Exam 3 Flashcards
What is gestational hypertension?
o Gestational hypertension: Greater than 140/90 after 20 wks gestation
What is preeclampsia, risks ect..
o Preeclampsia: HTN and proteinuria
• Severe: htn (>160/110), proteinuria (>3+), low platelets, neurologic symptoms, oligouria (changes in kidney function), epigastric pain
• Risks: primigravida, multifetal, interval (10yrs), obesity, exposure to trophoblast tissue, preexisting medical/genetic conditions, extremes of age (40), poor outcome in previous pregnancy, family/personal hx, thrombophilias, periodontal disease
Nursing care for preeclampsia
- Nursing Care: assessments (hematocrit, platelet, liver function tests and 24hr urine for protein/week, 2x weekly= BP and urine protein, and BPP or NST at clinic. Daily FMC (normal 4/hr)
- Homecare: BP<500mg/day, normal platelet count, reassuring fetal status, no s/s or severe preeclampsia.
- If severe: drug of choice= magnesium sulfate
What is Eclampsia?
o Eclampsia: seizures or coma in preeclamptic woman
Nursing care for Eclampsia
• Nursing care: airway patent (turn to side, suction and 10L O2 via nonrebreather), observe and record convulsion activity, start IV fluids, give mag sulfate or other anticonvulsant, urinary cath, monitor BP, fetal and uterine status, lab work (kidney and liver function, coagulation system and drug levels. Provide hygiene and quiet environment, support and keep them informed. When stable assist with birth.
Magnesium sulfate action
o Action: Prevention of seizures (interferes with release of Ach at the synapses- depressing cardiac conduction and decreasing neuromuscular and CNS irritability)
Magnesium sulfate therapeutic level and dose
o Therapeutic Level: 4-7 mEq/l
o Dose: 4-6g over 15-30min, then 2g/hr
Side effects of magnesium sulfate
o Side effects: warm, flushed, diaphoresis, burning at IV site
Toxicity and antidote of magnesiam sulfate
o Toxicity:
• mild: lethargy, muscle weakness, decreased or absent DTR, dbl vision, slurred speech
• Worsening: bradycardia, bradypnea, hypotension, cardiac arrest
o Antidote: calcium gluconate or calcium chloride, and stop infusion
Nursing care for magnesium sulfate
o Nursing care: vitals q30min, monitor FHR and contractions. Monitor I&O, proteinuria, DTRs, presence of HA’s, visual disturbances, LOC, and epigastic pain hourly. UO at least 30ml/hr.
What is HELLP syndrome
Laboratory diagnosis for severe preeclampsia with hepatic dysfunction. Increased risk for adverse perinatal outcomes
Hemolysis, elevate liver enzymes, and low platelets
o Hydatidaform mole
- Incidence: 1 in 1000 pregnancies
- Signs and symptoms: Early stages can’t be distinguished from normal pregnancy. Later stage vaginal bleeding occurs (may be dark brown like prune juice or can be bright red) and ca be scant or profuse. Anemia, excessive n & v, and abdominal cramps/pain. Good chance show signs of preeclampsia.
- Treatment: Most abort spontaneously. If not suction curettage offers a safe and rapid method of removing mole. Post-evacuation admin of Rh (D) immune globulin to women who are Rh negative
Nursing care for Hydatidaform mole
• Nursing care: Nurse provides family with information about disease process and need of subsequent long course follow up and possible consequences of disease. Help family cope with pregnancy loss and recognize that this was not a normal pregnancy, encourage pt to express feelings (provide information about support groups) Explain the importance of postponing subsequent pregnancies.
• Late pregnancy bleeding : Placenta previa
o Placenta previa: Placenta is implanted in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix
• Incidence: 1 in 200 pregnancies (c/s, more than 35-40 years of age, multiparity, history of suction and curettage, and smoking)
• Signs and symptoms: Painless bright red vaginal bleeding during the 2nd or 3rd trimester. Initial bleeding is small and often forms clots (bleeding can reoccur at any time. Vital signs may be normal so a better indicator is urinary output. Abd exam is soft, relaxed, nontender uturus with normal tone. Fundal height is often greater than expected for gestational age. Breech and transverse presentation is common.
Late pregnancy bleeding: Abruptio placentae
o Abruptio placentae (placental abruption)
• Incidence: 1-75 to 1-226 (maternal hypertension, cocaine use, and abd trauma/ maternal battering, smokes, previous history, preterm PROM)
• Signs and symptoms: Vaginal bleeding (result in maternal hypovolemia so shock, oliguria, anuria), abd pain (mild to severe), uterine tenderness and contractions. Bleeding may be present through the vagina, may remain concealed, or both. If have c/s blood clots may be notes on entry to uterus. If a lot of bleeding has occurred the uterus will appears purple or blue and will have lost it contractility.
• What is a cerclage, why is it indicated and when is it placed?
o Cerclage is the use of a non-absorbable suture to keep a premature dilating cervix closed; released when pregnancy is at term.
o Is indicated for Incompetent cervix and is placed at 11-15 weeks of gestation and is removed at 37/when spontaneous labor begins.
• What are the normal physiologic changes that occur in the cardiovascular system related to pregnancy?
Increased cardiac output, HR and blood volume (plasma and RBC), slightly decreased BP
• Describe nursing care in the prenatal, labor, and postpartum periods for women with heart disease : Prenatal
• Prenatal:
o preconception care, limit stress on heart (greatest b/t 28 and 32 wks of gestation.
o Signs of decompensation: increased fatigue/difficulty breathing, feelings of smothering, cough, palpitations, generalized edema, irregular rapid pulse, lung crackles, orthopnea, rapid RR, cyanosis of lips and nailbeds.
o Infections treated promptly- b/c they can accelerate the HR and spread to heart structures.
o Nutrition counseling, avoid valsalva with BM (when released causes blood to rush to the heart and overload the cardiac system)
o Med management (cardiac meds, anticoagulants- monitor PT and INR)
o Tests for fetal well-being and placental sufficiency. Close medical supervision
• Describe nursing care in the prenatal, labor, and postpartum periods for women with heart disease : Intrapartum
• Intrapartum
o Calm environment (minimizes anxiety and promotes cardiac function). Head and shoulders elevated and resting on pillow, side-lying position
o Cardiac monitoring- EKG, BP, and O2, and FHR
o Antibiotics- penicillin prophylaxis, prevent bacterial endocarditis
o Open-glottis pushing
o Assist with 2nd stage (forceps or vacuum)- to decrease the length and workload of heart
o Epidural- provides better pain than narcotics and less hemodynamic alterations
• Describe nursing care in the prenatal, labor, and postpartum periods for women with heart disease: Postpartum
• Postpartum-
o Monitor for cardiac decompensation- HIGH RISK for 1st 48hrs
o Good nursing assessment (vitals, O2, lungs and heart sounds, edema, bleeding, uterus, UP, pain (esp chest), emotional state, dietary intake, mom-baby interaction)
o Longer hospital stay- close monitoring of vitals. Semi-fowlers or side lying- head and shoulders elevated.
o Progressive, gradual activity
o Lactation generally okay
• Thiazide diurectics may suppress lactation. And can cause neonatal diuresis that leads to dehydration.
o Increased risk of usual pp complications: thrombus, infection, anema.
o Increased risk of congenital heart disease in neonate if parent has one.
• What is the most critical time for possible decompensation related to heart disease?
1st 48hrs after birth are highest risk for decompensation d/t increased blood flow to heart, CO, blood volume. Decompensation= inability of heart to maintain sufficient cardiac output
What assessment should be performed on the laboring and postpartum woman with heart disease?
Routine assessments for all laboring women, and ABGs, pulmonary artery catheter may be inserted to monitor hemodynamic status, ECG monitoring and continuous BP and O2 and continuous fetal monitoring.
• How is CPR and foreign body airway obstruction care different for pregnant women (later in pregnancy).
Uterus should be displaced laterally for chest compressions (manually or towel under a hip), paddles of defib one rib interspace higher than usual. If CPR not effective in 5 min, c-birth if fetus viable.
In 2nd and 3rd tri- use chest thrusts rather than abdominal thrusts.
• What is the most common medical disorder of pregnancy?
Anemia
• What are common signs and symptoms of anemia, what is the treatment?
Symptoms: fatigue, drowsiness, malaise, dizziness, weakness, HA’s, sore tongue, skin pallor, pale mucous membranes, loss of appetite, N&V
Treatment: increase iron rich food or iron supplementation.
• What can a woman do to increase iron absorption?
Diet rich in Vit C (citrus fruits, tomatoes, melons, and strawberries)
• What effect can asthma have on pregnancy? How is asthma managed in pregnancy?
Unpredictable effect, associated with uteroplacental insufficiency, IUGR, and preterm birth.
Managed- peak flow meters, avoid asthma triggers, education
• What is the most common reason for abdominal surgery during pregnancy?
appendicitis
• Why is appendicitis difficult to diagnosis in pregnancy?
Its pushed upward and to the right
• What is the most common cause of trauma in pregnancy?
Blunt abdominal trauma- MVAs and falls.
• How can trauma affect mom and fetus?
Mom- death from head injury or hemorrhagic shock.
Fetus- death from maternal death or placental abruption. Increase incidence of preterm labor and birth, PROM, fetomaternal transfusion, skull injuries, hypoxia.
• What is a major concern for the health of mom and fetus following blunt abdominal trauma?
Placental abruption. Also maternal death from head injury, serious hemorrhage
• What is the role of ultrasound in care of the pregnant woman who has experienced trauma?
Help establish gestation age, locate placenta, and evaluate cardiac activity (determine whether fetus is alive), and determine amniotic fluid volume.
• What are warning signs for PTL/PTB?
Biochemical markers: fetal fibronectins (glycoprotein found in plasma and produced during fetal life- vagnial swab) before 35wks= 25% accurate and before 28wks= 65% accurate.
Endocervical length- changes in cervical length occur before uterine activity- occurs over a period of weeks
S/S of preterm labor:
o Uterine activity: UCs >q10min for 1hr or more, painful or painless
o Discomfort: low abd cramping, may be accompanied by diarrhea. Dull, intermittent low back pain (below the waist). Painful, menstrual-like cramps. suprapubic pain or pressure. Pelvic pressure or heaviness; feeling that “baby is pushing down.” Urinary frequency
o Vaginal Discharge: change in character and amt of usual: thicker (mucoid) or thinner (watery), bloody, brown, or colorless, increased amt, odor. Rupture of amniotic membranes
• What is the definition of preterm labor (PTL)?
PTL: cervical changes and UC’s occurring b/t 20 and 37wks gestation. PTB: birth before end of 37th wk.
• What is the role of infections in PTL?
Only factor definitely shows to cause PTL
• What is the role of corticosteroids in PTL? Which ones are commonly used?
Promote fetal lung maturing. Antenatal glucocorticoids- IM inj. Stimulates fetal surfactant production. Common- Betamethasone 12mg (2 doses) q24h or Dexamethasone 6mg (4 doses) q12h.
• What lifestyle changes may be anticipated for the woman with PTL?
o Activity Restriction- Bed rest (modified is best) and limited work.
o Restriction of Sexual Activity- not effective at preventing preterm birth. If s/s of PTL after sex, obstain until 37wks.
o Home Care- “take it easy”- keep essentials w/i reach, eggcrate mattress, smaller more frequent meals. Activities, limited naps, and hygiene and grooming reduced boredom and maintains control and normalcy.
• What is the role of bedrest in PTL management?
No evidence in literature has supported the effectiveness of this intervention in reducing preterm birth rates. Intended to provide maternal rest and decrease stress. May disrupt family function and cause more maternal distress. Adverse effects- risk of thrombus formation, muscle atrophy, osteoporosis, and cardiovascular deconditioning.
• What is the relationship of PPROM to PTL/PTB?
PROM responsible for about 1/3 of all PTB. PROM results from weakening of amniotic membranes from inflammation, stress from UCs, or other factors that cause increased IUP.
• What is a major concern for the women with PPROM?
Chorioamnionitis (bacterial infection of amniotic cavity)- most often occurs after ROM of during labor. Risks: long labor, such as prolonged ROM, multiple vag exams, internal FHR and contraction monitoring. Also young age, low SES, nulliparity, preexisting lower genital tract infections.
Can lead to: dysfunctional labor, c-birth and infection, neonatal pneumonia, bacteremia, sepsis
• How are hypertonic and hypotonic labor dystocia different?
o Hypertonic labor dystocia- R/T fear and tension (unknown) UCs frequent and painfully strong- ineffective in causing cervical dilation and effacement. UCs in latent phase of 1st labor stage (less than 4cm).
Feeling exhausted and loss of control r/t pain and lack of progress
o Hypotonic labor dystocia- R/T cephalopelvic disproportion of fetal malposition. (More common) Rise in IUP during UCs not sufficient to promote cervical effacement and dilation. Normal progress in active 1st phase and then UCs become weak an insufficient or stop. Becomes exhausted and increased risk of infection.
• How is management different between the two?
o Hypertonic labor: therapeutic rest measures, analgesics (morphine) to inhibit UCs, reduce pain and encourage sleep. Rest and relaxation- hydrotherapy, massage, music, distracting activities.
o Hypotonic labor: rule out cephalopelvic disproportion. Augment labor with Pit, perform amniotomy, enhance progress of labor- position changes, ambulation, hydrotherapy
• What are maternal causes of labor dystocia
o Maternal causes:
• secondary powers (bearing-down efforts) compromised from large amounts of analgesia
• abnormal labor patterns: prolonged latent phase, protracted active phase dilation, secondary arres (no change), protracted descent, arrest of descent, and failure of descent
• alterations in pelvic structure: pelvic dystocia (contractures of pelvic diameters that reduced capacity of the body pelvis, inlet, midpelvis, or outlet) or soft-tissue dystocia (obstruction of birth passage by anatomic abnormality, such as placenta previa, uterine fibroids, ovarian tumor, full bladder, etc.)
• position of mom: alters relationship b/t UCs, fetus, and moms pelvis
• psychologic responses: hormones and neurotransmitters (catecholamines) released in response to stress (pain and lack of support person) can cause dystocia
• What are fetal causes of labor dystocia?
o Fetal causes:
• Anomalies: gross ascites, large tumors, open NTD, hydrocephalus
• Cephalopelvic disproportion (CPD): b/t size of fetus and size of moms pelvis. d/t macrosomia or malposition of presenting part
• Malposition: persistent occipitocposterior position (ROP or LOP)= severe back pain
• Malpresentation: breech (frank, complete, foolting)
• Multifetal pregancy
• What is a Bishop score and what is it used for?
Used to evaluate inducibility. Cervical ripeness is most important predictor of successful induction. 8 or more= induction of labor is usually successful.
• What are common methods of cervical ripening?
Chemical agents: prostaglandins- PGE1 and Cytotec (Misoprostol): ripens cervix, making it softer and causing it to begin to dilate and efface, stimulates UCs
Mechanical methods: balloon catheters to ripen and dilate cervix (pressure and stretching), hydroscopic dilators (absorb surrounding fluid and enlarge), laminaria tents and synthetic dilators containing Lamicel (mag sulfate) into endocervix. Amniotic stripping or sweeping- release of prostaglandins and oxytocin (insert finger and rotate 360 degrees to separate membranes from wall of cervix and lower uterine segment.
Physical methods such as sexual intercourse (prostaglandins in semen, and stimulation of contractions from orgasm), nipple stimulation (oxytocin), and walking (pressure on cervix by gravity)
• Describe methods of induction and augmentation
Induction of labor: (chemical or mechanical intiation of UCs before their spontaneous onset, to bring about birth) amniotomy (AROM)- labor usually w/i 12 hrs, committed to labor , oxytocin (high alert drug, tachyststole)
Augmentation: (stimulation of UCs after labor has started spontaneously but progress is unsatisfactory). Methods: Pit infusion and amniotomy. Noninvasive= empty bladder, ambulation and position changes, relaxation measure, nourishment and hydration, hydrotherapy. Active management of labor- aggressive use of Pit for birth w/i 12h of admission.
• What are possible detrimental effects of pitocin augmentation or induction?
Maternal hazards: placental abruption, uterine rupture, unnecessary c-birth d/t abnormal FHR and patterns, PPH, and infection. Placental perfusion diminished by too frequent or prolonged UCs= fetal hypoxia and acidemia
• What are nursing implications for using pitocin for augmentation or induction of labor?
o Teaching and support (reasons for oxytocin, effects to expect concerning UCs (intensity increases more rapidly, holds peak longer, and ends more quickly), update on progress
o Assessment: fetal status q15min during 1st stage and q5min during active phase of 2nd stage. Monitor UC pattern and uterine resting q15min in 1st stage and q5min in 2nd stage. Monitor BP, P, and R q30-60min, assess I&O, perfrom vag exam as indicated, monitor for side effects (N&V, HA, hypotension), observe emotional response
o Uterine tachysystole (more than 5 UCs in 10 min, or single contraction >2min, or contractions occurring w/i 1 min of each other)
o Rate of infusion to lowest dose to achieve acceptable labor progress. And document.
• What are maternal and fetal reasons for vacuum assisted or forceps assisted birth?
Forceps-assisted birth: 2 curved blades to assist in birth of fetal head.
o Maternal indications: Prolonged 2nd stage of labor and need to shorted for maternal reasons (maternal exhaustion or maternal cardiopulmonary or cerebrovascular disease)
o Fetal indications: fetus in distress or abnormal presentations, arrest of rotation, or extraction of head in a breech position.
Vaccuum- assisted birth: vacuum cup to fetal head, neg. pressure to assist in birth of head.
o Indications same as outlet forceps. Advantages are ease in which vacuum can be placed and less anesthesia needed. Less skill needed.
• Describe the complications that are more common for women who are obese.
o Venous thromboembolism
o Cesarean birth- emergency ones
• What are maternal and fetal reasons for cesarean births?
o Maternal: specific cardiac or respiratory disease, conditions associated with increased ICP, mechanical obstruction of lower uterine segment (tumors, fibroids), mechanical vulvar obstruction (condylomata), hx of previous c-broth
o Fetal: abnormal FHR or patter, malpresentation, active maternal herpes lesions, maternal HIV, congenital anomalies
o Maternal-fetal: dysfunctional labor, placental abruption, placenta previa, elective c-birth
• Are cesarean sections more often done for the health of the mother or the fetus?
Fetus
• Describe nursing care for a woman with a prolapsed umbilical cord
o Call for assistance, notify MD immediately
o Glove hand and use a finger on either side of cord on presenting part to exert upward pressure to relieve cord compression- do not move hand! Another person can put rolled towel under R or L hip.
o Place woman in extreme trendelenburg or modified sims position, or knee-chest position
o If cord protruding from vagina= wrap in warm sterile NS solution- do not replace in vagina
o Administer O2 8-10L nonrebreather mask until birth
o Start IV fluids and increase rate
o Continue to monitor FHR continuously
o Explain to woman and support person what is happening and how it’s being managed.
o Prepare for immediate vag birth if fully dilated, otherwise c-birth
• What is a shoulder dystocia, what birth injuries is it associated with?
o Head is born, but anterior shoulder cannot pass under pubic arch (turtle sign- retraction of fetal head immediately following its emergence= early sign)
o Birth injuries R/T asphyxia (from delay of birth or trauma from maneuvers), brachial plexus damage (Erb palsy), and fracture
• Describe nursing care for the birth complicated with shoulder dystocia.
o Maneuvers- suprapubic pressure and maternal position changes
o McRoberts maneuver- legs flexed apart with knees on abdomen, causes sacrum to straighten and symphysis pubis to rotate toward moms head, angle of pelvic inclination is decreases which frees the shoulder.
o Hands and knees (Gaskin), squatting, or lateral recumbent positions
o Fundal pressure- associated with neurologic complications (should be avoided)
o Stay calm and immediately call for help. Help position mom, assist MD with maneuvers and techniques during birth, and document. Provide encouragement and support to reduce anxiety and fear. Examine newborn clavicle or humerus and brachial plexus injuries or asphyxia.
• What are signs and symptoms of a vaginal hematoma?
o A mass or swelling develops o Agonizing anal/genital pain o Shock/Fever o Urinary retention o Discolored skin o Possible decrease in BP o Tachycardia o There will be a significant decrease/absence of lochia after birth
• What are risk factors for postpartum hemorrhage?
Uterine atony
o Overdistended uterus (large or multiple fetus, hydramnios, distention with clots)
o Anesthesia and analgesia
o Previous hx of uterine atony
o High parity
o Prolonged labor, pit-induced labor
o Trauma during labor and birth (forceps, vacuum, or c-birth)
o Unrepaired lacerations during labor and birth
o Retained placental fragments, manual removal of retained placenta
o Ruptured uterus or inversion of uterus
o Placenta accrete, increta, perceta
o Coagulation disorders
o Placental abruption or previa
o Magnesium sulfate during labor or post-partum
o Chorioamnionitis
o Uterine subinvolution
• What is the most common cause of postpartum hemorrhage?
o Uterine atony
• What medications are used to manage postpartum hemorrhage related to uterine atony?
o Oxytocin, methergine, hemabate, cytotec- cause contraction of uterus
• What are risk factors for uterine atony?
o Associated with high parity, hydramnios, macrosomic fetus, and multifetal gestation
• Describe nursing management of postpartum hemorrhage.
o Assess vital signs (are looking for signs of shock and hypovolemia/bleeding)
o Palpate pulses (quality, rate)
o Listen to heart and lung sounds
o Inspect: Skin color, temp, turgor, LOC, cap refill, neck veins, mucus membranes
o Observe for: presence or absence of anxiety, apprehension, restlessness, disorientation
o Measure BP, urinary output and pulse oximetry
o Assess fundus
o Give drugs to help manage bleeding: Pitocin, Methergine, 15-Methylprostaglandin, Dinoprostone, and Cytotec (all help the uterus to contract)
• Define retained placental tissue. (pg 826/Chap 34)
o Retention of all or part of the placenta in the uterus after birth
o Nonadherent Retained Placenta: results from partial separation of the normal placenta, entrapment of the partially or completely separated placenta by a hourglass constriction ring of the uturus of mismanagement of the third stage of labor. (is common in very preterm birth)
o Adherent Placental Tissue: Abnorma adherence of the placenta occurs for an unknown reason (is thought that zygotic implantation in an area of defective endometrium so that no zone of separation is present between the placenta and the decidua (with this one normal attempts to remove the placenta will not work and are likely to perforate/lacerate the uterine wall (severe PPH risk)).
• What are some possible findings and negative effects of retained placental tissue?o
Placenta accreta: slight penetration of the myometrium by placenta tropoplast
o Plcenta Increta: Deep penetration of myometrium by placental tropoplast
o Placenta pecreta: perforation of uterus by the placenta
o Bleeding
o Cesarean hysterectomy (2/3 of woman)
• Describe common sites of postpartum infection.
o Genital/Puerperal infection o UTI o Wound Infection (c/s, vaginal lacerations) o Mastitis o Respiratory infections
• Symptoms of postpartum infection
o Fever (38 degrees C for 2 consecutive days during first 10 days o Increased pulse o Chills o Anorexia o Nausea, fatigue, pelvic pain o Foul smelling profuse locia o Urinary retention o Pyuria o Redness/swelling
