternal & fetal surveillance
Possibly in an ICU setting
Quiet, nonstimulating environment & seizure precautions
Pharmacological interventions
Delivery
When is mag sulfate administered post-partum?
12-24 hrs to prevent development of eclampsia
What is DIC?
Pathological form of diffuse clotting that consumes large amounts of clotting factors causing widespread external and/or internal bleeding.
Labs for DIC?
Platelet – decreased
Fibrinogen – decreased
Prothrombin time – prolonged
Activated partial thromboplastin time (APTT) – prolonged
Fibrin degradation Products (fibrin split) – increased
D-dimer test - increased
Nursing responsibilities for DIC?
Monitor for bleeding- (petechiae, oozing form injection sites, hematuria, and reposition frequently to assess for bleeding in dependent tissues)
Monitor urinary output with Foley catheter (usually with a urimeter bag attached)
If still pregnant, place patient in side-lying position
Oxygen if ordered 10-12L/min
Administer blood and blood products as ordered
Patient and family education and emotional support
Clinical manifestations of DIC?
Signs of Thrombosis
Bleeding from 3 unrelated sites
Spontaneous Epistaxis
Oozing from venipunture sites
Petechiae
Ecchymosis (bruising)
Large subcutaneous hematomas
Hypotension
Tachycardia
How will patient present with abortion?
Less than 20 weeks gestation fetus is nonviable.
Greater than 20 weeks or 500 g, funeral
arrangements are needed
Symptoms include uterine cramping, backache
and pelvic pressure
If bleeding is noted count of perineal pads/hour
Be aware of S/S of shock
HR elevated; Weak thready pulse
Skin: Pallor. Cool, clammy
Hypotension
Nursing interventions for abortion?
d type of abortion and management
Monitor UC if necessary
Monitor VS , LOC until stable
Start IV with large bore (over 18)
Administer RhoGAM to Rh negative clients with Rh+ baby.
Teach client to notify nurse if:
Temp > 100.4
Foul odor to vaginal discharge
Bright red bleeding
Bleeding with any tissue fragments
Diagnosis of ectopic pregnancy?
Abdominal pain, spotting, positive pregnancy test, verified by US, signs of shoulder pain (Ruptured tube)
signs of shock
Nurse management for ectopic pregnancy?
Methotrexate
to dissolve
the pregnancy
May need a
tubal ligation
Diagnosis of hydatiform mole?
Transvaginal US & serum hCG
Nurse manage of hydatiform mole?
Dilation &
Curettage
(D&C)
What is placenta previa?
placenta is
implanted in
lower uterine
segment
Diagnosis of placenta previa?
Painless bright red bleeding after 20 weeks
Nurse manage of placenta previa?
Observation
and bed rest
What is placental abruption?
premature
separation of
the placenta
How to diagnose placental abruption?
Painful abdominal pain with or without bleeding, uterine tenderness, confirmed after delivery
Nursing management for placental abruption?
immediate delivery
What is accreta, increta, percreta?
when the placenta grows too deeply into uterine wall
What is the nurse manage for accreta, increta, percreta?
Deliver by C-
section after
U/S has
determined
where
placenta is
located. Also
called a
Cesarean
hysterectomy.
How are lacerations documented?
degrees
How is an episiotomy documented?
cut, midline, left or right mediolateral
S/Sx of UTI?
a burning sensation when you pass urine
feeling the urge to urinate more often than usual
urinating before you reach the toilet (‘leaking’ or incontinence)
feeling like your bladder is full, even after you have urinated
urine that looks cloudy, bloody or is very smelly
pain above the pubic bone
fever
Nursing interventions for UTI?
antibiotics, cranberry products, acupuncture, probiotics and behavioural modifications)
Presentation of mastitis?
■ Fevers or chills
■ Pain or tenderness in the affected breast
■ Reddish or pink area on the affected breast
■ Tenderness to touch
■ Warmth at the infection site
■ Generalized aches, fatigue, and malaise
■ Nipples with cracks, fissures, or sores
■ Axillary adenopathy of the affected side
■ Purulent drainage from the nipple or with expressing
milk
Treatments for mastitis?
antibiotics, heat or cold to breasts, hydration, analgesics, maintain breastfeeding, proper hand wash before and after feeding, and avoid breast creams
S/Sx of DVT?
elevated temperature, cough, tachy- cardia, hemoptysis, pleuritic chest pain, and increasing apprehension
Nursing care for DVT?
heparin for 3 months post-partum (protamine sulfate antidote), measure vital signs every 4-6 hrs, analgesic admin, circumference measured and recorded daily, and blood draws for pt and ptt count
Side effects of mag (maternal)?
hot flashes, N/V, HA, lethargy, dyspnea, hypocal, hypermag, blurred vision, respiratory distress, pulm edema, absent DTRs, CP, urine less than 25-30 mL/hr, hypotension
Dosage and route of mag?
loading dose 4-6 grams/30 mins, maintenance dose 1-4 grams/hr
Action of mag?
relaxes smooth muscle, including uterus
S/E of terbutaline?
tachy & hypergly
dose and route of terbutaline?
subcutaneous injection of 0.25 mg every 4 hr
