Exam 2 Modules 5-8 Flashcards
risk factors for pregnancy at risk
HTN, diabetes, PCOS, zika, autoimmune, nutrition, substance abuse, genetics, environment, age, parity
risk factors are synergistic
meaning more factors = more risk
pregestational risks
heart disease, substance abuse, diabetes, anemia, HIV/AIDS
gestational onset risks (risks that can arise during pregnancy)
HTN disorders, spontaneous abortions, ectopic pregnancy, Rh alloimunization, herpes, GBS +, CMV, hyperemesis gravidarum, gestational trophoblastic
cardiac changes d/t pregnancy
increased demand for cardiac output by as much as 50%
signs of cardiac disease worsening
progressive gen. edema, crackles at base of lung, rapid and weak irregular pulse, difficulty catching breath, cough, increased fatigue
Labor/delivery nursing care
EKG/FHR monitoring, O2 and pulse ox., anticoagulants for thrombus, pain/stress management to decrease HR, antibiotics to prevent endocarditis, avoid fluid overload, optimize placental perfusion
substances of abuse
alcohol, cocaine, opioids, tobacco
alcohol effects
brain and neuron development abnormalities, LBW, prematurity, FAS, leading cause of mental retardation
cocaine effects
cardiac events leading to maternal death, abruption, PROM, fetal vasoconstriction and neuroexcitation
opioid effects
withdrawal symptoms in neonate (NAS)
tobacco effects
decreased fertility, increased risk of miscarriage, previa, IUGR, long term cognitive function, increase risk of brain damage
heroin treatment
behavior and pharmacological: methadone, buprenorphine, naltrexone
4 cardinal signs of diabetes
polyuria, polydipsia, weight loss, polyphagia
type 1 diabetes mellitus
born with it; 10% of all diabetes; insulin deficient
type 2 diabetes mellitus
acquired; 90% of all diabetes; insulin resistant
gestational diabetes mellitus
onset is fist discovered during pregnancy; shortage of insulin during pregnancy (not producing as much as is needed)
pregnancy influence on diabetes
insulin decreased in first trimester and increased in second and third; increase d/t attempting to get more glucose to fetus which meaning mom has more glucose meaning insulin is higher
insulin antagonist hormones
HPL and somatotropin
maternal diabetic risks (what risks because of diabetes)
polyhydramnios, preeclampsia-eclampsia, hyperglycemia/ketoacidosis, C-section, increased susceptibility to infections, worsening retinopathy
macrosomic baby
> 4000g
fetal/neonatal diabetic risk
congenital anomalies, macrosomia, IUGR, respiratory distress syndrome
IUGR
decreased blood to placenta or fetus
high risk for gest. diabetes
over 40, family history of diabetes in first-degree relative, prior macrosomic/stillborn/malformed, obesity, PCOS, HTN, glucosuria; screen as early as possible
low risk of gest. diabetes
screen at 24-28 weeks
high gest. diabetes risk screening
> 126 mg/dL fasting; >200 mg/dL random; >6.5% ha1c
gestational diabetes screening image
target Hgb A1C
less than or equal to 6%; levels between 5-6% are associated with malformation rates of those in normal pregnancy
pregnancy complications
Rh factor, ABO incompatability, ectopic pregnancy, HSV, GBS+, preeclampsia-eclampsia, gestational trophoblastic disease
maternal alloimmunization/isoimmunization
woman’s immune system is sensitized to foreign erythrocyte surface antigens and produce IgG antibodies; Rh - mom and Rh + fetus
causes for maternal alloimmunization
blood transfusion, fetomaternal hemorrhage antepartum/intrapartum, abortion, ectopic pregnancy, placental abruption, abdominal trauma, amniocentesis/CVS, manual removal of placenta
interventions of Rh incompatibility
indirect coombs test, monitor the pregnancy, early birth, intrauterine transfusion of fetus (correct anemia), exchange transfusion (erythropoietin and iron)
if mother Rh - and baby Rh + (not sensitized)…
300 mcg Rh immune globulin (Rhogam) IM at 28 weeks (prophylactic); if baby Rh + give 300 mcg Rhogam IM w/in 72 hours
other times to give rhogam
birth to Rh + baby, spontaneous abortion, ectopic pregnancy, following invasive procedures, following maternal trauma
how does ABO incompatibility work
maternal serum antibodies cross placenta causing hemolysis of fetal RBC, anemia, bilirubinemia
parent infections
HSV (herpes simplex virus) and GBS (group beta streptococcus)
HSV risks of fetal-neonatal
spontaneous abortion, preterm labor, IUGR, neonatal infection, presence of lesion (route variable), cesarean if outbreak during labor; antiviral after 36 weeks
GBS neonatal risk
unexpected intrapartum stillbirth
HTN disorders of pregnancy
Chronic HTN, Chronic HTN w superimposed preeclampsia, preeclampsia-eclampsia, gestation HTN
HTN threshold pregnant
140/90 mmHg
Chronic HTN
> 140/90 before 20 weeks gestation and absence or stable proteinuria
Preeclampsia superimposed on chronic HTN
> 140/90 before 20 weeks gestation, new or increased proteinuria, increasing BP or HEELP syndrome
Preeclampsia
> 140/90 after 20 weeks gestation, absent or present proteinuria, can have gestational HTN
characteristics of preeclampsia
vasospasm and decreased organ perfusion (HTN), intravascular coagulation, increased permeability and capillary leakage (edema), headache
risk factors for preeclampsia
nulliparity, moms under 19 and over 30, Af. Am. and Hisp., low socioeconomic status, family history of preeclampsia, chronic HTN, DM, lupus, multigestation, gestational trophoblastic disease, fetal hydrops
eclampsia
presence of seizure or coma (multifocal, focal, generalized)
treatment of eclampsia
magnesium sulfate and antihypertensive agents
use for magnesium sulfate
not given to decrease BP, CNS depressant, seizure prophylaxis, smooth muscle relaxant, safe for fetus
HELLP syndrome
hemolysis, elevated liver enzymes, low platelet count (associated with severe eclampsia)
eclampsia increases risk of
abruptio placentae, retinal detachment, acute renal failure, cardiac failure, stroke
preeclampsia fetal risks
growth retardation, death, hypoxia
ectopic pregnancy
pregnancy outside uterine cavity (2% of all pregnancies); 95% implant in fallopian tube
risk factors for ectopic
PID or STI, prior tubal or pelvic or abd surgery, endometriosis, IVF, IUD, abnormalities of reproductive organs
ectopic pregnancy treatment
salpingostomy/salpingectomy, methotrexate, monitor blood loss, emotional support
hydatiform mole (molar pregnancy)
1:1500; increased in women with low protein intake, women >35, asians, prior miscarriage, ovulation stim.; 20% become malignant
signs/symptoms of hydatiform
rapid growing uterus, vag. bleeding, N/V, HTN, abnormal high hCG, not fetal heartbeat, US shows cysts only (no fetus)
Haydatiform management
D&C (dilation and curretage), monitor serial hCG for malignancy, no pregnancy for 1 year, emotional support
placenta previa
implantation in lower uterine segment, over or near the cervical os
placenta previa risk factors (what makes you at risk)
scarring, large placenta or multiple gestation, infertility, non-white, low socioeconomic, short interpregnancy interval, impeded endometria; vascularization (>35Y), diabetes, smoking, cocaine
placenta previa signs/symptoms
painless intermittent bleeding, US confirmation,
primary fetal risk from placenta previa
prematurity; malpresentation, fetal anemia, IUGR
primary maternal risk placenta previa
hemorrhage; lower uterine not responsive to oxytocin so use methergine
precautions when have placenta previa
avoid vaginal exam, monitor maternal vitals, continuous EFM, BPP, amniocentesis (for lung maturity)
when active bleeding placenta previa
large bore IV access, measure I&O, weigh pads, CBC and coag. studies, known blood type, keep O2 >95%, anticipate emergent C-sect.
placental abruption
premature separation of normally implanted placenta; bleeding can be concealed or external; severity dependent on degree of separation
grade 1 placental abruption
partial (or concealed); blood retroplacental; pain and abd rigidity form blood pooling
grade 2 placental abruption
Partial; marginal bleeding apparent (mild to moderate bleeding)
Grade 3 placental abruption
complete abruption (bleeding concealed or apparent); moderate to severe bleeding; high mortality rate
risk factors for placental abruption (what puts you at risk for developing)
HTN (140/90), blunt trauma to maternal abdomen, short umbilical cord, previous abruption, smoking or cocaine
placental abruption symptoms
sharp abd. pain, uterine irritability, increase resting tone, vaginal bleeding may or may not be present, dark port-wine stained amniotic fluid, FHR could be compromised, maternal tachycardia
treatment of placental abruption
assess fundal height, assess pain and tenderness, assess signs/symptoms of shock, I&O, weigh pads, continuous EFM, O2 >95%, observe for DIC and admin blood, prep for emergency delivery
polyhydramnios
excessive amniotic fluid >2000mL; associated with maternal diabetes and fetal GI abnormalities; amniocentesis if SOB appears
oligohydramnios
scanty amniotic fluid <500mL; risk for fetal adhesion and malformations; amniofusion for treatment
assessment of prenatal newborn
- anticipate what might have compromised fetus in utero
- maternal medical/prenatal history: blood type, lab values, GBS/HIV/HepB, diabetes or preeclampsia, smoking/substance abuse
assessment of intrapartum newborn
what may have occurred in labor: analgesia/anesthesia, prolonged ROM, meconium amniotic fluid, nuchal cord, forceps/vacuum, distress, precipitous birth (rapid)
postpartum newborn first assessment
Need for resus, ABCs, thermoregulation, APGAR, P.E., if all well then skin-skin
postpartum newborn secondary assessment
physical exam, general measurements, gestational age assessment,attachment
ongoing postpartum newborn assessment
progress of adapting to extrauterine life, nutritional status/ability to feed, behavioral state
avg measurements
weight 2500-4000g (7lb 8oz); head circum. 33-35cm (2cm greater than chest); chest circum at nipple line; abd circum; length 18-22 in (48-52cm)
gestational age
established in first 4 hours to predict at risk infants; ballard tool used
assessment of physical maturity chracteristics
skin, lanugo, sole creases, areola and breast bud tissue, eye/ear formation, genitalia
neuromuscular maturity assessment characteristics
posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear
newborn vital signs
HR 110-160 (low as 70 during rest and 180 when crying), Respirations 30-60, BP 70-50/45-30 at birth (90/60 day 10), rectal temp. 36.6-37.2 C (97.8-99F)
Normal Fetal head assessment
anterior fontanelle is diamond shape (closes 18 months); posterior fontanelle is triangle shaped (closes 8-12 weeks); asymmetry is normal; normal term infants should be able to hold head up temporarily
abnormal fetal head assessment
depressed fontanelles (dehydration/decreased intracranial pressure); bulging fontanelles (signs of increased intracranial pressure)
head variations of newborn
molding d/t birth canal; cephalohematoma d/t broken blood vessels under scalp within suture line; caput succedaneum d/t formation of edema under scalp that crosses suture line
craniosynostosis
premature fusion of cranial sutures leading to growth restriction
plagiocephaly
infant rapidly growing head attempts to expand but meets resistance from flat surface like bed mattress
eye and ear newborn assessment
symmetry; tearless crying (immature lacrimal), peripheral vision, fixate on near objects (8-12 in), can perceive faces shapes colors, blink in response to light, pupillary reflex; ears soft and pliable, ready recoil, pinna parallel with inner and outer canthus
abnormal eye and ear variations
low set ears can indicate chromosomal or renal abnorm.; edema of eyelids can indicate infection, increased intracranial pressure, or trauma
normal eye and ear variations
subconjuctival hemorrhage can be due to traumatic birth, transient strabismus (cross-eyed/lazy eye)
normal nose and mouth findings
nose: small and narrow, nose breathing, no chonal atresia; mouth: pink lips, taste buds present, epstein pearls (keratin cysts)
abnormal nose and mouth findings
flat philtrum (FAS), ankyloglossia (tongue tied- tight frenulum), cleft lip (indicative of chromosomal abn.)
normal chest findings
cylindrical, 1-2cm smaller than head, engorged breasts w/ white secretion (pseudomenses milk), diaphragmatic respirations, normal heart sound
abnormal chest findings
retractions while breathing, murmur (common in 24 hours but issue after)
signs of fetal respiratory distress
nasal flaring, intercostal substernal or xiphoid contractions, expiratory grunting (may sound cute), seesaw respirations, tachypnea (>60)
fetal cardiac abnormalities
low pitched murmur, decreased strength or femoral pulses, congenital heart defects, heart heard on right side
heart heard on right side
transposition or pneumothorax
fetal abdominal findings
cylindrical, soft, bowel sounds present after 1 hour, umbilical cord initially white with 2 arteries 1 vein
umbilical cord blood supply
2 arteries remove blood and waste; 1 vein brings nutrients and blood
fetal genitalia findings
females labia majora covers labia minora; male testes are descended with pendulous scrotum
fetal extremities findings
short flexible and symmetrical movement; legs equal in length with symmetrical creases
musculoskeletal variations
prominent xiphoid cartilage (benign); fractured clavicle shows asymmetry d/t traumatic birth
fetal extremity abnormal findings
gross deformities, extra digits (polydactyly), webbing (syndactyly), clubfoot, hip dislocation
testing for hip dysplasia
barlow test (click is normal, clunk is abnormal), ortolani test
female genitalia variations
vaginal tag (hormonally related and normal, dries up and falls off); pseudomenstruation (resides by day 4)
male genitalia variations
hypospadias (urethra under penis), phimosis (foreskin cannot be retracted), hydrocele (fluid/edema), cryptorchidism (undescended testes)
when do male testes usually descend
about 3rd trimester
fetal skin variations
acrocyanosis, mottling, jaundice, erythema toxicum, milia
acrocyanosis
bluish discoloration of hands and feet; poor indicator of poor perfusion d/t immature circulatory system
mottling
d/t dilated blood vessels; usually benign but systemic can indicate sepsis, apnea, hypothyroidism
jaundice
hyperbilirubinemia, progresses head to toe, within first 24 hours can be pathologic
erythema toxicum
newborn rash
not as common skin variations
vernix caseosa (protects skin in utero), forceps mark (look for paralysis) , telangiectactic nevi (stork bites), mongolian spots (usually on back and look like bruising) nevus flammeus (capillary density)
newborn reflexes
tonic-neck, moro, graspin, rooting, sucking, babinksi, trunk incurvation
moro reflex
arms out when being placed down quickly; appears 32 weeks and disappears 6 months
stepping relfex
baby steps when holding them upright
babinski reflex
stroke foot heel to toe and baby curls toes then extends
trunk incurvation
stroke 1 side of vertebral column and baby moves butt to that side
protective reflexes of baby
blink (protect eye), yawn (overstimulated), cough(airway protection), sneeze (clear nare)
behavioral states of newborns
deep sleep, light sleep, drowsiness, quiet alert (best feeding outcomes), active alert, crying
behavioral response
habituation, orienting response, motor organization, consolability, cuddliness
daily newborn care
thermoregulation, feeding, skin/cord care, prevention of infection, security
daily newborn assessments
vitals, weight, overall color, I&O, umbilical cord, feeding, attachment
prep for discharge
Hep B vaccine (and immunoglobuling if mom +), state screening, hearing screening, CHD screening
parental education
proper picking up,holding/feeding, diaper changing, newborn cues, bathing, voiding and stooling, safety
newborn safety
car seat safety, SIDS, shaken baby
newborn signs of illness
temp above 38 or below 36.6 (axillary), frequent vomiting, refusal of 2 feedings in a row, difficulty awakening baby, cyanosis, jaundice, apnea (>20sec), inconsolable cry, no wet diapers (18-24 hours), eye drainage, bleeding from umbilical, circumcision, or any orifice
extrauterine physiologic transitions
respiratory, circulatory, thermoregulation
4 heat loss mechanisms
evaporations, convection (air current), conduction (direct skin contact) radiation (indirect source)
why do infants lose heat
large body surface related to mass, less insulating fat
closure of which fetal shunts
foramen ovale, ductus arteriosus, ductus venosus
APGAR scores
assessed at 1 and 5 minutes; 1-3 severe distress, 4-6 moderate difficulty with transition, 7-10 stable
APGAR Pulse (HR)
0= absent, 1= 60-100, 2= >100
APGAR Respiratory
0= apnea, 1=slow, irregular, weak cry, 2= lust cry
APGAR Grimace (reflex)
0= no response, 1= grimace, 2= vigorous cry
APGAR Appearance (color)
0= cyanotic/pale, 1= body pink, extremities blue, 2= pink
APGAR Activity (muscle tone)
0= flaccid, 1= some flexion, 2= active motion
delayed cord clamping results
~61% increase in blood volume
vaccines administered after birth
vitamin K (coagulation) and erythromycin eye drops (prevent infection)
reasons for hyperbilirubinemia
accelerated destruction of RBC d/t ABO or Rh incompatibility, delayed cord clamping causing increased blood
the infant is able to excrete conjugated bilirubin but not unconjugated
true
sign of neurological development
losing of reflexes
when to initiate breastfeeding after birth
within 1 hour; when starting to breast feed do not use bottle, artificial nipples, pacifiers
contraindications to breastfeeding
HIV, active untreated TB, Human T-cell Leukemia, chemical exposure, illegal drug use, children with galactosemia, some medications
infant nutritional requirements
100-120 cal/kg/day; whey and casein, carbs, fats; fluids 100-150mL/kg/day, iron, fluoride, vitamin D, vitamin K
colostrum
thick watery yellow consistency; higher in proteins fat soluble vitamins and minerals than mature milk; maternal antibodies
infant stomach size
day 1- 5-7mL, day 3 0.75-1oz, day 7 1.5-2oz
signs of effective breasfeeding
nursing >= times in 24 hours; audible swallowing, breast soften after feeding, increasing wet diapers, stools lighten
let-down reflex stimulated by
lullaby music, changing a diaper, eliciting palmar grasp reflex, maternal thoughts of infant
difference in cows milk and breast milk
breast milk has higher amount of lactalbumin
common complications in newborn period
gestation age and birthweight issues, drug exposure, congenital anomalies, hypothermia, hypoglycemia, RDS, TTN, MAS, PPHN, sepsis, hyperbilirubinemia
mortality of neonates
75% of all neonatal deaths occur in 1st week; risk decreases as gestational age and birth weight increase
morbidity of neonates
based on gestational age and birthweight
age of viability
22-23 weeks
conditions present at birth
IUGR, SGA, LGA, infant of diabetic mother, preterm baby, CHD, inborn errors of metabolism, infant of substance abusing mother
gestational age classifications
preterm infant (<37 weeks), full term infant (39-41 weeks), late-preterm infant (34-37 weeks), postterm infant >42 weeks)
IUGR
deviation and reduction in expected fetal growth pattern; multiple conditions can cause this
IUGR associated factors
fetal factors: affecting genetic growth; maternal factors: age, drug use, smoking; Placental factors: inadequate delivery of nutrients
symmetric IUGR
intrinsic factors; growth failure early
asymmetric IUGR
extrinsic factors; growth failure late
characteristics of SGA
large head compared to body, reduced subcutaneous fat, decreased breast tissue, scaphoid abdomen, wide skull sutures, poor muscle tone, loose dry skin, thin umbilical cord
SGA complications
chronic hypoxia, hypoglycemia, hypothermia, polycythemia, cognitive difficulties d/t hypoxia, intrauterine infection (torch), congenital malformations
characteristics of LGA
birth weight >90% for gestational age, increased C-section, hypoglycemia, polycythemia, birth trauma, often apneic, shoulder dystocia, cephalopelvic disproportion
infant of diabetic mother complications
hypoglycemia, hypocalcemia, hyperbilirubinemia, birth trauma (macrosomia), polycythemia, RDS, congenital malformations
postterm newborn
after 42 weeks (4-14% of pregnancies), postmaturity syndrome, risk of perinatal asphyxia and meconium passage, polycythemia, hypoglycemia, decreased amniotic fluid (cord compress. ad thicker meconium stained amn. fluid)
CHD screening
pulse oximeter on right hand and either foot to detect diminished oxygen delivery
newborn screening
used to detect 50+ inborn errors that effect metabolism
inborn errors
enzyme defects that block metabolic pathways causing toxin accumulation which can lead to end organ function
tobacco effects on infant
LBW, SIDS more likely, 30% increase of prematurity
common complication with FAS
developmental delay (long term behavioral and cognitive delays), phenotypic features like growth restriction, CNS abnormalities, facial dysmorphology
management of infants from substance abuse mothers
reducing withdrawal symptoms (jittery, irritable for 6-8 weeks), promote adequate respiration temperature and nutrition, administer meds as ordered, swaddling
cold stress infant
newborn compensates by increasing metabolic rate, decreased surfactant production = hypoxia, increase glucose consumption = hypoglycemic, metabolic acidosis increases risk of jaundice
infant cold stress management
rewarm: skin to skin, heat lamp, swaddling. monitor glucose levels, monitor saturation, educate parents
who to screen for hypoglycemia
LGA, SGA, IUGR, preterm, cold stress, premature, respiratory distress
glucose target in newborn
> 40mg/dL
signs of hypoglycemia in newborn
jittery, tachypnea, diaphoresis, hypotonia (floppy), lethargy, apnea, temperature instability
physiologic jaundice
usually occurs on days 2-5 postpartum; increased bilirubin d/t polycythemia and short life span of RBC, decreased liver uptake, inability to conjugate, breast feeding, over production or underclearance
pathological jaundice
first 24 hours of life
bilirubin encephalopathy
unconjugated bilirubin in excess which binds to albumin and crosses BBB; can cause neurotoxicity signs: lethargy, irritability, retrocollis (neck arch) and trunk (opisthonos)
kernicterus
end stage hyperbilirubinemia; brain damage caused by excessive jaundice; causes specific movement disorders, hearing loss or deafness, impairment of eye movements, abnormal staining of baby teeth enamel
hyperbilirubinemia interventions
phototherapy, exchange transfusion
newborns with infections
anticipate sepsis neonatorum, immature immune system, vertical transfusion, horizontal transmission (nosocomial)
antibodies that are passed from mother to infant
IgG; gives passive acquired immunity
signs of respiratory distress syndrome in newborn
grunting, flaring, retracting, tachypnea, gray skin color, hypoxemia, acidosis from hypoxemia
management of RDS in newborn
pulse oximetry, cardiac monitoring, exogenous surfactant, O2, CPAP, intubation, ECMO
Transient tachypnea of newborn
failure to clear lung fluid, mucus, and debris; exhibits signs of distress shortly after birth (usually from c-section d/t not being squeezed during birth canal)
TTN signs
expiratory grunting and nasal flaring, subcostal retractions, slight cyanosis
meconium aspiration syndrome
mechanical obstruction of airway, chemical pneumonitis, vasoconstriction of pulmonary vessels, inactivation of natural surfactant
