Exam 4 Flashcards
What is placental previa? Types?
placenta abnormally implants in lower uterine segment near or over cervical oss
Complete/total
incomplete/partial
marginal/low laying
What is the danger with marginal placental previa?
if the cervix opens even slightly bright red bleeding may occur
impaired circulation of the part over the cervix once it opens due to the villi no longer being able to circulate
What is the treatment for placenta previa?
often just needs monitoring at the beginning
as the fetus develops and everything is in close proximity the placenta may look low lying but as the uterus continues to grow the placenta should be attaching to the fundus
What are the risk factors of placenta previa?
previous placenta previa
uterine scarring from previous C-sections, curettage, endometriosis
maternal age >35
multiple gestation and multiparity
closely spaced pregnancies
smoking or cocaine use
What are the clinical manifestations of placenta previa?
painless
bright red vaginal bleeding during 2nd or 3rd trimester
soft, relaxed, nontender uterus
fundal height>for gestational age
fetus in breech, oblique, or transverse position
VS will be normal while the cervix is not dilated
What is the Kleihauer-betke test? What is it used for?
detects fetal blood in maternal circulation for any potential active bleeding
placenta previa and placenta abruptio
What are nursing interventions for placenta previa?
cannot have vaginal birth d/t placenta being in front of uterus
assess for bleeding, contractions, and fetal wellbeing
refrain from inserting anything enter the vagina (including vaginal exams) to decrease risk of cervix dilation
recommend bed rest
administer betametasone if pregnancy <37 wks (preterm)
What is betametasone?
a drug that will help fetal lung development by helping surfactant development
What is placenta abruptio?
premature separation of placenta from uterus when >20wks which can be complete or incomplete
What can placenta abruptio cause?
maternal death (leading cause)
fetal: low birth weight, preterm delivery, asphyxia, stillbirth, perinatal death
What are the risk factors for placenta abruptio?
maternal HTN, preeclampsia
blunt external trauma to abdomen
cocaine and cigarette (vasoconstriction)
previous abruptio placenta
PROM
multiple gestation, multifetal
IUGR
What are the clinical manifestations of placenta abruptio?
sudden onset of intense localized uterine pain
dark red bleeding (if it’s present it will cause the pain)
firm, tender abdomen
uterus boardlike
contractions with hypertonicitiy
fetal distress (decreased fetal mvt)
hypovolemic shock
What are nursing interventions for placenta abruptio?
immediate birth
continuous fetal monitoring
What is ectopic pregnancy?
abnormal implantation outside the uterine cavity
locations can include: ovary, intestine, cervix, abdomen, fallopian tube (can cause fatal hemorrhage if ruptures)
second most frequent cause of bleeding
leading cause of infertility
What are the clinical manifestations of ectopic pregnancy?
lower-abdominal quadrant unilateral stabbing pain and tenderness (usually starts as dull pain and progresses into colicky, then sharp and stabbing, then diffuse)
delayed, lighter than usual, or irregular menses
scant, dark red or brown vaginal spotting, 6-8wks after LMP or red, vaginal bleeding if ruptured
referred shoulder pain d/t rupture and increase of blood in peritoneal cavity irritating diaphragm or phrenic nerve
s/s of shock and hemorrhage (hypotension, pallor, tachy)
What are the risk factors of ectopic pregnancy?
STI (gonorrhea/chlamydia)
assisted reproductive technologies
tubal surgery
have or using an IUD
What do the labs show during ectopic pregnancy?
decrease of progesterone and hCG
hCG is drawn every 48 hrs to determine viable pregnancy
progesterone >25 nanograms of millimeters almost always rule out ectopic or abnormal pregnancy
How is ectopic pregnancy managed if a rupture has not occurred?
methotrexate to dissolve the embryo
What are the nursing considerations for methotrexate?
the metabolite that is broken down from methotrexate is considered toxic for 72 hrs (need to double flush, can be present in stool for up to 7 days)
avoid alcohol and vitamins containing folic acid which can cause a toxic reaction to medication
avoid sun exposure
avoid gas forming foods
What is spontaneous abortion? Types?
pregnancy terminated before 20 wks or fetal weight<500g
types are classified by manifestations and if products of conception are partially or completely retained or expelled
threatened, inevitable, incomplete, complete
What is threatened spontaneous abortion? Clinical manifestations? Management?
cervix is not dilated, placenta still attached to uterine wall
cramping/backache, vaginal bleeding
bedrest
What is inevitable spontaneous abortion? Clinical manifestation? Management?
cervix dilated, placental separation from uterine wall
craping and moderate bleeding, membranes may rupture
if infection also present then a medical abortion will be performed
What is incomplete spontaneous abortion? Clinical manifestation? Management?
embryo or fetus are passed but the placenta remains in uterus
profuse bleeding and extensive cramping, cervix obviously dilated, hemorrhage
curettage of the remaining placenta to avoid any further complications
What diagnostics are done for spontaneous abortion?
labs: hCG, CBC, US (to determine what is still in uterus and if viable)
FHB
What nursing education will be given for spontaneous abortion?
Heavy, bright red vaginal bleeding; elevated temperature; or foul-smelling vaginal discharge
Expect a small amount of vaginal discharge for 1-2 weeks
Take RX antibiotics, pain meds, or other meds for nausea
Medications to aid expulsion of products of conception (Misoprostol: stimulate uterine contraction and Mifestopristone: stimulate uterine contraction and promotes endometrium to slough)
Avoid tub baths, sexual intercourse, no tampons for 2 weeks
What is the ideal BG level during pregnancy? Ideal A1C?
70-110
<6
What changes to BG control occurs during pregnancy?
unable to respond to demands of pregnancy, especially in the third trimester
insulin resistance increases to provide more nutrients to fetus
become hyperglycemic and damage to vascularization
What risk are there to the fetus with maternal diabetes?
spontaneous abortion
high risk of birth defects
polyhydraminos
ketoacidosis
What changes to the fetus can happen with hyperglycemia?
macrosomia
difficult birth (shoulder dystocia)
fetal demise
birth defects
What is hyperemesis gravidarum? Possible causes?
prolonged excessive nausea and vomiting occuring >20 wks
elevated hCG during early 3rd trimester
What labs are done for hyperemesis gravidarum?
urinalysis (ketones and acetone, elevated urine specific gravity)
chemistry (metabolic acidosis (starvation) metabolic alkalosis (excessive vomiting), elevated liver enzymes, biliruben)
thyroid (hyperthyroidism)
CBC (hct elevation)
What is gestational trophoblastic disease? Types of growth? How are the types determined?
proliferation and degeneration of trophoblastic villi in placenta, the embryo will fail to develop (non-viable)
complete mole, partial mole
chromosomal analysis
What is complete mole GTD? Clinical manifestations?
no genetic material
develops from an “empty egg” fertilized by normal sperm
46 chromosomes
hmeorrhage into uterine cavity resulting in dark brown or bright red vaginal bleeding
anemia
preeclampsia
hyperemesis gravidum
uterus larger than expected for wk
20% progress to choriocarcinoma
What is partial mole GTD? Clinical manifestations?
two sperm fertilize ovum - 69 chromosomes
contains abnormal embryonic or fetal parts, an amniotic sac, and fetal blood
small or normal size uterus for dates
vaginal bleeding
hypermesis gravidarum
6% progress to choriocarcinoma
What is preterm PROM? Management?
premature rupture of membranes occurring <37 weeks with a great concern for infection and preterm birth
induce labor at 34 wks if benefit over risk
What tests are done to rule in ROM?
amnisure: swabbing looking for fetal fibronectin
nitrazine: nitrazine paper should turn blue to indicate rupture (done in addition to other tests)
fern: swab amniotic fluid and smear on glass slide, when it dries it’ll look like a boston fern
sterile speculum exam: speculum inserted and fluid will flow out
US: views amniotic fluid index
What is preterm labor?
contractions that causes cervical change before 37th wk
What is cervical insufficiency? Treatment?
premature cervical dilation that can cause preterm labor
prevent cervix from dilating and loss of pregnancy with prophylactic cervical cerclage
What is prophylactic cervical cerclage? Nursing education? Postoperative monitoring?
surgical reinforcement of cervix to prevent premature cervical dilation done 12-14wks and removed at 37wks or spontaneous labor
no heavy lifting and no not insert anything into vagina
uterine contractions, ROM, signs of infection
What are the types of HTN?
chronic, gestational, preeclampsia, eclampsia, chronic HTN with superimposed preeclampsia
What is chronic HTN? Nursing management?
existing HTN prior to pregnancy or before 20th wk or persistence >12 wk postpartum
frequent antepartial visits, monitor for abruptio placenta, preeclampsia, daily rest periods, home BP monitoring, close monitoring during labor, birth, and postpartum
What is gestational HTN?
BP >140/90mmHg occurring after 20 wks w/o proteinura, BP will return to normal by 12 wk postpartum
may develop into preeclamsia and eclampsia
What screening is done for gestational HTN at every prenatal visit?
weight
bp
edema - orbital edema
proteinuria
headaches (progressive that does not resolve with interventions)
blurred vision
urine retention
epigastric pain
What is preeclampsia?
HTN with proteinuria (at least 300mg in 24hrs) that effects multiple systems and can be mild or severe depending on amount of organ involvement
What are maternal risk factors for preeclampsia?
high BMI
previous preeclampsia
multiple gestations
DM, chronic HTN, renal disease
family hx
pregnancies resulting from insemination
younger than 19yr and older than 40
What are the effects of preeclampsia to CV system?
vasoconstriction and vasospasm: reduced renal perfusion and GFR (edema), reduced placental perfusion, IUGR
What are clinical manifestations of preelampsia?
increased BP
visual changes: blurred and/or scotma
epigastric/RUQ pain (d/t liver involvement)
jaundice
N/V
bleeding gums
headaches
edema
decreased urinary output and proteinuria
fetal impact
What is fetal impact?
poor placental perfusion and prolonged vasonctriction resulting in: IUGR, placenta abruptio, presistent fetal hypoxia and acidosis
What is management for mild preeclampsia?
bedrest
daily BP monitoring
fetal movement counts
hospitalization and IV Mg sulfate during labor
What is management of severe preeclampsia?
goal: stabilize and prepare for birth
treat aggressively
control HTN
prevent seizures
bedrest - left lateral position
prevent maternal and fetus death
birth is the only “cure”
while in labor: Mg sulfate and oxytocin
antepartum: antiHTN medications, Mg sulfate
What are the differences between mild and severe preeclamspia?
mild: >140/90, proteinuria: 300mg/24hr
severe: 160/110, proteinuria>500mg/24hr
What are clinical manifestations of severe preeclampsia?
hyperreflexia
Oliguria
Elevated serum creatinine greater than 1.1 mg/dL
Cerebral or visual disturbances (H/A, blurred vision, blind spots)
Pulmonary or cardiac involvement (pulmonary edema)
Extensive peripheral edema
Hepatic dysfunction (epigastric and RUQ pain)
Thromocytopenia (platelet count <100,000 platelets/mm)
HELLP syndrome
What is eclampsia?
preelampsia with seizures
What is an eclamptic seizure?
life threatening event
convulsive activity begins with facial twitching, followed by generalized muscle rigidity
apnea during seizure compromises fetal oxygenation
What is the management for eclampsia?
maintain open airway and remove secretions
increase placental perfusion by lying on left side
Mg sufate drip that continues until 48hr postpartum
after stabilization continue monitoring or prepare for delivery either IOL or C section
What are clinical manifestations of eclampsia?
seizure activity preceded by headache
severe epigastric pain
hyperrelexia
bp>160/110
proteinuria
genearlized edema
cerebral hemorrhage
renail failure
HELLP
What is assessed during labor?
cervical changes: ripening, effacement (100%=paper thin), dilation (0-10cm)
station
contractions
What is station?
level of the presenting part in relation to the ischial spines
measured in cm above and below ischial spines
ischial spines are 0 station = engagement
above the spines are negative, below the spines are positive
floating = when presenting part is entirely out of pelvis and freely moveable in inlet
How do contractions present during labor?
latent: onset of labor, irregular, palpate mild to moderate, 5 to 30 min apart lasting 30 to 45 sec
active: become regular, palpate moderate to strong, 3 to 5 min apart lasting 40 to 70 sec (cervical changes will occur here)
transition: very intense, palpate strong to very strong, 2 to 3 min apart lasting 45 to 90 sec
What is fetal attitude? What fetal attitude is optimal for birth?
degree of flexion or extension of fetal head in cephalic presentation
vertex: most common and normal presentation, fetal dimension is smallest, chin tucked to chest, body curled into ball
What is baseline FHR?
average over 10 minutes, rounded to nearest 5 bpm
What is variability FHR?
beat to beat fluctuations in baseline FHR that are irregular in amplitude and frequency, should be 6-25bpm
What is acceleration FHR?
transient increase in FHR from baseline rise of >15bpm lasting >15sec (at >32 wks)
strong predictor of adequate fetal oxygenation and acid-base status
What is early deceleration? Cause? Interpretation? Interventions?
category 1
uniform, gradual decrease and return to baseline
onset, nadir, and recovery from deceleration show an inverse relationship with beginning, peak, and ending of uterine contraction
cause: head compression causing vagal stimulation as it pushes through pelvis
no intervention needed, continue monitoring, good indication of movement of fetus through labor
What is variable deceleration? Cause? Interpretation? Interventions?
category 2
abrupt decrease in FHR from baseline
independent of contraction
shape is usually V or W, varies
cause = umbilical cord compression d/t loss of amniotic fluid
indeterminant: not predictive of abnormal fetal acid-base status
nursing intervention: reposition patient, evaluation and continue monitoring
What is late deceleration? Cause? Interpretation? Intervention?
category 3
uniform shape in FHR late in timing with nadir occurring after peak of uterine contraction, at the peak of contraction there is vasoconstriction
cause: uteroplacental insufficiency (decreased blood/oxygen supply to fetus during uterine contraction d/t maternal hypotension, placental previa, placenta abruption, uterine hyperstimulation w/ oxytocin, preeclampsia, DM, post term)
reflects decreased oxygenation to fetus causing it to become acidotic
nursing intervention: change position to left lateral side lying, fluid bolus, d/c oxytocin, O2, prepare for vaginal birth or C-section
What is nadir?
lower point of FHR at the peak of uterine contraction
What is prolonged deceleration? Cause? Nursing intervention?
visually apparent FHR decrease below baseline, decrease of 15bpm or more lasting 2 minutes or more with less than 10 min from onset to return to baseline
causes: uteroplacental insufficiency, umbilical cord prolapse, maternal hypotension, fetal congenital heart block, anesthetic medications
nursing intervention: d/c oxytocin, side-lying positon, O2, tocolytic meds
What are the phases of labor?
first stage: 0cm to complete cervical dilation (10cm), true labor, longest of all stages, phases: latent (longest, cervix variable dilation) and active (steady cervical changes)
second stage: cervix 10cm dilation to birth of fetus, phases: latent (individual may not perceive need to bear down, contraction pattern may be spread out) and active (individual will be bearing down, Ferguson’s reflex (cervix and upper portion of vagina begin getting sensation of pressure, can cause spontaneous breath holding)
third stage: birth to placental separation, passive process (pt will not need to bear down), placental separation and expulsion
fourth stage: 1 to 4 hours antepartum
What are some non-pharmacologic interventions for labor pain relief?
sacral counterpressure (to aid in backpain d/t fetal back is pushing against maternal back)
massage
therapeutic touch
heat and cold
relaxation
imagery
effleurage: rubbing in purposeful motion
acupuncture
hypnosis
biofeedback
What are systemic analgesics used for? Examples? Side effects?
relief of moderate to severe pain
morphine, fentanyl, butorphanol
n/v puritus, respiratory depression, maternal hypotension, if given too close to time of birth fetus will have to use its liver to breakdown the narcotic which could send it into respiratory distress
What is epidural block?
continuous infusion or intermittent injection usually started when dilation >5cm to not slow labor down
What is a pudendal block?
intrathecal analgesia usually for 2nd stage, episiotomy, or operative vaginal birth
placed into pudendal nerve bilaterally to block pain to cervix and bladder
What are neuraxial analgesia technique? Side effects? Nursing interventions? Advantages?
use of analgesic continuously or intermittently into epidural or intrathecal space
antiemetic (used in combo with opioids to decreasee n/v), respiratory depression, maternal hypotension
nursing intervention: safety (fall risk), assess for n/v, monitor maternal vital signs and allergic response
advantages: usually safe and effective pain relief, sometimes speeds labor
How is an epidural block monitored?
administer IV fluid bolus to prevent hypotension before give block (as long as no preeclampsia)
monitor maternal hypotension and respiratory depression
assist with position (left-lateral side lying)
coach patient on pushing efforts
assess for bladder distention
monitor sensation and motor control
What is spinal blood patch?
treatment done to counter act complications of epidural block uses blood to stop the leaking of CSF through dural holes
What is spontaneous rupture of membranes? Nursing intervention?
can occur at any time but most likely during transition, spontaneous labor will occur in majority of women within 24 hours (if it takes too long there can be complications and infection)
first priority is to listen to FHR for decelerations
How is spontaneous rupture of membranes assessed?
watery, clear, pale (put down white towel to see if there’s any discolorations and if it’s green could be meconium (an indication of fetal distress))
no foul odor
volume:500-1200mL
nitrazine to confirm it is alkaline (turns dark blue, if it turns yellow it could be acidic)
amnisure and/or ferning test
What is bishop score? Indications? What scores would indicate ready for induction for multiparous and nulliparous?
evaluation of cervix to determine readiness for induction based on cervical exam
any medical condition that threatens well-being
multiparous (had multigestations) >8
nulliparous: 10
What is cervical ripening?
ripening gets cervix ready for labor by softening, dilation, and effacement
What are nonpharmacologic methods for cervical ripening?
herbal agents: primrose oil, black haw, black and blue cohosh, red raspberry leaves, caster oil
sexual intercourse with breast stimulation: natural prostaglandins promote release of oxytocin
What is trial of labor? Indications? Contraindications?
ability to have a vaginal birth after previous cesarean section
indication: low transverse uterine incision, no other uterine scars or hx of previous rupture, adequate pelvis
contraindication: large for gestational age, malpresentation, cephalopelvic disporportion, previous classical vertical uterine incision, previous transfundal uterine surgery (myomectomy), cervical ripening agents are contraindicated due to increase chance of uterine rupture
What are indications for artificial rupture of amniotic membranes? Nursing interventions?
slow labor progression
induction of labor
vertex and engaged
amnioinfusion needed for cord compression
monitor FHR prior to an immediately following AROM
assess color, odor, consistency of fluid
temperature Q2H
comfort measures for leaking of fluid
What are nursing interventions for cord prolapse?
an emergency
call for help immediately and notify provicer
lift presenting part away from cord to relieve pressure on cord
change patient position to knee-chest
cover cord with warm, sterile saline soaked gauze
O2, IV fluid bolus
prepare for immediate birth
What is shoulder dystocia? What are the signs? What can it cause?
an emergency where the fetal neck is compressed by maternal pelvis d/t shoulders being wider than head
delayed fetal descent, turtling (when the pregnant person pushes the fetus moves but when the pregnant person relaxes the fetus moves back)
fetal anoxia, asphyxia, increased ICP and brain damage (5min = hypoxemia and acidosis, 6min or more = permanent brain and organ damage),
What are the types of perineal lacerations?
first degree: skin of perineum
second degree: skin and muscles into perineum
third degree: skin, muscles, perineum, extrenal anal sphincter muscle
fourth degree: skin, muscles, anal sphincter, anterior rectal wall
What are indications for assisted birth?
postterm fetus >42wks
preelcampsia/eclampsia
prolonged rupture of membranes >24hrs
maternal medical conditions (Rh-isoimmunization, DM, pulmonary, cardiac, or renal disease, gestational HTN)
fetal demise
chorioamnnionitis
hx of precipitous labor or how far the pt lives from hospital
What nursing cares are done during the first stage of labor?
ask about childbirth plan
check lab results/special tests previously done
complete physical assessment: fundal height, uterine activity, status of membranes, cervical dilation, contraction, effacement, FHR, position, station, pain
orient to room
orient to pain management
what changes to expect
vaginal examination
encourage ambulation, position changes, and support from support person
What nursing cares are done during the second stage of labor
assessment: contraction (frequency, duration, intensity), maternal VS (coping), FHT, amniotic fluid status (color, volume), support of partner, watch for bulging perineum = fetal head ready to crown
interventions: continuous support, set up birthing equipment, prepare for neonatal resuscitation, assist with birth, provide immediate care of newborn, as crowning occurs put warm compress for support with slight resistance to avoid sheering force on perineum and make the process smooth and gentle to avoid perineal trauma
What nursing cares are done during the third stage of labor?
assess: placental separation, fundal massage (after placenta is expelled to ensure bleeding is controlled), examine placenta to ensure it is all there, determine est. blood loss, exam of placenta and fetal membranes, perineal lacerations, explaining/performing assessments of mother and neonate
interventions: placing neonate on mom’s chest, establish breastfeeding within first hr of birth, provide warmth, give oxytocin, assist women into comfortable position, care for perineum (cleaning and ice), cord management (assess for vessels, obtain cord blood)
What are the ways of pushing?
directed pushing: interferes with o2 exchange between mother and fetus d/t forced bearing down and compression, can lead to damage to pelvic floor and maternal exhaustion, closed glottis (deep breath and hold for 10s, repeat 3-4x each contraction)
spontaneous pushing: recommended, urge to bear down and use own breathing pattern (become in tune with ferguson’s reflex), open glottis (instinctively hold breath as needed for about 6s while bearing down), more sense of control
What are three signs of placental separation
umbilical cord lengthens
fundus rises in abdomen (uterus becomes more firm and globular)
bleeding may increase
Why and when is pitocin given?
aids uterine contraction after placenta is expelled
given right after fetal birth to allow for it start working after placenta is expelled
Why is newborn placed on chest right after birth?
increases secretion of oxytocin
ensures warmth of fetus
What is nifedipine?
tocolytic (relax uterine muscle) for preterm labor, very commonly used
worried about hypotension
What is magnesium sulfate? Side effects? Signs of toxicity?
tocolytic (relax uterine muscle) for preterm labor
facial flushing, fatigue, hypotension
need to monitor for toxicity: depressed respiratory rate, decreased urinary output, pulmonary edema
What is hypertonic uterus? When does it occur?
uterus never fully relaxes could compromise the fetus, contractions are excessively frequent, uncoordinated, strong intensity
rarely occurs due to spontaneous labor
artifical prostaglandins
things done to induce labor
How do you count number contractions on a strip?
start at the beginning of contraction and end of the second
What are risk factors of using chemical ripening agents for cervix?
fetal distress, fetal tachy systole
What is induction versus augmentation?
induction: stimulating contractions via medical or surgical means, initiated d/t medical complications
augmentation: enhancing ineffective contractions after labor has begun (ex/ AROM)
