Final Flashcards

Question

Methods of Contraception: Combo estrogen and progesterone OC Type Advantages (3) Disadvantages (3)

Answer 1

Type: hormonal Advantages - Suppresses ovulation - Reduces risk for endometrial and ovarian cancer - reduce risk of benign breast disease, anemia, acne, painful menses Disadvantages - prescription only - side effects - must be taken daily

Answer 2

Type: hormonal Advantages - Can be used during lactation Disadvantages - prescription only - side effects - One pill a day at same time each day

Answer 3

Type: hormonal Advantages - Can be used during lactation - One injection, 4 times a yr. - stops menses Disadvantages - Prescription only - Delayed fertility return (1 yr) - shot every 12 wks (compliance needed)

Answer 4

Type: hormonal Advantages - New patch applied each week for 3 weeks then removes for 1 week (greater compliance) - Usually applied anywhere but the breast Disadvantages - Prescription only - Less effective for obese women - Need backup if patch removed more than 24 hrs

Answer 5

Type: hormonal Advantages - Ring inserted in vagina for 3 weeks then removed one week - May be left in 28 days w/ immediate replacement after removal Disadvantages - Prescription only - may cause vaginal irritation or discharge

Answer 6

Type: hormonal Advantages - Reduces risk of pregnancy from one unprotected coitus but does not induce abortion - OTC for women over 17 yrs. (prescription for younger) - Suppresses ovulation - only contraindication is confirmed pregnancy Disadvantages - Cannot be regular birth control - Must take within 72-120 hrs of intercourse

Answer 7

Advantages - Can be placed during postpartum period and during lactation - Highly effective (3-5yrs for hormonal, up to 10 yrs for copper) - Copper can be emergency contraceptive within 7 days of intercourse - Useful for teens or women with contraindications to other hormonal methods - Quick return to fertility - Often stops menses

Answer 8

Type: Long-acting reversible contraceptive; hormonal but progestin-only Advantages - Minimal discomfort once placed - Can be placed during postpartum period and during lactation - Lasts several years (up to 3 yrs) - More effective than sterilization Disadvantages - Must be removed eventually - minor surgical procedure - irregular menses bleeding

Answer 9

Type: sterilization Advantages - Highly effective - safe and easy recovery Disadvantages - Discomfort for 2-3 days - Need another contraceptive for 2 days until sperm tests indicate procedure success - Difficult to reverse

Answer 10

Type: sterilization Advantages - Highly effective - Immediately effective (unless tubal occlusion then 3 months till effective) Disadvantages - Surgical procedure - Bleeding at incision site - Difficult to reverse

Answer 11

- Indication: medical abortion within 70 days of gestation; takes days to weeks to be complete - Side effects: heavy bleeding, severe cramping, nv, fever, chills - Precautions: not recommended with ectopic pregnancy, IUD in place, long-term corticosteroid use or adrenal failure, anticoagulant therapy, porphyria

Answer 12

- uterine fibroids - congenital uterine anomalies - introital scaring - asthma (acts as weak bronchodilatory

Answer 13

- heavy bleeding (>2 maxi pads soaked in an hr. for 2 hrs straight) - severe abdominal or back pain—may be products of conception retained - foul-smelling discharge - fever (above 100.4 F, 38 C)-- infection

Answer 14

Suction curettage/aspiration - most common abortion - Only for first trimester - Cervix is dilated and thin plastic tube inserted in uterus and suctions pregnancy out Dilation and evacuation - 2nd trimester after 13 weeks of pregnancy - Fewer complications than medical abortion - Anesthesia is used then fetus is removed through vagina then suction removes excess tissue

Answer 15

- Mammograms (annual from age 40 yrs or 10 yrs prior based on fam risk) - MRI screening and mammogram for high-risk w/ known BRACA1 or BRACA2 mutation or family hx - Monthly self-breast exam (done after menses starting at puberty) - Clinical breast exam (annual from 40 yrs)

Answer 16

- lump (usually in duct vs lobe, bump, hard lump; may be benign) - skin dimpling - change in skin color or texture (red, sores, growing vein) - nipple changes (inversion, pulling inward, crust) - clear or bloody fluid leaking out nipple (Spontaneous (needs further eval); Elicited (normal if milky color and nonbloody) - Pain (usually from hormonal changes i.e., perimenopause OR cysts)

Answer 17

- Pap tests every 3 years for 21-29 yrs. - Pap test and HPV test every 5 years for 30-65 yrs. - Women > 65 can stop cervical cancer screening if they have not had any precancerous cells found in the previous 10 years. - Women w/ total hysterectomy can stop screening unless hysterectomy due to cervical precancer or cancer.

Answer 18

- Colonoscopy every 10 years for 50-75 then based on risk - Eye exam at 40 yrs. then every 2-4 yrs, 1-2 yrs. for 65+ - Hearing test every 10 years till 50 then every 3 year

Answer 19

- Blood pressure every 1-2 yrs - Type 2 diabetes yearly if overweight or over 45 yrs - DXA scan (for osteoporosis) and Cholesterol based on hx - STI tests yearly if sexually active and under 24, if new or multiple partners, or pregnant

Answer 20

- typically when menopausal signs and symptoms begin - lasts 4-8 yrs - Pregnancy possible in this period - Quality and quantity of ova decline gradually in late thirties leading to decreased estrogen and progesterone - may have dysfunctional uterine bleeding/endometrial hyperplasia in obese

Answer 21

- 12 months after last menstrual period - natural phase of life

Answer 22

- Irregular periods (longer or shorter cycles, change in flow; may be anovulatory) - Hot flashes and night sweats due to vasomotor response to hormone levels - Sexual dysfunction (decreased libido, dyspareunia (due to vaginal dryness), vaginal atrophy (thin and dry)) - Weight gain - Dry skin and nails; loss of skin elasticity - Food cravings - irregular heartbeat or palpitations - Psychological signs: mood swings, anxiety, lethargy, panic attacks, forgetfulness, difficulty coping, depression, irritability

Answer 23

* Avoid alcohol, hot or spicy foods, caffeine, or stress * Dress in layers and use fans * Avoid wool or synthetic clothing * Low-dose antidepressants (fluoxetine), antiseizure (gabapentin), antihypertensive (clonidine)

Answer 24

* Sleep in cotton nightwear and on cotton linen * Sleep in cool room with fan * Take cool shower prior to bed

Answer 25

* Regular bedtime (get 8 hrs) * No TV, cell phone, computer use in bed * Keep room dark, quiet, and cool * Wear loose fitting garments * Eat dinner early (balanced diet and exercise * No alcohol or caffeine close to bedtime

Answer 26

* Use water-based lubricant (never oil based) * Vaginal moisturizers and Estrogen vaginal cream * Flaxseeds and soy flour decrease vaginal dryness

Answer 27

Two types - Estrogen-only for women w/o uterus - Estrogen and progesterone for women w/ uterus to reduce risk of endometrial cancer Benefits - relieve vasomotor symptoms (night sweats, flushing) and most other symptoms - osteoporosis prevention - decrease risk for colon cancer Risks - increased breast cancer risk - increased CVD, DVT risks

Answer 28

- hx of DVT, pulmonary emboli, CAD - uncontrolled hypertension - liver disease - clotting disorders - active cancer - smoker (>35 yrs.) - undiagnosed abnormal bleeding - migraines with aura - pregnancy

Answer 29

- nausea, vomiting - headache - spotting - weight gain (edema) - breast tenderness - chloasma - increased risk for clotting, heart disease, stroke - mood swings (change in libido)

Answer 30

- weight gain - bleeding abnormalities - decreased bone density - headache - mood changes - breast tenderness

Answer 31

- when on menses - if started at any other point, use condom for 2 weeks

Answer 32

- Hepatic mass or abdominal RUQ pain - Severe pains in chest, left arm, neck - Headache, Unilateral numbness, weakness, tingling - Hemoptysis - Eye problems- Loss of vision, proptosis, diplopia, papilledema - Severe pains, tenderness, swelling, warmth in legs - Slurring of speech

Answer 33

Type: Long-acting reversible contraceptive Disadvantages - Low risk for uterine perforation - Contraindicated w/ pelvic inflammatory disease within 3 months - preferred for monogamous women - Increased cramping and bleeding in 1st few cycles

Answer 34

- women who smoke - women w/ shortened cycles (q21 days) - women who have surgical removal or medical ablation of the ovaries (hysterectomy) - Premature ovarian failure if menopause prior to age 40

Answer 35

- Increasing age (more common around menopause) - BRCA1 or BRCA 2 defects - Family hx of breast cancer (1st degree) - Personal hx of breast cancer in at least one breast - Dense breasts - Excess exposure to estrogen through early onset of menarche or late menopause

Answer 36

- Mammogram(x-ray): give info on size and character of mass - Ultrasound: determine if area of concern is fluid-filled cyst or solid mass - MRI: differentiates benign from malignant tissue - Biopsy: differentiate benign from malignant (ideal test w/ fine-needle aspiration)

Answer 37

- usually 3 to 4 weeks after surgery Types * External radiation: machine aims radiation toward the tumor (5 days a week for 5-6 wks.) * Internal radiation (mammo site): radioactive substance sealed in needles, seeds, wires, or a catheter placed directly into or near the tumor. (BID for 5 days i.e., 10 sessions)

Answer 38

Indication: usually used for advanced metastatic cancer or prevention of recurrence of cancer after Oncotype DX test done to determine if likely to benefit Side effects: NVD, myelosuppression (anemia, thrombocytopenia, neutropenia), loss of appetite, constipation, hair loss, nail changes, mouth sores (mucositis and stomatitis), fatigue

Answer 39

- Women who did not breastfeed - Exposure to head or chest radiation - Excess weight/ obesity or sedentary lifestyle - Excess estrogen exposure through use of hormone therapy(including OCs) - Excessive use of alcohol - Exposure to diethylstilbestrol (DES)

Answer 40

Best for dense, fibroglandular breast, scar tissue from previous surgery, or new tumors in women w/ previous lumpectomy

Answer 41

- Primary cause is HPV (most common STI) - Early onset of sexual activity (before age 16) - Cigarette smoking - Immunocompromised - Multiple sex partners - In utero exposure to DES - Use of oral contraception for 5 or more years - Multiparity (3 or more)

Answer 42

- Pap smear for early screening (If abnormal Pap test or HPV screening, further eval done) - Colposcopy (visual exam w/ biopsy) = definitive diagnosis by APRN or OB-GYN

Answer 43

- typically, slow growing - Begins with dysplasia (precancerous condition that is treatable w/ cryotherapy) - If dysplasia not treated, cervical cancer develops and metastasize

Answer 44

- None in early stage - Vaginal discharge (watery, pink, brown, bloody, or foul-smelling) - Leaking of urine or feces from the vagina - Abnormal vaginal or uterine bleeding b/w periods, after intercourse, or after menopause - Dyspareunia (pain w/ intercourse) - Loss of appetite or weight - Fatigue - Pelvic, back, or leg pain

Answer 45

- LEEP (burn off cervix; may leave scar tissue which can impair fertility) - Conization (cervical cone biopsy) - Cryosurgery - Total or radical hysterectomy - Radiation - Chemotherapy (if metastasized or recurrence) - Targeted therapy (Angiogenesis inhibitors (bevacizumab)) for advanced cervical cancer – adjuvant to chemo)

Answer 46

- Endocrine (Pituitary diseases or tumors, hypothalamic diseases, Low levels of LH, FSH, testosterone or high levels of estrogen and cortisol decrease sperm production) - Gonadotoxins (facts that interfere with spermatogenesis) - Sperm antibodies (produce immune reaction and decrease sperm motility; seen in vasectomy reversal or after testicular trauma)-- not common) - Sperm transport factor (missing or blocked structures in male anatomy that interfere w/ sperm transport, i.e. vasectomy, prostatectomy, inguinal hernia, congenital absence of vas deferens) - Intercourse disorders i.e., erectile dysfunction, ejaculatory dysfunction (retrograde or premature ejaculation), anatomical abnormalities (hypospadias, varicocle, torsion), or psychosocial reasons

Answer 47

- Drugs (chemotherapeutics, CCBs, heroin, alcohol, marijuana, smoking) - Infections (prostatitis, STIs, mumps after puberty) - Systemic illness - Prolonged heat exposure to testes (hot tubs, tight underwear, frequent bike riding) - Pesticides - Radiation to pelvic region

Answer 48

- Ovulatory dysfunction (anovulation or inconsistent ovulation) - Tubal and pelvic factors (Damage to fallopian tubes due to previous PID or endometriosis; Uterine fibroids, benign growths of muscular wall of uterus narrow uterine cavity -> spontaneous abortion) - Cervical mucus factors (interfere w/ ability of sperm to enter or survive in uterus)-- Infection; Cervical surgery (cryotherapy- treats cervical dysplasia)

Answer 49

- Infertility: inability to conceive after 12 months (6 months if >35) of unprotected sexual intercourse - Most effective way to get pregnant: sex every other day after menses OR when you know you’re fertile - women diagnosed by obgyn or repro endocrinologist; urologist diagnoses men

Answer 50

- STI screening - Lab tests for hormonal levels (TSH, FSH, LH, anti-Mullerian hormone (AMH), testosterone) - Semen analysis and penetration assay (may need multiple; cheap) - LH surge test (ovulation predictor test b-c LH surges 36 hrs before ovulation) - Ovarian reserve test - Sonohysterogram or hysteroscopy evaluates uterus - Hysterosalpingogram (HST) - scrotal ultrasound

Answer 51

Purpose: determine size of remaining egg reserve for Infertility Process - On day 3 of menstrual cycle, blood drawn to evaluate levels of FSH, estradiol, and AMH - On same day, transvaginal ultrasound done to assess ovarian volume and antral follicle count

Answer 52

Purpose: radiological exam with dye to give info on endocervical canal, uterine cavity, and fallopian tubes for infertility analysis Useful to detects tubal problems such as adhesions, occlusions, or uterine abnormalities (fibroids, bicornate uterus, and uterine fistulas)

Answer 53

Purpose: analyze volume, sperm concentration, motility, morphology, WBC count, immunobead, and mixed agglutination reaction test to determine fertility Process - Man abstains for 2-3 days then masturbates to provide semen sample - Specimen provided at site of testing or within 1 hr. of collection at home

Answer 54

- stress reduction - improved health (weight control, daily exercise, proper nutrition) - Abstinence from alcohol, nicotine, recreational drugs

Answer 55

* Clomiphene citrate (very high success rate) * Letrozole-ovulation induction * Injectable gonadotropins (HCG, FSH) * Gonadotropin-releasing hormone [GnRH] pump * Progesterone * Bromocriptine * Metformin- restores cyclic ovulation and reduces insulin levels

Answer 56

Indication: stimulate ovulation; high success rate Side effects (generally safe): hot flashes, blurry vision, breast discomfort, headaches, insomnia, bloating, nausea, vaginal dryness

Answer 57

- Hormonal therapy for endocrine factors - Corticosteroids to decrease sperm antibodies - Repair of varicocele or inguinal hernia to facilitate sperm transport - Transurethral resection of ejaculatory ducts to treat disorders related to intercourse

Answer 58

- Drug therapy, lifestyle modifications, or surgery to resolve cause (if known) - Adoption - Gestational surrogate (another women carries baby) - cryopreservation (freezing eggs) - Assisted reproductive technologies (ART): surgical removal of oocytes and combination of them w/ sperm in lab (many ethical questions)

Answer 59

- hormonal imbalances - hyper or hypothyroidism - high prolactin - PCOS - premature ovarian failure (menopause before 40 yrs.) - Eating disorders - Chronic conditions (diabetes, obesity, autoimmune) - excessive exercise

Answer 60

- Mutated BRCA genes found by genetic testing - Strong family history (such as breast cancer in several close relatives) - Lobular carcinoma in situ (LCIS) detected on biopsy - Previous cancer in one breast (especially in someone with a strong family history)

Answer 61

Risk factors - age 16, 18, 45 (common in sexually active but usually reverts in 6-12 months) - cigarette smoking Symptoms: genital wart lesion on skin Prevention of new disease (not treatment): Gardasil – HPV vaccine – from age 11-26 in US x2 doses if <15, 3 doses if >15; condom use

Answer 62

- sperm and egg for fertilization (hormonal balance, adequate sperm # and motility to travel 12-24 hrs to ova) - cervix and uterus for housing (cervix that is open enough for sperm to enter; Uterus must be receptive to implantation) - fallopian tubes for transportation ( must be open and able to allow transfer of the ovum)

Answer 63

Side effects: diarrhea, skin changes (redness or bruising), fatigue, fertility issues, urinary and bladder issues, breast pain, infection, breakdown of fatty tissue in the breast, fracture of the ribs (rare), diarrhea

Answer 64

Sloughing off and expulsion of endometrial tissue if no pregnancy)

Answer 65

- After ovulation until menstruation onset - Endometrium thickens more (primary hormone is progesterone) * If pregnancy occurs, endometrium develops more and secretes glycogen (energy source for blastocyst) * If pregnancy does not occur, corpus luteum degrades and endometrium degenerates

Answer 66

Length: 24-36 days (average is 28; but varies cycle to cycle) Duration: 3-6 days (average 5 days) Total Blood loss: 20-80 mL (average 50 mL) Regularity impacted by stress, exercise, nutrition

Answer 67

Action: oxygenated fatty acids; hormones Effects - Ovulation (ovum trapped if prostaglandin does not increase w/ LH surge) - Fertility - Changes in cervix and cervical mucus - Tubal and uterine motility - Sloughing of endometrium (menstruation) - Onset of abortion (spontaneous and induced) - Onset of labor (term and preterm)

Answer 68

- Basal body temperature: drops 1 day (< 37 C) prior to ovulation then rises 1 degree at ovulation for 10 -12 days - Spinnbarkeit: Change in cervical mucus (abundant, watery, clear, more alkaline, ferns under microscope) - Mittleschmerz- localized abdominal pain that coincides with ovulation

Answer 69

Obtaining a family history going back 3 generations on both maternal and paternal sides (most other genetic tests are not done unless risk factors)

Answer 70

- chromosomal abnormalities (25% of first trimester losses) - Prior pregnancy loss - Advanced maternal age (> 35 yrs) - Endocrine abnormalities (DM, luteal phase defects) - Drug use or environmental toxins - Autoimmune disorders (SLE) - Infections - Uterine or cervical abnormalities - black woman

Answer 71

- amniocentesis (cells from amniotic fluid)- risk for miscarriage - cells from fetal blood - cells from fetal skin - CVS-Chorionic Villi sampling (sample from placenta b/w 9-11 weeks)

Answer 72

Autosomal Dominant-If one parent carries the gene, 50% chance of child being affected. Autosomal Recessive Inheritance - both parents must be carriers and both pass on abnormal gene to child for trait, disorder, or disease to be present (1 in 4 chance each pregnancy)

Answer 73

- maternal age > 35 yrs by due date (esp trisomy 21) - paternal age 50 or older - History of miscarriage or stillbirth - Diabetes in mom (not fam hx) - Family history of birth defects/genetic diseases (Huntington's, Down Syndrome, Muscular dystrophy, hemophilia, cystic fibrosis, intellectual disability) - Family history of hypercholesterolemia and PKU

Answer 74

Ovulation occurs -> mature ovum enters a patent fallopian tube (fimbriae of fallopian tube capture ovum and cilia propel ovum to uterus) Sperm cells are deposited in vagina & travel to fallopian tube surviving 48 hrs (max 5 days) One sperm cell must penetrate ovum usually in outer third of fallopian tube (ampulla) within 24 hours of ovulation.

Answer 75

Zygote - secretes BhCG to signal pregnancy - has 46 chromosome - single fertilized oocyte Morula - develops by day 3 - 16-cell sphere - outer cells secrete fluid creating blastocyst

Answer 76

- Week 3 through 8 of pregnancy - Period of organogenesis - highest risk of structural damage by teratogens (chemicals, drugs, viruses, fever) - rapid hyperplasia of fetal cells

Answer 77

Total Pregnancy: 40 weeks, 280 days Conception: 2 weeks after 1st day of menstrual cycle 1st trimester: 1st day of LMP through 13 weeks 2nd trimester: Week 14 through 26 3rd trimester: Week 27 through 40+

Answer 78

Function - maintain body temp - barrier for infection - musculoskeletal development (freedom for movement and symmetrical growth via prevention of membrane tangling) - fetal lung development (swallow fluid) - electrolyte balance (urinates around 11 wks) - cushion

Answer 79

- 9 weeks to end of pregnancy - refinement of structure and function - viability (ability to live outside uterus, 22-25 weeks based on CNS and lung maturity)

Answer 80

Function: Supplies the embryo with maternal nutrients and oxygen Composition - Wharton's jelly (CT cushions vessels from compression) -2 arteries (carry deoxygenated blood from embryo to placenta), 1 vein (carry oxygenated blood from placenta to embryo- larger than 2 arteries) Problems - thin cord - short cord - cord w/ one artery and one vein (risk for cardiac or vascular anomaly)

Answer 81

Composition - Chorionic villus (contains fetal blood vessels and imbeds in decidua basalis) - intervillous space (contains maternal blood) - Cell layer (prevents mixing of maternal and fetal blood) Problems - small placenta (poorly nourished and oxygenated child) - teratogens can cross placenta (C, D, X drugs, live vaccines, viruses (rubella, cytomegalovirus)

Answer 82

Yolk sac - Becomes primitive digestive system Endometrium - Decidua parietalis (lines uterine cavity) - Decidua basalis (maternal part of placenta; divided in cotyledons/lobes; hemorrhage here usually for miscarriage)

Answer 83

Secreted from the anterior pituitary Stimulates growth of the ovarian follicles stimulates the follicles to secrete estrogen. Stimulates sperm production Decreases in pregnancy (Amenorrhea)

Answer 84

- Secreted from the follicle cells, - promotes the maturation of the ovum - Stimulates enlargement of breasts and uterus. - Decreases maternal use of insulin. - Increases vascularity - responsible for hyperpigmentation

Answer 85

Secreted from the pituitary gland Stimulates testosterone production

Answer 86

- Facilitates implantation by thickening and making endometrium more vascular - decreases uterine contractility to maintain pregnancy by relaxing smooth muscles

Answer 87

- produced by fertilized ovum and chorionic villi - Stimulates corpus luteum so it will secrete estrogen and progesterone until placenta takes over - Pregnancy tests detect this hormone in 1st trimester

Answer 88

Prepares breast for lactation

Answer 89

- Stimulates uterine contractions - stimulates milk ejection from breasts (milk let-down or ejection reflex)

Answer 90

- urine in amniotic fluid - male/female anatomy (9-12 weeks)

Answer 91

- Placenta complete - organ systems complete - thumb sucking - somersaults - heart tone heard on doppler ( heart forms in week 3 and beats at day 17)

Answer 92

- meconium in bowel - sucking motions - skin transparent

Answer 93

- hearing develops - quickening - vernix caseosa and lanugo covers body - sleep/wake cycles - insulin produced - brown fat develops

Answer 94

- Lungs allow gas exchange) - hair on head - eyes open and close - senses develop (taste buds, process sounds) - subQ fat develops

Answer 95

- rapid brain growth - hiccups - vernix caseosa = thick - Lecithin (L) present (lungs begin producing surfactant)

Answer 96

- bones fully developed - increased subQ fat - Lecithin/sphingomyelin (L/S) ratio (1.2:1) - enough surfactant to increase survival

Answer 97

- decreased amniotic fluid - Lanugo disappears - Lecithin/sphingomyelin (L/S) ratio > 2:1 (lungs mature)

Answer 98

Ductus venosus - Connects umbilical vein to inferior vena cava - Allows most of oxygenated blood to enter right atrium Foramen ovale - may not fully close till 3 months of age - Opening b/w right and left atria which shunts oxygenated blood right-to-left Ductus arteriosus -lungs do not function for gas exchange; ductus arteriosus (b/w aorta and pulmonary artery) used to bypass lungs - Majority of oxygenated blood shunted from left atria to aorta; small amount to lungs - Constricts after delivery due to higher blood oxygen levels and prostaglandins

Answer 99

- considered full term at 38 weeks - Hepatic (enough iron for 5 months post birth)

Answer 100

- ionizing radiation (>10 rads) or radioiodine - Tetracycline - carbamazepine (NTDs) - ACE inhibitors (renal tubular dysplasia, IUGR) - warfarin (spontaneous abortion, hemorrhage)

Answer 101

- offered to all expectant women Types - Multiple Marker Screen (Triple, Quad or Penta Screen)– during 2nd trimester for Trisomy 21, Trisomy 18, NTD - Cell free DNA (cfDNA) blood test for gender, trisomy 21 and 18 but not NTD Results (quad screen) - Alpha-Fetoprotein (AFP) is high = increased risk for NTDs - Low AFP levels = increased risk for Trisomy 21 (Down Syndrome)

Answer 102

- offered to high risk OR positive screening Types - Chorionic Villi Sampling (CVS) at 11-13 weeks - Amniocentesis at 14-16 weeks (results in 2 weeks) - Percutaneous Umbilical Cord Sampling (PUBS)- assess for fetal anemia, isoimmunization; diagnosis genetic disorders

Answer 103

- Toxoplasmosis (protozoan)- fetal demise, blindness, mental retardation - Cytomegalovirus- hydrocephaly, microcephaly, cerebral calcification, mental retardation, hearing loss - Syphilis (RPR)- skin, bone, or teeth defects; fetal demise - Varicella- hypoplasia of hands and feet, blindness or cataracts, mental retardation - Zika - microcephaly, blindness, hearing defects - HSV - Influenza - HIV - Chlamydia - HPV - Rubella

Answer 104

- any subjective symptoms reported by patient - Amenorrhea - Nausea/vomiting (weeks 2-12) - Breast changes (sore, enlarged) - wks 2-3 - Fatigue (1st trimester) - Increased Urinary frequency (pressure of enlarged uterus) - Quickening (sensation of fetal movement around 18-20 wks)

Answer 105

- Chadwick’s sign (bluish-purple cervix) - 6-8 wks - Goodell’s sign (cervix softens w/ leukorrhea) - 8 weeks - Hegar’s sign (softened lower uterine segment) - 6 weeks - Uterine growth - Skin hyperpigmentation (chloasma, linea nigra) - Ballottement (tap of examiner finger causes fetus to bounce in amniotic fluid) - 16-18 wks - Positive pregnancy test (hCG blood, urine or home test) - detects anywhere from 1 week before missed period to 4 weeks gestation

Answer 106

- Auscultation of fetal heart (normal: 110-160 bpm) - 10-12 wks - Observation and palpation of fetal movement by provider - 20 wks - Sonographic visualization (cardiac movement or gestational sac) - 4-8 wks

Answer 107

- 1st day of LMP + 7 days - 3 months = EDD - inaccurate if irregular cycles or cycles > 28 days

Answer 108

Gravida: total # of times woman has been pregnant (INCLUDES CURRENT PREGNANCY and no regard to # of fetus) Term: # of births after 37 weeks’ gestation whether live or stillbirths ( twins= 1 delivery) Preterm: number of Preterm deliveries (b/w 20 weeks & 1 day to 36 weeks & 6 days) Abortion: number of Abortions (either spontaneous/miscarriage or induced) before 20 weeks’ gestation Living: number of children currently Living (not including adopted or step children)

Answer 109

- striae (thighs, breast, buttocks, abdomen--usually darkish gray) - chloasma (mask of pregnancy, brownish pigmentation on face) - linea nigra (dark line on abdomen) - acne (due to increased estrogen, progesterone, sebaceous glands secretions) - Angiomas (spider nevi) - Palmar erythema (pinkish-red mottling over palms of hands; red fingers) - Vasomotor instability (hot flashes, flushing, alt hot and cold, increased perspiration)

Answer 110

- tenderness - enlarged and darkened areola - colostrum @ 16 weeks

Answer 111

- heart shifts up and to the left - systolic murmur and S3 - 45% increase in blood volume - anemia (physiologic b-c hemodilution of high volume more than polycythemia AND iron-deficiency from fetal demand) - high WBC (no infection) - decreased systemic vascular resistance - increased circulation (10-20 bpm increase) - supine hypotension ( enlarged uterus compresses inferior vena cava so reduced blood flow to right atrium; decreased CO, BP, GFR, and urine output - varicose veins and venous stasis (incl. hemorrhoids - hypercoagulability (increased fibrin and decreased inhibition of coagulation)- low platelets

Answer 112

- increased nasal congestion and epistaxis - upward displacement of diaphragm (dyspnea, decreased capacity) - increased oxygen needs ( high RR, increased inspiratory capacity and decreased expiratory volume) - slight hyperventilation (light respiratory alkalosis)

Answer 113

- increased UTI risk due to dripping - delayed emptying times (urinary stasis b-c poor tone) - Hyperemia (increased renal blood flow b-c increased CO and blood volume)-- decreased in 3rd trimester - glycosuria and proteinuria (b-c exceeds tubal reabsorption threshold)

Answer 114

- NV due to HcG (better by 16 weeks) - lost of esophageal tone (heartburn) - delayed emptying (normal may be BM q3days) - displaced intestines (bloating, flatulence, cramping, pelvic heaviness, constipation) - gingivitis/bleeding gums r/t vascular congestion - change in taste and smell ( Pica, aversions) - gallstones and cholestasis (b-c bile stasis and elevated LDL, Pruritis is sign) - profuse salivation (ptyalism)

Answer 115

- round ligament spasm - waddle gait (softens ligaments; increases joint mobility) - lordosis (lumbar curvature to compensate for change in center of gravity) - widening and increased mobility of pubis - diastasis recti (separation of rectus abdominis muscles in midline; benign in 3rd trimester)—weakened muscles

Answer 116

- level blood sugar before getting out of bed (eat crackers) - scopolamine patch - biggest concern = dehydration (hyperemesis gravidarum)

Answer 117

- Tylenol - hydration - tap of caffeine - normal discomfort in 1st trimester; concern in 3rd trimester due to possible hypertension and preeclampsia)

Answer 118

- antacids (tums) - stay upright postprandial - eat smaller meals

Answer 119

- urinate as soon as the urge comes (b-c UTI from stasis possible and can lead to preterm pregnancy or pylonephritis) - encourage wearing pads for dripples - do kegel exercises (prevent prolapse as well) - do not limit fluids - Prevent UTI (wipe front to back, cotton underwear, voiding after intercourse, and not douching)

Answer 120

- wear good supportive bra b-c heavy breast can impair posture - maternity belt and clothes to support uterus esp in multigravida or multi-gestation - use pillow b/w legs - Tylenol

Answer 121

- hydration - increased fiber - avoid straining - understand BM q3day (may be impaction if > 5 days) - never use enema during pregnancy - stool softeners are okay but risk for rebound constipation

Answer 122

- monthly until 28 weeks - Biweekly until 36 weeks - Weekly until delivery/ 40 weeks - twice a week over 40 weeks

Answer 123

- 1st day of LMP and degree of certainty about the date (Regularity, frequency, and length of menstrual cycles - hx of current pregnancy (knowledge of conception date, Recent use or cessation of contraception, Signs and symptoms of pregnancy) - psychosocial concerns (intended or unintended?, woman’s response to being pregnant, familial and partner support) - Obstetrical history (GTPAL, Type of birth experiences, complications and neonatal outcomes) - Physical and pelvic exams (bimanual) - Fetal Heart rate w/ ultrasound doppler around 10-12 wks.

Answer 124

- ABO and Rh (RhoGAM @26-28 wks if Rh-) - Hct/Hgb (detect anemia, give iron if low) - serological (varicella, rubella, syphilis, gonorrhea, chlamydia, HIV) - Urine culture and protein ( UTI) - HepB (Hep B vaccine at birth) - HPV (pap q3 yrs even if pregnant till 30 then q5 yrs) - TB skin test (if high risk)

Answer 125

- Vaginal bleeding (postcoital spotting is normal) - Urinary symptoms (dysuria, frequency, urgency)- (UTIs need antibiotic) - Abdominal cramping or pain( threatened abortion, UTI, or appendicitis) - Absence of fetal heart tone (missed abortion) - Fever or chills (infection) - Prolonged NV (hyperemesis gravidarum, risk of dehydration)

Answer 126

- BP decreases slightly at end of 2nd trimester - Urine dipstick for glucose, albumin, ketone (mild proteinuria and glucosuria normal) - Fetal- quickening (confirms EDD), FHR, kick count - Leopold’s maneuvers (palpation of abdomen) to identify fetus in utero - Ultrasound (to confirm EDD - Fundal height measurement (equal weeks of gestation) - Edema (slight in lower body is normal, abnormal if upper body esp. face) - discuss psychosocial (fetal attachment, sexual activity, familial support, body image)

Answer 127

- Glucola (1-hr @ 24-28 weeks, earlier if obese; not done if pregestational diabetic) - ABO and Rh (RhoGAM @26-28 wks if Rh-) - Hct/Hgb (detect anemia, give iron if low) @ 29-32 weeks

Answer 128

- Absence of fetal movements once felt ((fetal hypoxia or death)) - s/s of preeclampsia (swelling in face; new onset heartburn (liver involvement), severe headache, visual changes) - Rhythmic intermittent Abdominal or pelvic pain ( PTL, UTI, pyelonephritis, or appendicitis) - Vaginal bleeding (possible infection, friable cervix due to pregnancy changes, placenta previa, abruptio placenta, or PTL) - Leaking of amniotic fluid (PROM)

Answer 129

Procedure: pt. palpates abdomen and tracks fetal movement (kicks, flutters, swishes, rolls) daily for 1-2 hrs while at home Reassuring: - at least 10 movements in 2 hrs - at least 4 movements in 1 hr.

Answer 130

- GBS vaginal and rectal swab at 35-37 wks (intrapartal antibiotics if positive) - repeat STI (gonorrhea, chlamydia, syphilis, HIV, Hep B) - do glucola, H&H if not done in 2nd

Answer 131

- avoid chemicals (hair dyes) in first trimester - avoid piercings and tattoos - avoid contact w/ cat feces (no cleaning or changing litter box- toxoplasmosis risk) - cook all EGGS, MEATS,FISH thoroughly - do not eat food left out for > 2hrs - rinse all rare fruits and veggies

Answer 132

- sushi or smoked seafood) - cold deli meats and hot dogs (must be heated) (listeriosis risk) - unpasteurized products (brie, camembert, feta cheeses; juices, dairy) - limit caffeine to 200 mg (includes coffee, tea, soft drinks, cocoa butter) - rare beef or lamb (toxoplasmosis risk) - Certain fish (king mackerel, orange roughie, marlin, shark, swordfish, tilefish) due to high mercury - Raw sprouts of any kind

Answer 133

Changes with trimester - Ambivalence in 1st trimester (Concern if ambivalence in 3rd trimester) - nesting behavior in 3rd trimester

Answer 134

Caloric requirements - at least 300 extra calories Needs - Vitamins (folic acid) - Hydration (8 to 10 glasses) Cravings - Pica: nonnutritive cravings (clay, dirt, starch)—can be toxic or lead to malnutrition

Answer 135

Underweight: 28-40 lb Normal: 25-35 (37-54 for twins) Overweight: 15-25 (31-50 for twins) Obese (>30): 11-20 (25-42 for twins)

Answer 136

Miscarriage: loss of intrauterine pregnancy before 20 weeks/viability Spontaneous abortion: Nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus w/o fetal heart activity within the first 12 6⁄7 weeks of gestation ( prior to 20 weeks’ gestation) Early Pregnancy loss: Spontaneous pregnancy demise before 10 weeks of gestational age

Answer 137

S/s - Uterine bleeding and cramping - infection (fever, uterine tenderness, foul smell) Confirmation: Ultrasound (if had previous ultrasound, now is bleeding and has an empty uterus) or serial HCG

Answer 138

- surgical evacuation - mistoprostol (prostaglandin) - 800 microgram to remove products - Rhogam (50 micrograms) if Rh- and unsensitized (given 72 hrs after diagnosis)

Answer 139

- report heavy bleeding (if soak 2 pads in 1 hr for 2 hrs) esp if mistoprostol used - prevent miscarriage w/ vaginal micronized progesterone in women w/ hx of early pregnancy bleeding and miscarriage - diet high in iron and protein to replace blood loss - Pelvic rest (Nothing per vagina i.e. no tampons, douching, sexual intercourse - Pericare (hygiene, prevent hemorrhage and infection)

Answer 140

- Educate parents about what to expect (What the baby might look like) - Encourage them to hold the baby. - Ask them what they want (Funeral, burial, chaplain, pastor, priest) - Encourage memory making with the family (Take photos, footprints, use a special gown for the baby, provide blankets and bereavement boxes as the hospital provides) - Allow as much time with the baby as they want.

Answer 141

- Uteroplacental Insufficiency (placenta abruption, hypoxia, asphyxia) - intolerance of labor (Premature Birth) - IUGR - metabolic and Cardiovascular diseases (DM, obesity, metabolic syndrome) - oligohydramnios - stillbirth

Answer 142

Gestational hypertension - Onset of hypertension without proteinuria after week 20 of pregnancy and returns to normal 12 weeks postpartum Preeclampsia (Pregnancy-specific syndrome) - new onset hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman Eclampsia - Onset of seizure activity or coma in a woman with preeclampsia - can occur during pregnancy or postpartum

Answer 143

-severity of HTN and organ damage assessed at initial visit to determine risk for complications - limit sodium to 2.4 g per day - use methyldopa (Aldomet) OR labetalol, hydralazine, nifedipine-- safe for breastfeeding - increase # of prenatal visits

Answer 144

- Abnormal Placental implantation with abnormal trophoblasts invasion of uterine vessels at 8-10 wks gestation (higher systemic resistance) - (early onset before 34 wks gestation) - Immunological maladaptive tolerance between maternal, paternal (placental), and fetal tissues ((late onset after 34 wks gestation) - Maternal maladaptation to cardiovascular changes or inflammatory changes of pregnancy - Genetic factors incl. inherited predisposing genes and epigenetic influences

Answer 145

- HTN > 140/90 on 2 occasions (4-6 hrs apart) - Proteinuria = 2+ or 3+ dip on 2 occasions (6hrs apart) OR > 300 mg in 24 hrs - Dependent or pitting edema (esp on face, hands, feet) - CNS (Blurred vision, Scotoma (blindspot), headache, irritability) - Hepatic signs (RUQ pain, jaundice, elevated enzymes) - muscle changes (Hyperreflexia (DTR 3+ or 4+, clonus), seizures, coma)

Answer 146

- Nulliparity - Age >35 years - Pregnancy with assisted reproductive technology - Family hx or personal hx of preeclampsia; poor outcome in pregnancy - Interpregnancy interval >7 years - Woman herself born small for gestational age - obesity (> 30 prepregnancy) - multifetal gestation

Answer 147

- Renal disease - Type 1 DM or GDM - Antiphospholipid antibody syndrome - Factor V Leiden mutation - Autoimmune (SLE) - chronic HTN - thrombophilia

Answer 148

- poor perfusion to placenta secondary to vasospasm, increased peripheral resistance, and increased endothelial cell permeability leading to poor tissue perfusion

Answer 149

- hypertension - uteroplacental spasm (IUGR) - glomerular damage (oliguria, increased plasma, uric acid, creatinine, calcium; decreased GFR) - cortical brain spasm ( headaches, hyperreflexia, seizures) - retinal arteriolar spasm (blurred vision, scotoma, double vision, photophobia) - hyperlipidemia - liver ischemia (elevated liver enzymes, NV, epigastric pain (microvascular fat deposits), RUQ pain (hemorrhage necrosis))

Answer 150

- hemolysis of RBCs - platelet adhesion (thrombocytopenia, Disseminated intravascular coagulation) - increased factor VIII antigen

Answer 151

- proteinuria - generalized edema - pulmonary edema (dyspnea; left ventricular failure b-c high vascular resistance) - hemoconcentration (high hct)

Answer 152

- oliguria - platelets < 100,000 (thombocytopenia) - BP > 160/110 (4-6 hrs apart x 2) - Proteinuria (> 3+ dip or > 500 mg 24 hr) - Creatinine > 1.1 or doubled in absence of renal disease - Elevated liver enzymes (2x normal) - New onset cerebral or visual disturbances (headaches, blurred vision, scotoma (blind spot), hyperreflexia), photophobia - Persistent epigastric pain (RUQ pain) due to subcapsular hematoma in liver from hemorrhagic necrosis - Pulmonary edema (r/t volume overload from high vascular resistance)---s/s: SOB, chest tightness, cough O2 < 95%, increased RR or HR, apprehension, anxiety, restlessness

Answer 153

- Renal Failure - Coagulopathy (DIC, thrombocytopenia) - Cardiac (higher risk for heart disease, CHF, Pulmonary edema) - hepatic Failure (HELLP) - Placental abruption - CNS (Stroke, cerebral edema, hemorrhage)

Answer 154

Chronic hypertension - Hypertension present before pregnancy or diagnosed before week 20 of gestation - Persist longer than 12 weeks postpartum Chronic hypertension with superimposed preeclampsia - Chronic hypertension with new onset proteinuria - Significant worsening of hypertension or proteinuria

Answer 155

Goal: control BP and prevent seizures - corticosteroids (fetal lung maturity) if preterm - magnesium sulfate - benzos (if magnesium sulfate contraindicated) - antihypertensives - Induced birth indicated at >34 weeks if unstable or with severe features to prevent poor outcomes (hospitalization if < 34 weeks)

Answer 156

- low dose prophylaxis aspirin - Activity restriction - Frequent office visits (weekly) - BP monitoring - Antenatal testing (BPP, NST, kick counts, serial ultrasounds)

Answer 157

Use: CNS depressant/muscle relaxant to prevent seizures Action: Promotes cerebral vasodilation and reduce ischemia caused by vasospasm Loading dose: 4-6 grams in 100 ml over 15-20 minutes Continuous piggyback infusion: 1-2 g/hr in 100 ml Therapeutic level: 4.8-9.6 mg/dl (4-7 mEq/L) Antidote: calcium gluconate

Answer 158

* Side effect: maternal hypotension * Contraindication: mitral valve disease

Answer 159

Side Effect: neonatal bradycardia Contraindication: HF, heart disease, asthma

Answer 160

- Continuous EFM ( intrauterine resuscitation of fetus (IV fluid, O2, lateral position)) - Seizure precautions (side-lying) - Limit stimulation (Quiet environment, dim lighting, relaxation techniques) - Strict I & O and daily weights (fluid < 2 L/24 hr) - check DTRs (brachial if regional anesthesia used) - check BP at level of heart (not left lateral b-c gives false low)

Answer 161

- Hot flashes and sweating - burning at IV site - N&V - dry mouth - drowsiness, lethargy - blurred vision and headache - SOB - transient hypotension

Answer 162

- hypocalcemia (muscle weakness) - RR < 12/min - absent DTRs - Mg level > 8mEq/dl - Urine output < 30/hr - slurred speech - dysrhythmias and circulatory collapse - pulmonary edema and chest pain

Answer 163

- monitor CNS (DTRS, clonus) q 1 hr - may need oxytocin stimulation for contractions - give 24 hr after delivery (discontinue within 48 hrs) - Verify dose / second nurse - Labs: Serum magnesium levels q 4-6 hours

Answer 164

* Stay with patient * Call for help and notify HCP * Safety (lower bed, turn on side, suction PRN to prevent aspiration; keep side rails up and padded) * Record time, length, and type of seizure activity

Answer 165

* Delivery after maternal hemodynamic stabilization * Monitor maternal and fetal vitals * Give meds (magnesium, antihypertensive) * Give oxygen 10L/min via mask

Answer 166

- Increased maternal adiposity - Insulin desensitizing hormones from placenta ((Progesterone, growth hormone, Corticotropin releasing hormone, human placental lactogen, insulinase secretion, human chorionic somatomammotropin (HCS)) shift energy source to ketones and fatty acids - increased calories - Glucose is the primary fuel for the fetus - Insulin needs increase during the first trimester

Answer 167

Pregestational diabetes: glucose levels above normal but below cutoff for overt diabetes in nonpregnant women Gestational Diabetes: glucose intolerance not present before pregnancy due to insulin resistance in pregnancy

Answer 168

- Establish glycemic control before conception (Poor glycemic control at conception and in the early weeks increases risk for miscarriage and fetal anomalies) - Diagnose any vascular complications (kidney, heart, thyroid function, ophthalmic tests) - May need 3-4x prepregnancy level of insulin

Answer 169

- polyhydramnios ( >2000ml = risks for abruption, PROM and preterm labor, anomalies) - infection, inflammation, leukocyte function (UTI, monilial vaginitis) - placental abruption - Postpartum hemorrhage and anemia - C-section, assisted delivery - type 2 DM, GDM in future - Metabolic disturbances (hyperemesis, NV) - Exacerbation of chronic conditions (DKA (2nd semester), HTN, preeclampsia) - Oligohydramnios (decreased placental perfusion)

Answer 170

- macrosomia (> 4-4.5 kg b-c high glucose= high insulin = high growth) - congenital defects (NTDs, skeletal, heart, renal during organogenesis; mainly for pregestational) - IUFD (intrauterine fetal death) ( r/t hyperglycemia, infection)-- stillbirth - IUGR or SGA (due to vascular issues and placental insufficiency)

Answer 171

- hypoglycemia (few hrs) r/t depletion of glycogen stores and poor feeding - Polycythemia (appears as red, ruddy skin) r/t decrease in ECF or fetal hypoxia. - Hyperbilirubinemia r/t polycythemia, decreased ECF, bruising or hemorrhage from birth trauma. - hypocalcemia/ hypomagnesemia

Answer 172

- Respiratory Distress Syndrome (RDS) and transient tachypnea of newborn (TTN) ) r/t delay in surfactant production from maternal hyperglycemia and fetal hyperinsulinemia - cardiomyopathy - shoulder dystocia, birth trauma - chronic conditions later in life (Type 2 DM, obesity) - difficult to arouse and poor feeding ability

Answer 173

Fasting <95mg/dl 1 hr PP < 140 2 hr PP < 120mg/dl HgbA1C < 6%

Answer 174

- diet preferred (2000-2500 cals/day; minimum 1800) - Nutritional breakdown (40% carbs, 20% protein, 30-40% fat) - moderate exercise (3/ week for 20 min) - Self-monitoring (SMBG 4-8 times a day before and after meals - Medication Therapy: Insulin (if necessary) or Oral agents (Glyburide, metformin) - Fetal surveillance (detect compromise early to prevent IUFD-- NST around 28-32 weeks)

Answer 175

- all pregnant at 24-28 weeks (high risk also at first prenatal visit) Steps - Initial: 50-g oral glucose load (positive if > 135-140 mg/dl (fasting not necessary)) - If positive, do 3-hour oral glucose tolerance test (OGTT) with a 100gm oral glucose load: (fasting required)

Answer 176

Procedure - 3-hr glucose tolerance test after 8-12 hrs of fasting w/ 100 g glucose - Plasma glucose drawn at fasting, 1, 2, 3 hrs Criteria If 2 or more levels high GDM diagnosis made * Fasting > 95 * 1 hr > 180 * 2 hr > 155 * 3 hr > 140

Answer 177

- Metabolic syndrome (central obesity, dyslipidemia, hyperglycemia, hypertension) - Hx of fetal macrosomia, GDM - Physical inactivity - PCOS - Family hx of diabetes

Answer 178

- Glucose > 200 mg/dL - Moderate ketones in urine - Decreased fetal movement - Persistent nausea and vomiting

Answer 179

- Evaluate fetal lung maturity via checking amniotic fluid for phosphatidylglycerol (averts RDS in < 38 wks gestation) - glucose-maintained b/w 70-110 in labor (IV insulin given; glucose checked q1-2 hrs and ketones q4h) - If corticosteroid given to prevent preterm delivery, increase insulin - cesarean needed if fetus > 4.5 kg

Answer 180

Components: nonstress test (NST), fetal movement, fetal breathing, fetal tone, and amniotic fluid index (AFI)) Normal: 8 (w/ NST) to 10 (w/ reactive NST) Abnormal: <4 = fetal compromise

Answer 181

- renal failure - myasthenia gravis - pulmonary edema

Answer 182

- decreased variability - respiratory depression - hypotonia - decreased suck reflex

Answer 183

* Given within 30-60 minutes for severe hypertension * No need for cardiac monitoring if IV or immediate release * Monitor BP q5-15 mins * Give q20 min PRN

Answer 184

Fetal - Recurrent and prolonged FHR decelerations - Fetal tachycardia (bradycardia during seizure r/t hypoxia) - reduced variability Maternal - hypoxia - trauma - aspiration pneumonia - neurologic damage (impaired memory and cognition)

Answer 185

Blastocyst - develops by day 5 - fetus develops from inner cell mass (embryoblast) - placenta and membranes develop from outer layer (trophoblast) - trophoblast becomes chorion and secretes enzymes for implantation around 6-10 days

Answer 186

* insulin antagonist (promotes fetal growth by regulating glucose) * stimulates breast development in preparation for lactation.

Answer 187

- Cervical mucus plug (protective barrier b/w uterus and vagina via hypertrophy of cervical glands) -- opens during labor - Braxton-Hick’s contractions (2nd trimester; intermittent and painless; irregular pattern) - changes from elastic and muscular to thin in pregnancy

Answer 188

- Increased acidity to prevent bacteria (allows Candida albicans) - Relaxation and softening of wall and perineal body to stretch - Leukorrhea: increased discharge in response to estrogen-induced hypertrophy of glands and increased vascularity

Answer 189

- Thyroid (hyperplasia and increased vascularity) - causes heat intolerance and fatigue - Decreased Glucose due to high BMR from fetal activity - Increased insulin and pancreatic activity due to fetal depletion of glucose - Increased cortisol (which increases risk of hyperglycemia if maternal resistance to insulin)

Answer 190

- used when unclear hx of LMP or irregular cycles - Pelvic pain or vaginal bleeding in first trimester - Hx of repeated pregnancy loss or ectopic pregnancy - Discrepancy b/w actual size and expected size of pregnancy based on history - screen for aneuploidy (enlarged nuchal translucency i.e fluid filled space on dorsal of neck)) - Fetal biometric measurements (gestational age measurements, growth, activity, amnionicity, number) - identify placental placement

Answer 191

- measure crown-rump length (< 14 weeks) - measure Biparietal diameter, Head circumference, Femur length, Abdominal circumference (> 14 weeks)

Answer 192

- in cm = gestational age starting at 10-12 weeks - zero tape on symphysis pubis and top on fundus - empty bladder prior to measurement - unreliable in obese, IUGR, multi-gestation

Answer 193

Structure - Volume is important to fetal well-being (700-1000 mL) - contains mostly water plus urine (urea), lanugo hair, epithelial cells - usually clear (brown/yellow if meconium) - maintained by amniotic membrane then fetal kidneys

Answer 194

Problems - Oligohydramnios (< 500 ml) cause reduced fetal lung development, renal problems - Polyhydramnios (>1500-2000 ml) cause chromosomal, GI, cardiac, and NTDs

Answer 195

Function - metabolic (exchange of gases, nutrients, wastes, and antibodies b/w fetus and maternal) - endocrine gland (hCG, hCS, progesterone, estrogen, hPL, Growth hormone, Cortiotropin-releasing hormone)-- insulin antagonists starting at week 6 or 7 Expected appearance - maternal side dull, fetal side shiny

Answer 196

Passenger Passageway Position Powers Psyche Participants

Answer 197

First (latent until 5 cm; active 6 cm; transition 8-10 cm) Second (10 cm- birth of baby) Third ( placenta delivery) Fourth (postpartum

Answer 198

Maternal - vitals and pain q2h until ROM then q1h - cervical exam - review prenatal records and assess risk factors - wellbeing q30min (focus more inward as contractions progress)- latent stage = good for pt education Fetal - FHR monitoring and maternal wellbeing q30 minutes - leopold's maneuvers for fetal position

Answer 199

- comfort measures (no supine position; clear liquids; frequent position changes) - GPS prophylaxis - encourage voiding q2h (more room for baby)

Answer 200

- assess FHR and maternal wellbeing q5-15 minutes - assess vitals q1h - sterile vaginal exam as needed (limit to prevent infection) - perineum flattens and bulges when pushing

Answer 201

- Placenta to be out in 15 minutes ( prolonged if > 30 minutes) - vitals q15min - 1 and 5 min APGAR for infant

Answer 202

- give uterotonics for placental delivery - check placenta for completeness - Complete documentation of delivery (labor summary, delivery summary, infant info, Apgar, infant resuscitation, documentation of personnel in attendance)

Answer 203

- Lightening (2 weeks prior to labor; fetal descent into true pelvis; easier to breathe; more urinating) - Braxton-hicks contractions (irregular and do not change cervix) - Cervical movement (Ripens, softens, moves posterior to anterior, partially effaced, thinned, dilates) - Increased discharge then loss of mucus plug (bloody show w/ pink/red discharge) - Nesting - NVD, indigestion - 1-2 lb weight loss

Answer 204

- progressive cervical dilation and effacement (effacement 0-100%; dilation 0-10 cm) - lower back discomfort radiates to abdomen - regular contractions (short intervals, increased duration and intensity) - contractions do not respond to hydration, rest, bath

Answer 205

- irregular contractions (braxton-hicks) - abdominal discomfort - no change in cervical dilation or effacement - contractions respond to hydration and rest

Answer 206

Attitude - Flexed: back convex, head flexes to chest, thighs flexed over abdomen; easier passage through birth canal - Deflexed (straight) - Extended: concave back; larger diameter of head moves through birth canal Lie - Longitudinal: long axes/spine of fetus = parallel to woman’s; usual case - Transverse: long axis of fetus = perpendicular to woman); need c-section

Answer 207

Pelvic types - proven pelvis (prior vaginal delivery proves ability to deliver vaginally) - Gynecoid (typical and optimal; rounded)) - Android (typical male; heart shape) - Arthropod (narrow oval; okay for birth) - Platypelloid (wide and flat; short AP; difficult for birth) Fetal station - 0 = head even w/ ischial spine; narrowest diameter fetus must pass through - +3 when out of vagina - best way to assess labor progress

Answer 208

Frequency - minutes b/w beginning of 1 contraction to the next - expected q2-3min (< 5 in 10 min) - tachysystole if > 5 in 10 minutes (prevents reoxygenation of baby r/t oxytocin, dehydration, violence, preeclampsia, placental abruption, meth) Duration - seconds b/w beginning of contraction to end of contraction

Answer 209

- mental and physical preparation (birth plans help) - previous experiences - emotional status (anxiety and stress slow labor) - social support (calm, direct, confident, gentle voices)

Answer 210

Pros - short acting - no IV access needed for nitrous oxide Cons - not continuous, not given close enough to birth - respiratory depression (less w/ butorphanol; decreased FHR) for opioids - dizziness or drowsiness for nitrous oxide

Answer 211

Pros - long lasting, can be given at anytime Cons (informed consent required - rids to bed and prolongs labor - numbing - risk for hypotension and spinal headache - Other risks: hematoma, infection, urinary retention, pruritus, respiratory depression, hyperthermia, NV

Answer 212

* Position changes (birth ball, ambulation, chair sitting) * Massage (firm on legs and back) * Hydrotherapy (shower or tub) * Aromatherapy (lavender to distract) * Acupressure * breathing techniques (deep or hyperventilation into bag to prevent respiratory alkalosis) * Distraction * hot and cold (do not use w/ epidural)

Answer 213

Use: labor induction for 1cm/hr, labor augmentation, PP hemorrhage prevention Indications - gestational age (after 41 weeks) - maternal (abruptio placentae, chorioamnionitis, preeclampsia, PROM, chronic conditions) - fetal (multifetal, IUGR, isoimmunization, demise, oligohydramnios) - control PP bleeding after placental expulsion

Answer 214

What it includes? (all of the following) - Baseline rate 110 to 160 bpm - Baseline variability moderate - Late or variable deceleration absent - Early decelerations absent or present - Accelerations absent or present What it means? favorable so routine management-

Answer 215

What it includes? (any of the following) - Bradycardia OR Tachycardia - Minimal OR Marked baseline variability - Absent baseline variability w/o recurrent decelerations, bradycardia, or tachycardia - Absence of induced accelerations after fetal stimulation - Recurrent variable or late decelerations w/ minimal or moderate baseline variability - Prolonged decelerations b/w 2-10 minutes - Variable decelerations w/ other characteristics, such as slow return to baseline “overshoot accelerations” or “shoulders" What it means? surveillance and interventions needed

Answer 216

What it includes? - smooth sine wave in FHR baseline with a cycle frequency of 3 to 5 mins that persists for 20 mins or more (r/t opioid admin) - Absent variability w/ Recurrent late decels, recurrent variable decelerations, or bradycardia What it means? - imminent delivery or intrauterine resuscitative measures needed

Answer 217

- high alert med (use IV pump on piggyback, - stop if tachysystole (recontinue if FHR reassuring after 10-30 minutes) OR when active labor starts - Monitor EFM continuously or q15 or 5 mins in low risk - Monitor UCs for strength, frequency, duration, resting tone, maternal pain q30 minutes - Assess vitals q2h - Assess I&O q8 hrs

Answer 218

Characteristics - rounded to increments of 5 bpm during 10-minute window. - at least 2 minutes of identifiable baseline segments (not necessarily contiguous). - does not include accelerations or decelerations or periods of marked variability (amplitude greater than 25 bpm). Changes - Periodic: occur in relation to UCs. - Episodic: occur independent of UCs - Recurrent: occur in greater than or equal to 50% of the contractions in a 20-minute period. - Intermittent: occur in less than 50% of the contractions in a 20-minute period.

Answer 219

- irregular fluctuations in fetal HR - Most important predictor of fetal oxygenation regardless of accels or decels - Develops around 28-30 weeks’ gestation

Answer 220

gradual periodic decrease in FHR from baseline to nadir lasting more than 30 seconds Cause: head compression

Answer 221

abrupt periodic or intermittent decrease in FHR (15 bpm or more) from baseline to nadir lasting b/w 30 seconds and 2 minutes Cause: umbilical cord compression (fetal HTN, acidemia) Key interventions - amnioinfusion if less than 60 bpm depth (contraindicated w/ vaginal bleeding, uterine anomalies, active infections, polyhydramnios) - tocolytics (terbutaline) - SVE for cord, labor progression, and fetal scalp stimulation - IURM (change position, oxygen, discontinue oxytocin)

Answer 222

gradual periodic decrease in FHR (15 bpm or more) from baseline to nadir lasting more than 30 seconds; occurs after contraction (prolonged if > 2 minutes) Cause: uteroplacental insufficiency

Answer 223

Maternal - decreased progesterone - increased prostaglandins and oxytocin - Estrogen and relaxin (soften cartilage and increase elasticity of ligaments so joints and tissue stretch for fetal passage) Fetal - increased cortisol and prostaglandins

Answer 224

- urge to push in 2nd stage (push w/ open glottis during contractions) - ferguson reflex (stretch receptors in pelvis cause increased oxytocin release) - push while upright

Answer 225

Timing: labor within 24-48 hrs of rupture Confirmation * Speculum exam: assess amniotic fluid in vaginal vault (pooling); ask pt. to cough to enhance flow * Ferning: Amniotic fluid dries in fern pattern when placed on slide * Nitrazine paper: turns blue in contact with amniotic fluid; use Q-tip or dip in vaginal fluid (uncommon b-c unreliable)

Answer 226

- when contractions 5 minutes apart, last 60 seconds, and regular for an hour - Membrane ruptures, water breaks - Intense pain - Bloody show increases or frank bleeding - Decrease in fetal movement - Severe headache, blurred vision, epigastric pain

Answer 227

Risks - umbilical cord prolapse if presenting part not engaged in true pelvis - infection if ruptured more than 24 hrs OR if foul smelling - fetal compromise if meconium stained - bleeding (vasa previa) - severe variable decels if AROM Nursing care - assess FHR and maternal temp - Assess color (clear and cloudy), amount, and odor (ocean/forest smell) of amniotic fluid - document date and time of ROM

Answer 228

- Determine part of fetus located in fundus of uterus - Determine location of fetal back - Determine presenting part - Determine location of cephalic prominence

Answer 229

* Absent: Amplitude range is undetectable. * Minimal: Amplitude range is visually detectable at 5 bpm or less * Moderate: Amplitude from peak to trough is 6-25 bpm * Marked: Amplitude range greater than 25 bpm.

Answer 230

After 32 weeks; 15 bpm above baseline (10 bpm above baseline if < 32 weeks) Cause: fetal movement

Answer 231

Assessments - vital and uterine activity for fever, hypotension, tachysystole - cervix for umbilical cord prolapse, rapid dilation, rapid descent of fetal head - fetal acid-base status w/ scalp or vibroacoustic stimulation Interventions - Maternal position (left or right) - IV bolus 500 mL LR - Ephedrine for hypotension - Give 10 L/min O2 via nonrebreather - Reduce uterine activity (stop oxytocin, Remove cervical ripening agent, give Terbutaline) - Amnioinfusion (contraindicated w/ active infection, vaginal bleeding, polyhydraminos) - Alter pushing efforts (q3 UCs instead of every UC) - Decrease pt. anxiety (support)

Answer 232

- Vasa previa (vessels not in placenta) or complete placenta previa - Transverse fetal lie - Umbilical cord prolapse - Previous classical cesarean birth - Active genital herpes infection - Previous myomectomy entering the endometrial cavity

Answer 233

Dose: start at 0.5 mU/min and increase dose by 1 to 2 mU/min every 30 to 60 minutes until labor progresses to 1 cm/hr (more for PP) Risks - tachysystole (also r/t dehydration, violence, preeclampsia, placental abruption, meth) - FHR decelerations - Water intoxication (w/ high concentrations w/ hypotonic solutions (s/s of fluid overload: decreased urine output, edema, hypertension, pulmonary edema)-due to ADH effect - PP use: coma, seizures

Answer 234

Mechanical - Hygroscopic dilator (dried seaweed promotes dilation by water absorption which leads to local prostaglandin release) - Transcervical balloon catheters (placed in extra-amniotic space and inflated w/ sterile water above internal os to put direct pressure on cervix); falls out once cervical dilation happens usually 6-12 hrs Pharmacological - Prostaglandin E2 (PGE2) (dinoprostone, e.g., Prepidil gel or Cervidil insert) - Prostaglandin E1 (PGE1) (misoprostol, e.g., Cytotec)

Answer 235

Indication - little to no cervical effacement - bishop score (< 6)- r/t fetal station, dilation, effacement, position and consistency of cervix) Nursing care - Ensure HCP gets informed consent - Continuous FHR and UC monitoring (4 hrs after intravaginal misoprostol, 2 hrs after oral misoprostol, 15 mins after insert removal) - Delay oxytocin for 30-60 mins after removal of insert (4 hrs after last misoprostol dose) - for insert, pt in supine or lateral for 2 hrs after insert

Answer 236

- Ruptured membranes (relative) - regular contractions or tachysystole - unexplained vaginal bleeding - Active herpes - Fetal distress (malpresentation, nonreassuring FHR) - hx of prior traumatic delivery, uterine myomectomy w/ the endometrial cavity or cesarean delivery esp transverse scar (no prostaglandins in TOLAC) - Vasa or Placenta previa

Answer 237

Intensity - measured by palpation OR IUPC - Mild (nose); moderate (chin), strong (forehead) Resting tone (2) - pressure in uterus b/w contractions - Palpated (hard or soft)

Answer 238

Presentation (part of fetus that enters pelvic inlet first) - Cephalic (occiput/flexed (preferred); frontum (brow); mentum/chin (face)) - Breech (pelvis, butt, feet)- reference: sacrum - Transverse (shoulder) – reference: acromion - Compound (extremity prolapses w/ presenting part i.e arm and head)

Answer 239

Position (in relation to maternal pelvis)- want OA; OP will be causes back pain - 1st letter: location of presenting part to woman’s pelvis (Left or Right) - 2nd letter: specific fetal part presenting: occiput (O), sacrum (S), mentum (M), shoulder (A) - 3rd letter: relationship of fetal presenting part to pelvis: anterior (A), posterior (P), Transverse (T)

Answer 240

Uterine contractions and progressive cervical change between 20 and 37 weeks gestation due to decidua and fetal membrane activation, stress, uterine distention, Signs and symptoms - Contractions > q10 min for more than 1 hour (may be painful or painless) - Discomfort (Abdominal cramping, low back pain, menstrual-like cramps, suprapubic/pelvic pressure) - Vaginal discharge (ROM, increased amount) - cervical change (80% effacement, dilation 2cm or more)

Answer 241

- hx PTB (most important) - IVF - Behaviors: smoking, substance abuse, multiple sexual partners, hx of DES exposure - poor health (low/high BMI, low SES, anemia, infection, inflammation) - pregnancies < one yr apart - Extreme ages (very young, very old) - uterine or cervical abnormalities (short cervix, distention due to multiple fetus; Hydramnios or oligohydramnios) - Inadequate support (IPV, late Prenatal care, unmarried) - Stress - Chronic health conditions (HTN, DM, clotting disorders, abnormal lipid metabolism)

Answer 242

- education is key - Teach pt about timing/palpation of contractions, may be painless - Document FHR baseline and note any patterns b-c FHR lower in preterm since CNS less developed - Identify and treat infections - UTI/STDs - Encourage Hydration - care for in antenatal unit (bedrest, tocolytics, stopping sexual stimulation no longer recommended routinely) - may use progesterone or tocolytics to prevent PTL w/ observation

Answer 243

Goal: prolong labor 48-72 hours to give steroids time to increase lung maturity Types - Magnesium sulfate: - Beta-adrenergic drugs – Terbutaline, Ritodrine - Calcium channel blockers – Nifedipine - Prostaglandin synthesis inhibitors – Indomethacin

Answer 244

Action: relax smooth muscle and cause bronchodilation Dose: 0.25 mg q4h SubQ for no more than 24 hrs Contraindications (anything that relaxes smooth muscles) - cardiac disease sensitive to tachycardia - GDM - hyperthyroidism - hemorrhage - seizure disorders

Answer 245

Action: relax smooth muscle for tocolysis or maternal hypertension Dose: 10-20 mg q3-6h PO (no more than 24 hrs) Side effects - hypotension (maternal and fetal) - headache - flushing - maternal tachycardia - dizziness and nausea

Answer 246

Indication: Prevent/reduce severity of neonatal respiratory distress syndrome or IVH b/w 24- and 34-weeks gestation if risk for PTB in 7 days Action: Stimulates fetal lung maturity and helps w/ neuroprotection Dosage and Route: Betamethasone – 12mg IM, two doses 24 hours apart Dexamethasone – 6mg IM, four doses 12 hours apart Maternal and fetal effects - increase in WBC count - hyperglycemia (lasts 72 hrs) - decrease in fetal breathing in body movements (lasts 72 hrs)

Answer 247

Assessment - malpresentation - fetal and/or early neonatal loss - dilation 4 cm or more Care - neonatal resuscitation - mag sulfate to prevent/reduce neonatal neurologic sequelae

Answer 248

- transverse (horizontal) - best prognosis - Classical (vertical) - unable to TOLAC; used for PTL

Answer 249

- Establish IV and foley catheter access - Labs: CBC, Type & Cross - Uterine assessment and abdominal prep - Assist w/ anesthesia: Epidural (if was laboring), Spinal (if planned c-section), CSE - Pre-op meds: Reglan (metoclopramide), Bicitra (sodium citrate- lowers acidity of stomach contents), antibiotics - Transfer to OR suite and call neonatologist/NICU (if needed), - Circulating nurse duties (Intraoperative nursing care; surgical tool count)

Answer 250

General care - Recovery assessments – fundus q15min (same as for SVD) - Monitor incisional bandage for bleeding and intactness - Splinting with pillow or binder to assist w/ coughing, ambulation and prevent undue pressure - foley for 12-24 hrs - clean incision w/ mild soap (no lotions)

Answer 251

- One lower uterine transverse incision - more than one, twin pregnancy, or induction of labor WITH appropriate counseling - facility must be able to do emergency c/s - low risk (normal BMI, term pregnancy, normal birth weight, avg. maternal age, spontaneous labor)

Answer 252

- Shoulder dystocia - Prolapse of umbilical cord - Vasa previa/ruptured vasa previa - Rupture of the uterus - Anaphylactic syndrome/amniotic fluid embolism - Disseminated intravascular coagulation (DIC)

Answer 253

Appearance - Cord below presenting part through the introitus or into vagina - May be occult and palpable through membranes Risks: hypoxia Risk factors - polyhydramnios - multiple gestation - ROM or PROM when presenting part not engaged

Answer 254

- Check FHR after ROM - Elevate the presenting part off of cord - Position (knee-chest, Trendelenburg) - O2 - IV fluid - discontinue Pitocin, consider tocolytic (terbutaline to stop contractions) - Must expedite delivery, usually by c/section

Answer 255

Causes: - anterior shoulder unable to pass under pubic arch - Fetopelvic disproportion (FPD) - Maternal pelvic abnormalities Risk Factors: - Maternal diabetes - previous history of shoulder dystocia - prolonged 2nd stage of labor - fetal macrosomia (>4.5 kg) - excessive weight gain

Answer 256

Neonatal Complications - Birth injury -brachial plexus injury, fracture of clavicle/humerus - asphyxia r/t neck compression - hyperbilirubinemia - neonatal encephalopathy if > 5 min delay b/w head and body delivery Maternal complications - Hemorrhage - vaginal/rectal injury (symphyseal separation, 4th degree lacerations) - infection - peripheral neuropathy

Answer 257

- Slowing of descent into the pelvis - Development of caput on baby’s head (swelling) - Turtle sign (head sucks back in after delivery of head)

Answer 258

- call for assistance - instruct patient not to push unless directed - McRoberts maneuver (legs hyperflexed against the abdomen; opens the pelvic outlet and straightens the sacrum)- 2 people - suprapubic pressure w/ palm or fist (NO FUNDAL PRESSURE to prevent uterine rupture)

Answer 259

Pathophysiology: disruption of maternal-fetal interface exposes vascular system and allows amniotic fluid into maternal blood stream leading to cardiopulmonary collapse/arrest S/s - change in LOC - negative inotropism (decreased cardiac output and shock) - pulmonary edema and vasospasm - severe sudden hypoxia and ARDS (dyspnea) - massive fibrinolysis

Answer 260

Pathophysiology - impaired coagulation and bleeding/hemorrhage r/t platelet and clotting factor consumption AND fibrinolysis - multi-organ ischemia r/t mucrovascular thrombosis from endothelial damage Labs - decreased platelets - increased aPTT and PT - increased D-dimer

Answer 261

- placental abruption - Amniotic Fluid Embolism - sepsis - acute fatty liver of pregnancy - dead fetus syndrome (prolonged retention of fetus/stillbirth) - severe preeclampsia - HELLP - hemorrhage

Answer 262

Temperature: < 35 or > 38 SBP: < 90 or > 160 DBP: >100 HR: <40 or > 120 RR: <10 or >30 O2 sat: < 95% LOC Changes: Agitation, confusion, unresponsive Output: <35 mL/hr for 2 hrs or more

Answer 263

Benefits - shorter hospital stay - fewer complications (hemorrhage, thromboembolism, infection) - fewer neonatal breathing problems - Reduced consequences of multiple c-sections (hysterectomy, bowel or bladder injury, transfusion, infection, placenta previa or placenta accreta) RIsks - rupture of the uterus and associated sequelae (hemorrhage, hypovolemic shock, bladder/bowel injury, hysterectomy; HIE for baby) - hypovolemia and need for blood transfusions - maternal bladder or bowel lacerations

Answer 264

- Gaskin all-fours for woman - Woods corkscrew maneuver (rotate posterior shoulder out then anterior) - episiotomy extension (not preferred b-c bone issue not tissue issue) - Zavanelli maneuver (rare; head replacement then c-section)

Answer 265

- dilated > 6cm - preeclampsia with severe features or eclampsia - maternal bleeding w/ hemodynamic instability - infection (chorioamnionitis) - cardiac disease - fetal distress or demise (IUFD, lethal anomaly, nonreassuring fetal status) - PROM

Answer 266

Fetal Side effects - tachycardia - hyperinsulinemia - hyperglycemia When to notify provider - HR > 130 -- need ECG monitoring - BP <90/60 - Pulmonary edema - FHR > 180 bpm

Answer 267

- Tachycardia - hypokalemia -> chest discomfort (palpitations, dysrhythmias, SOB) - Tremors - CNS (Headache, dizziness, nervousness) - nasal congestion - N&V - hyperglycemia - hypotension

Answer 268

Contraindications - hypotension - aortic insufficiency (any preload-dependent cardiac lesions) Nursing care - help ambulate - do not give w/ terbutaline or mag sulfate - monitor hepatic enzymes

Answer 269

Action: prostaglandin inhibitor for tocolysis Maternal Side effects - gastritis (NV) - esophageal reflux Fetal side effects - Premature closure of fetal ductus arteriosus - intraventricular hemorrhage - oligohydramnios - necrotizing enterocolitis in preterm newborns Contraindications - Platelet dysfunction of bleeding disorder - hepatic or renal dysfunction (hepatitis) - gastrointestinal ulcerative disease - asthma (in women with hypersensitivity to aspirin)

Answer 270

- Avoid infection / sepsis (Hand-washing, keep incision dry, check lochia for odor) - Avoid respiratory stasis (Deep breathing, coughing, incentive spirometer) - Prevent DVT thrombosis r/t hypercoagulability (SCDs, Leg rollers, leg exercises, ambulation ASAP) - Prevent GI effects (gas, constipation, ileus) via monitor for abd distention, bowel sounds, flatulence, Stool softener (Colace), laxatives (Ducolax), rocking chair, ambulation

Answer 271

Patho: uterus returns to prepregnancy size, shape and location through uterine contractions, atrophy of the uterine muscle, and a decrease in size of uterine cells. Fundal height - Immediate after birth = midway b/w umbilicus and symphysis pubis - 12 Hours PP: @ umbilicus or 1 cm above - 24 hours PP: 1 cm below umbilicus - After Day 1: Uterus decreases by 1 cm/day (1 finger) - 14 days: Below symphysis pubis, no longer palpable - 6-8 weeks: Pre-pregnant size.

Answer 272

Factors - retained placental fragments - infection (endometritis) - fibroids Manifestations - Soft and larger than normal uterus - Lochia returns to rubra and is heavy. - Back pain

Answer 273

- contractions (for PP hemostasis r/t release of oxytocin)- prevent PP hemorrhage) - afterpains (moderate to severe cramping; more noticeable in multipara; decreased after 3rd PP day) - Lochia: bloody discharge from uterus (RBC, sloughed off endometrial tissue, epithelial cells, bacteria)

Answer 274

- Decreased Placental hormones (estrogen, progesterone) by 3 weeks - Lactating women-prolactin levels increase by 3 weeks (suppresses menses) - lactating women- oxytocin released causing let-down reflex when infant nurses - Menses returns 7-9 wks PP if not breastfeeding, 4 months if breastfeeding - anovulatory until 4th menses cycle

Answer 275

- bladder distention can lead to uterine atony (displaced fundus) - Postpartum Fluid Loss via extreme diuresis (3000 mL; 150 mL q2-4 hrs) and diaphoresis r/t decreased estrogen (resolves 12 hr s PP) - decreased sensation to void and incomplete emptying r/t increased bladder capacity, pushing, epidural effects - transient stress incontinence (resolves in 6wk-3m PP

Answer 276

General - Immediately after birth till 14 hr. PP = full, soft, nontender - 2nd day PP = slightly firm nontender - 3rd day PP = Larger, firm, warm, tender, throbbing pain due to increase in vascular and lymphatic system. - Engorgement ends in 24-48 hrs.

Answer 277

- Blood loss (Vaginal-200-500 mls AND cesarean-500-1000 mls) - Physiologic edema - Stroke volume and Cardiac output increases for 24-48 hours ( pre-pg levels w/n 10 days) - transient anemia that resolves by 8 weeks (hct < 32, Hgb <11) r/t plasma volume increase from extracellular to intravascular - Risk for thromboembolism r/t pregnancy being a hypercoagulable state (clotting factors return to normal in 2 weeks) - PP chills right after birth r/t vascular instability. - Risk for orthostatic hypotension (normal after 1 week)

Answer 278

- due to elimination of uteroplacental circulation (decrease in uterine blood flow and shift of nearly 500 ml from uteroplacental bed) - due to loss of placental endocrine function - due to mobilization of extravascular water into intravascular space (Plasma loss > RBC loss, reverses hemodilution of pregnancy)

Answer 279

Temperature - 38°C is common in 1st 24 hours r/t exertion of L&D, dehydration, hormones - Temp of > 38° C(100.4 F) after 1st 24 hours = infection Blood Pressure - Usually normal (decrease = hypovolemia, increase = PP preeclampsia) - may have transient 5% increase in systolic and diastolic BP Respirations - normal Pulse - Bradycardia (>100 = hemorrhage, hypovolemia or infection

Answer 280

Breasts (breastfeeding) Uterus/Fundus Bladder elimination Bowel elimination Lochia Episiotomy (perineum) Homan’s Sign/Lower extremities (calf pain w/ dorsiflexion = DVT) Emotional state (comfort, pain, attachment) Timing - done q15 min for 1st hr, then q30 min for 2nd hr, q4 for 22hr, every shift after 24 hrs

Answer 281

- Hgb/Hct increases - WBC increases (12,000-25,000) (leukocytosis of puerperium may mask acute postpartum infections, thrombophlebitis) - Pre-pregs level by 7 days PP - If rubella nonimmune, need to be immunized for rubella prior to discharge. - If Maternal Rh (neg) blood type with neg direct Coombs, Rh pos newborn: mother needs Rhogam within 72 hours (no rhogam for rh- infant)

Answer 282

Factors - Overdistended uterus (macrosomia, hydramnios, multiples) - Anesthesia - High parity (> 5) - Rapid, Prolonged, dysfunctional(induced) labor - fibroids Interventions - maintain uterine tone (fundal massage) - prevent bladder distention (s/s fundus displaced from midline; empty bladder)

Answer 283

Early PP Hemorrhage Timing: 1st 24 hr (esp. 1st hr) Manifestation: soak 1 pad q15 mins Cause: Uterine atony, Distended bladder, high or unrepaired laceration or vaginal hematoma Late PP Hemorrhage Timing: >24H after the birth, but < 6 weeks Manifestation: soak 1 pad q1 hr Cause: subinvolution r/t Retained products of conception, Endometriosis

Answer 284

- Tachycardia - Tachypnea - Skin- cool, pale, clammy - Dizziness, nausea - Anxiety, “air hunger” r/t hemorrhage - Urine output decreases - Hypotension (late sign) - blood loss (> 500 mL in vaginal, > 1000 mL in cesarean) - decreased Hct by 10% since admission or 2% in first 48 hrs pp

Answer 285

- support lower uterine segment above symphysis pubis (prevents uterine inversion) - use circular motion - reassess after 5-10 minutes of massage

Answer 286

Timing: day 1-3 Consistency - bright red bleeding that diminishes in amount and pales in color (scant in C-section) - May have fleshy odor (similar to menstrual blood) - small clots - increased amount w/ standing or breastfeeding

Answer 287

Timing: Day 4-10 Consistency - pink-brown - scant amount and fleshy odor - increased amount w/ physical activity

Answer 288

Timing: Day 10-14 Consistency - creamy white or yellow discharge of mucus and leukocytes - scant amount and fleshy odor

Answer 289

Scant: < 1 inch or only on tissue when whipped Light: < 4 inches Moderate: < 6 inches Heavy: saturated within 1 hour Excessively heavy: soaked in 15 minutes

Answer 290

- void 300 mL q2- 4 hours - use bathroom/bedpan (Foley catheter may be needed if suspect retention (< 100cc/hr. or < 300cc/void) - Administer analgesics if dysuria - Use peppermint oil b-c vapors relax urinary sphincter - Drink minimum of 10 glasses per day (2L of water/day) - Do pelvic floor muscle training to improve continence, sexual function and prevent prolapse. - Cotton underwear - Nutrition (increase urine acidity w/ cranberry juice, apricots, plums)

Answer 291

Delayed due to: (for 2 weeks PP) - Fluid losses and dehydration - Decreased GI motility r/t pain meds, decreased physical activity - Perineal discomfort r/t hemorrhoids, lacerations, episiotomy GI changes - constipation - NV r/t labor - No BM expected for 2-3 days - increased appetite is normal - weight loss (11-12 lb immediately, 5-8 lb r/t diuresis)

Answer 292

- Position patient laterally and lift buttock to expose anal area (note # and size of hemorrhoids, thrombosis) - Topical anesthetics for discomfort - Topical steroids, sitz baths, cold compresses to reduce edema - Stool softeners (Colace)

Answer 293

- Wash hands - Cleanse front to back with peri-bottle lavage, blot dry - Change peri pads when soiled- monitor for odor as a sign of infection - Vulvar ice packs and cold sitz bath (1st 24 hrs) for edema - Warm sitz bath after 24hrs to promote circulation and healing. - analgesics (ibuprofen and acetaminophen) prn for discomfort - Topical anesthetics (Anesthetic creams/sprays, Witch hazel compresses, Hemorrhoidal creams) for discomfort - Tighten gluteal muscles as pt sits then relax them after she sits to cushion perineum and increase comfort.

Answer 294

Redness, Edema, Ecchymosis, Drainage, Approximation of edges of episiotomy or laceration Levels 1st Degree: Vaginal Membranes 2nd Degree: Vaginal Membranes + Fascia 3rd Degree: Vaginal Membranes + Fascia + Anal Sphincter 4th Degree: Vaginal Membranes + Fascia + Anal Sphincter + Anal Canal Types of epistiomies - Midline = heals quicker and less pain than mediolateral - Mediolateral = incision at 45-degree angle to perineum

Answer 295

Diet - clear liquids (no solids until peristalsis returns) - avoid straws and carbonated beverages b/c cause gas pain Education - rocking chair to relieve gas pain - prevent constipation (enema if no BM by day 3) - may have NV

Answer 296

- Last 24-48 hrs - Focused on self (not infant)- personal comfort, rest, food important - Decision making difficult so dependent on others for help in care - Re-lives delivery experience

Answer 297

- Lasts from 2 days-1 wk - Dependence -> independence (decision making) - shift from pregnancy role to maternal role - Increased energy level - need reassurance about ability to meet infant needs - great time for teaching

Answer 298

- From 1 week onward - See self as separate from infant - Give up fantasy delivery and baby - may have feelings of grief, guilt, Depression - Readjustment – giving up previous role

Answer 299

Timing - first few days – 2 weeks due to hormones, fatigue, role stress for most women - peak day 5-10 S/s - Able to care for baby - mild mood swings (emotional lability, feeling sad, anxious, or overwhelmed) - crying spells - insomnia and anorexia - fatigue or restlessness Management - assess at 1-2 week check up - encourage rest

Answer 300

- Sleep/appetite disturbances (insomnia, hypersomnia, weight gain, weight loss) - emotional distress (Anxiety, fear, panic, guilt) - inability to concentrate - Despondent (feeling down/depressed or hopeless; loneliness, isolation) - Thoughts of harming baby or self - unable to safely care for infant

Answer 301

- LGB > heterosexual - Hx of depression or anxiety during or prior to pregnancy - Inadequate social support (poor quality relationship w/ partner OR mother; life stressors) - young age - unintended pregnancy (ambivalent about having a baby) - family history - birth or pregnancy different from plan (cesarean, emergency w/ mother or newborn, NICU baby) - Abuse: IPV, history of childhood sexual abuse - Low SES

Answer 302

- may resume sexual activity at 2-4 weeks - 3 criteria for resuming: Bleeding is slowed/stopped; No discomfort experienced; Pt is ready psychologically - Episiotomy/lacerations typically healed after 2 weeks - Hormonal contraception safely initiated after 3 weeks (LARCs can be placed in immediate PP) - Use of lubricant advised due to vaginal dryness

Answer 303

- Soaking a pad/hr, presence of egg sized clots; return of rubra - Fever: Temp > 100.4 lasting 24hrs or longer in first 10 days - Mastitis: Redness, swelling, lump in breast - Cystitis: dysuria, frequency, urgency - Thrombophlebitis: Pain in calf; PE if SOB or chest pain - Endometritis: Foul smelling vaginal D/C, pelvic pain - Postpartum Depression: thoughts of hurting yourself or someone else - Preeclampsia: severe headache, seizures, blurry vision, epigastric or abdominal pain, facial swelling

Answer 304

Factors - retained placental fragments esp if manual removal - Acreta, increta, percreta (unusual placental adherence-doesn’t easily separate) - placenta Abruption or Previa Signs and symptoms - Subinvolution of uterus (remains larger than normal) - Profuse bleeding after 1st week PP - Pale skin or blue discoloration Interventions - may need D& C by provider

Answer 305

Factors - operative (forceps, vacuum) - Vaginal/cervical lacerations r/t macrosomia, multifetal, precipitous labor - Hematomas (Swelling, discoloration, tenderness and bulging area just under the skin) - Ruptured uterus Manifestations - Slow, steady flow of blood of unclotted blood - Lochia rubra that continues into the fourth day following birth - firm uterus Intervention - surgical removal of hematoma if > 3cm

Answer 306

Factors - Preeclampsia - Stillbirths - Coagulation disorders (DIC) Manifestations - Oozing from IV sites - abnormal clotting (Nosebleeds, Petechiae, Bleeding gums) - Hypotension (shock)

Answer 307

Use: uterotonic for PP hemorrhage prevention or treatment Side effects: hypertension, NV, headache Contraindications: BP > 140/90

Answer 308

Use: uterotonic for PP hemorrhage (prostaglandin) Side effects: NVD, fever, increased BP, headache Contraindications: asthma

Answer 309

- Call for help - Massage uterus (if firm, find source) - Empty bladder (foley) - IV access (increase rate of maintenance fluids and maintain blood products) - Add Uterotonic Medications: oxytocin, methergine, hemabate to IV (given in 4 hrs PP) - O2 (10-12 L via nonrebreather) - lateral position. elevate extremities for venous return - notify provider (bimanual compression, balloon tamponade, pack w/ gauze) - Weigh blood-soaked peripad (1g = 1mL)

Answer 310

- more fatigued than the usual pp woman - discharged w/ iron supplements OR increase iron foods((leafy green vegetables, beans, red meat, poultry, iron-fortified cereal, breads, pasta, dried fruits (raisins)) - increase fluids

Answer 311

- multiparity - rapid or prolonged labor - assistive birth (forceps, vacuum, c-section, large episiotomy, tocolytics or halogenated anesthetics) - ROM > 24hrs r/t infection risk - conditions (preeclampsia, Chorioamnionitis or intra-amniotic infection) - previous PPH or uterine surgery - Uterine overdistention (macrosomia, multiple gestation, polyhydramnios) - Placental abnormality (succenturiate lobe, placenta previa, placenta accreta, abruptio placentae, hydatidiform mole) - fetal demise

Answer 312

S/s - fever, malaise - Tachycardia - subinvolution - excessive fundal tenderness - return of lochia rubra - foul-smelling lochia Management - clindamycin and gentamicin OR ampicillin until afebrile for 24-48 (IV if severe)

Answer 313

- Cloudy urine - labs: hematuria, bacteriuria - frequency, urgency - dysuria and suprapubic pain - costovertebral angle tenderness with Pyelo - Small, frequent voiding of <150 mL per voiding

Answer 314

- History of c/s - PROM - Invasive procedures (Frequent cervical exams, Internal fetal monitoring, amnioinfusion, episiotomy/lacerations,) - Preexisting pelvic infection (bacterial vaginosis, UTI, cervicitis - Poor nutrition (obesity, malnutrition) - DM - Epidural (urinary retention) - Anemia ( < 11) - prolonged labor

Answer 315

- prevention with hand washing and aseptic technique - Monitor vitals and temperature (tachycardia, fever) q4h or q2h if elevated temp - Increase fluids and promote nutrition (2L fluids; 1800-2000 calories if lactating, 1500 cal if nonlactating) - Administer antibiotics and analgesics - Monitor for worsening of signs and symptoms: Bleeding, drainage, pain

Answer 316

inflammation/infection of breast which locally obstructs flow of milk usually at 3-4 weeks OR 3-6 months of breastfeeding Cause: due to bacteria entering nipple cracks r/t improper infant latch S/s - Red, warm lump in breast with radiating erythema - cracked, blistered, reddened nipples - Fever, malaise, chills - body and headache Complication: abscess formation

Answer 317

- Commitment, attachment, and preparation for infant during pregnancy - Acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the early weeks after birth. - Moving toward a new normal during the first 4 months - Achievement of a maternal identity around 4 months

Answer 318

- Maternal suicide - Hemorrhage (most common after suicide) - infection - hypertensive disorders - VTE

Answer 319

Management - continue to breastfeed b-c infection in breast tissue not milk - Nipple care (moist heat for circulation) - antibiotics (cephalexin, dicloxacillin) for 10-14 days Prevention - Fully empty both breasts during breastfeeding - Massage breast during breastfeeding esp. tender areas and under armpit - Wear larger bra. - Use correct latch-on and removal, air-dry nipples, and multiple breastfeeding positions to decrease nipple irritation and tissue breakdown. - Hand hygiene prior to feeding - Avoid missing feedings.

Answer 320

Breastfeeding care - feed on demand and q2-3 hrs to prevent milk stasis - stimulate milk flow w/ breast massage or warm compresses - increase calories 500-1000 per day - breasts produce milk on supply and demand schedule in PP period (in L/D, milk production r/t hormones) Non-breastfeeding care - good support bra 24 hrs/day - cold compresses - avoid stimulation (no heat or pumping)

Answer 321

- Administer stool softeners or Dulcolax (stimulant if needed) - Ambulate to increase GI motility and decrease risk of gas pains. - Drink 10 glasses (3000 mL) of fluid per day esp. water and prune juice - Increase fiber and roughage in diet (fruits, vegetables, whole grains, legumes)

Answer 322

Timing - Lasts longer than 2 weeks within 12 months PP Management - assess in pediatric setting or at 2-week PP visit - for mild PPD, Psychotherapy - for moderate PPD, Psychotherapy AND antidepressants - for severe PPD or suicidal ideation, Psychotherapy, Antidepressants, Intense psychiatric care, ECT

Answer 323

- Establishing respirations (short periods of apnea and crackles normal in 1st hr) - Adjusting to circulatory changes - Ingesting, retaining, and digesting nutrients - Regulating weight

Answer 324

Chemical factors – mild hypoxia stimulates diaphragm to contract Sensory factors – touch, lights, sounds etc. cause crying which clears lungs Thermal factors- ambient temperature change, chemoreceptors in the skin stimulate a breath Mechanical factors – intrathoracic pressure changes related to chest compression during vaginal birth which removes fluid from lungs

Answer 325

- Immature alveoli (less surfactant in premature = more effort to breath) - Thicker alveolar wall (less efficient gas transport) - Decreased lung elastic tissue and compliance - Reduced diaphragm movement - Tendency to nose breath (difficulty synchronizing swallowing and breathing esp in premature - Increased O2 consumption and RR - Immature respiratory control (periodic apnea)

Answer 326

- Nasal flaring - Retractions (Intercostal/subcostal, Suprasternal/ subclavicular w/stridor) - Grunting - Seesaw respirations - RR <30 (bradypnea or >60 bpm(tachypnea) - Central cyanosis (acrocyanosis okay for 24 hrs) - Hypotonia and inactivity (late sign) - Apnea (cessation of breathing for 20 sec; less than 20sec if cyanosis, pallor, hypotonia, or bradycardia (<100 bpm) present.

Answer 327

- Persistent tachycardia (>160) - Persistent bradycardia (<120) - Pallor - Central cyanosis - Jaundice - Respiratory distress

Answer 328

Flow of heat from body to cooler air around it Care - keep door closed and room warm - wrap baby - maintain neutral thermal environment

Answer 329

Loss of heat from body to cooler surface not touching but in close proximity Care: not placing near windows, drafts

Answer 330

Loss of heat when liquid is converted to vapor Care: dry off quickly

Answer 331

Loss of heat from body to cooler surfaces in direct contact Care: skin to skin OR radiant warmer

Answer 332

- increased oxygen consumption increases RR - increased RR causes pulmonary and peripheral vasoconstriction - vasoconstriction decreases oxygen uptake by lungs and tissue - anaerobic glycolysis increases which decreased PO2 and pH (metabolic acidosis, hypoglycemia results)

Answer 333

- Hypothermia (<36.5) - RR increases, then apneic spells - Peripheral vasoconstriction (Skin color mottled, pallor w/ acrocyanosis) -> cyanosis - decreased physical activity in term and preterm w/ Respiratory distress - increased physical activity (restless, crying, flexed) if no respiratory distress) - Non-shivering Thermogenesis: intense lipid metabolic activity in the brain, heart, and liver via brown fat (less mature = less brown fat)

Answer 334

- External heat sources, phototherapy lights, sunlight - Excessive bundling or swaddling - Maternal fever, infection in labor - Dehydration (hypotonia, poor feed, weak cry)

Answer 335

- Get History (Maternal substance abuse, Prenatal care, Maternal conditions (preeclampsia, GDM)) - do Initial head to toe physical assessment within 2 hrs - do Apgar scoring (1 and 5 minutes) - Establish respirations (Dry to prevent heat loss and stimulate breathing effort; suction mouth then nose in side lying) - ensure thermoregulation (dry, radiant warmer, hat, skin-to-skin) - Initiate safety interventions (Arm bands; Electronic alarm system bands or tags; never leave infant alone) - give erythromycin and vitamin K within 1 hr (hep B prior to discharge

Answer 336

Appearance- Generalized skin color * 0: central cyanosis or pale * 1: acrocyanosis * 2: pink Pulse- Heart rate * 0: absent * 1: < 100 * 2: > 100 Grimace- Reflex irritability to tactile stimulation * 0: absent * 1: grimace * 2: vigorous cry Activity- Muscle tone (flexion) * 0: flaccid * 1: some flexion of arms and legs * 2: well flexed, active movements Respiration- Respiratory rate * 0: Absent * 1: weak, irregular, gasping * 2: good, crying

Answer 337

- 7-10 is normal (Do 10 minute APGAR if 5 min <7) - 4-6 —indicative of moderate distress,may need additional help breathing (Extra suctioning; oxygen (supplemental or positive pressure with face mask & Ambu bag) - 0-3 —indicative of severe distress (Resuscitation likely)

Answer 338

Purpose: To prevent ophthalmia neonatorum (gonorrhea or chlamydial eye infections) or neonatal conjunctivitis Side effects: edema, inflammation of eyelids

Answer 339

Purpose: To prevent bleeding due to lack of coagulation factors in gut until day 7 Dose: 0.5-1 mg IM in vastus lateralis (25 G, 5/8 inch) Side effects: erythema, pain, swelling at site

Answer 340

Day 1-2: Meconium—sticky, thick, and greenish black, odorless (Passed in 24-48 hrs) Day 3: Transitional—looser, lighter, greenish black or greenish brown or yellow Day 4: yellow soft watery Days 5-7 - Breastfed (yellow, semi-formed then golden yellow and pasty, seedy appearance, sour odor) - formula-fed (firmer, more formed, pale yellow or brownish yellow; unpleasant odor - Diarrhea (loose, watery, green)

Answer 341

- breastfeed exclusively for first 6 months of life (donor milk then formula are next best) - Breastfeeding should continue for at least 12 months - Complementary foods can be introduced after 6 months (reduces allergies)

Answer 342

- Readily available and no preparation or cost - immune protection (Passage of maternal antibodies) - Stimulates uterine contractions (prevention of PP hemorrhage) - Promotes weight loss more rapidly than formula feeding - amount of each nutrient tailored for newborn needs (more protein and less fat and lactose in preterm; fat for brain growth) - reduced risk of conditions in babies (ear infections, diabetes, eczema, asthma, cancer, SIDS

Answer 343

- chemo or radiation or antimetabolites - Active TB not under treatment (can express milk) - Active HSV on breast (can express milk) - HIV except developing countries w/o clean water) - Galactosemia in infant (rare hereditary metabolic disorder of carb metabolism) - Varicella (can express milk) - Maternal substance abuse (cocaine, amphetamine, PCP, cannabis) - Certain meds (Amiodarone, tetracyclines, certain psychotropics)

Answer 344

- Assess patient's thoughts about breastfeeding (barriers, previous experience, concerns) - initiate in golden hr (1st hr after birth) - discourage pacifiers & formula fortification until breastfeeding established - feed baby every 3-4 hours (on demand after 3-4 weeks) - Remove from breast via sliding finger to break suction - Allow to finish nursing from one side before switching sides (ALWAYS offer second breast and switch breast you start with) - May or may not burp b-c less air taken in

Answer 345

- Before lactation - colostrum ( high protein and antibodies, less fat than mature milk - mature Milk (complex w/ anti-infectives, fatty acids, growth factors) will come in 48-72 hours after birth - engorgement can recur in breastfeeding who miss feedings, have inadequate removal of milk.

Answer 346

Early - rooting - mouth opening (lip smacking or licking) - stirring - quiet alert Mid - Hand to mouth movements (sucking fingers) - increased physical movement (stretching Late - crying and turning red - agitated movementts

Answer 347

- firm tugging sensation but not pinching or pain (breastfeeding is NOT painful)-- break latch with finger - Belly to belly (football hold, sidelying, cradle hold) - mother is comfortable (not leaning over baby; bring baby to mother while mouth open - Uterine contractions/increased bleeding while feeding - Breasts feel lighter/softer after feeding

Answer 348

- bursts of 15-20 swallows at a time - Audible swallowing present - baby sucks full nipple and part of areola w/ rounded cheeks - newborn has at least 3 bowel movements and 6 – 8 wet diapers every day - regains birth weight by 2 weeks

Answer 349

- have 500 calories above pre-pregnant diet (no calorie restrictions) - have a glass of water every time patient nurses b-c more thirsty when breastfeeding - Avoid smoking, alcohol and excessive caffeine intake (before eliminating food, see how baby reacts) - need Adequate calcium intake

Answer 350

- Mastitis - Candidiasis - sore nipples - engorgement - plugged milk ducts (tender, pea-sized lumps)

Answer 351

Ready to feed - Most expensive - Easiest to use (Pour desired amount into bottle) Concentrated - Less expensive - Dilute equal parts with water Powdered - Least expensive - Easily mixed using one scoop for every 60 ml water

Answer 352

- Store in refrigerator for 48 hours after opening then disregard - Discard formula left in bottle after feeding (infant’s saliva mixed) - iron-fortified artificial milk has adequate nutrients for 1st 6 months of life. - After 6 months, fluoride supplementation of 0.25 mg/day is required if local water not fluoridated. - appropriate mixing and dilution is key to prevent dehydration or water intoxication - never warm up in microwave due to uneven heating and potential for harm to baby with too hot of formula - infants do not need supplemental water

Answer 353

Time Frame - Appears after 24 hours of age, Peaks 3-5 days, normal level by 14 days due to higher hemolysis in neonatal period Impact - resolves w/o treatment (usually) - progresses from head to toe

Answer 354

- ABO or Rh incompatibility - ineffective feeding (breastfeeding != cause jaundice)- delayed or infrequent) - cold stress - delayed cord clamping - infection (TORCH) - prematurity - polycythemia (G6PD deficiency, - GI obstruction - Hypoxia, asphyxia -> acidosis

Answer 355

Unconjugated hyperbilirubinemia (1.5-2 mg/dL) caused by pathology or severe physiologic jaundice Time frame - Appears within first 24 hours and lasts more than 2 weeks Impact - Kernicterus (delayed motor skills, cerebral palsy, hearing loss) - acute bilirubin encephalopathy (lethargy, seizures, coma)

Answer 356

- Feed early and often (Stimulates passage of meconium which excrete bilirubins) - Monitor bilirubin levels (visual not accurate; do TSB) - Phototherapy (eye shield on; No lotions; Take temp q4h, Only diaper on)- risk for hyperthermia, fluid loss - Exchange blood transfusion (if phototherapy ineffective) - IV immunoglobulin (IVIG): for hyperbilirubinemia r/t isoimmune hemolysis.

Answer 357

Gestational age - Preterm (premature): Born before completion of 37 weeks. - Full Term: Born from 39 0/7 – 40 6/7 weeks. - Postterm (postmature): Born after 42 weeks. Birth weight - Extremely LBW: <1000 grams at birth - VLBW: Weight off 1000-1500 g (3.3 lb.) - LBW: Weight of 1500-2500 g (5.5 lb.) Size based on gestational age - LGA: Weight > 90th percentile for gestational age - AGA: Weight between 10th and 90th percentiles for gestational age - SGA: Weight < 10th percentile for gestational age Best prospect for survival: Born after 37 wks. and weighing more than 2500 gms.

Answer 358

- complications r/t immature organs (electrolyte imbalances - Infection/Sepsis (most significant esp. pneumonia) - Intraventricular hemorrhage - Cold stress r/t thin skin and low brown fat - Respiratory distress - Neurodevelopmental problems (cerebral palsy, visual-motor deficits, ADHD, intellectual ability) - Hyperbilirubinemia - Hypoglycemia (normal = 50=90)- also seen in Infants of diabetic mothers, LGA or SGA

Answer 359

Hemorrhage into and around ventricles caused by rupture of vessels when an event increases cerebral flow s/s - sudden deterioration (oxygen desats, bradycardia, shock, hyperglycemia) - worsening condition (decreased LOC, seizures, full fontanels) Nursing implications: - provide ventilatory support (maintain oxygenation and acid-base balance) - Avoid events that change blood flow to ventricles (pain, suctioning, hypoxia, rapid volume expansion) - Keep HOB flat or slight elevation w/ head midline ( hips below head during diaper changes)

Answer 360

- Antibiotics prophylaxis - Dopamine or dobutamine for hypotension - Erythropoietin for RBC production (reduce need for transfusion, decrease incidence of IVH, NEC) - Exogenous surfactant for RDS - Opioids for moderate to severe pain - Sodium acetate for metabolic acidosis (Sodium bicarb not recommended b-c may be unable to blow off excess CO2 produced in metabolism of bicarbonate)

Answer 361

Cause - lack of pulmonary surfactant due to underdeveloped alveoli - loss of functional residual capacity (Inability to maintain lung partially open leads to collapse/atelectasis due to energy expenditure) - ventilation-perfusion imbalance with an uneven distribution of ventilation. Risks - Metabolic acidosis r/t buildup of lactic acid from prolonged hypoxemia - Respiratory acidosis r/t collapsed alveoli inability to rid body of CO2 (hypercarbia) - Pulmonary artery vasoconstriction - Right-to-left shunting through ductus arteriosus and foramen ovale

Answer 362

- decrease severity w/ steroids in prenatal period - maintain adequate ventilation and oxygenation (for acid-base balance, perfusion)- CPAP, surfactant replacement - Maintain a neutral thermal environment (prevents cold stress) - Prevent hypotension - Maintain adequate hydration and electrolyte status

Answer 363

- Assess for s/s of respiratory distress, hypoglycemia, hyperbilirubinemia, polycythemia - Monitor blood glucose per institution protocol (Initial hypoglycemia for 4 hours) - If insulin-dependent or IV dextrose needed, baby will go to NICU - Provide early and frequent feedings (may be lethargic and hard to arouse for feedings)

Answer 364

Urine drug test - Reflects drugs taken within last 1-3 days (does not give info about drug use during entire pregnancy) - catch the first void after delivery Meconium (Improved accuracy over urine) - Best to collect multiple small samples over time - Reflects drugs taken during last 4-5 months

Answer 365

Time Frame - Symptoms can appear within hours, up to 4 days or even 2 weeks Common symptoms: (NOT correlated w/ maternal dose) - Irritable, high-pitched cry - increased muscle tone and/or reflexes (tremor, sleeplessness)) - tachypnea - sweating - poor feeding, frantic sucking, vomiting - yawning, sneezing

Answer 366

- stabilizing withdrawal symptoms (w/ morphine, buprenorphine, methadone, clonidine, phenobarbital, benzos) and then gradually weaning off medication - Decrease stimuli - Remain non-judgmental of family and promote bonding - Frequent, small feeds w/ high calorie formula (22-24 cal/oz)- may need gavage or slow flow nipple

Answer 367

Facial dysmorphia - Folds of skin b/w eyes and nose - poorly developed philtrum (Flat upper part of nose; smooth area b/w nose and upper lip) - Short nose - Thin upper lip - microcephaly - microphthalmia (small eye opening) - hypoplastic maxilla CNS abnormalities

Answer 368

- Tobacco (IUGR, preterm, stillbirth, SIDS, LBW; (risk for PROM, placenta previa, placental abruption) - nicotine = vasoconstrictor so decreased perfusion; goal: < 10 cigs/ day - Heroin, methadone (IUGR, prematurity, Neonatal abstinence syndrome(CNS irritability)) - cocaine (increases maternal BP, IUGR, placental abruption, prematurity; LBW, organ defects) - alcohol (> 1 drink/day (no safe level)-- fetal alcohol syndrome, SIDS, cognitive disabilities, preterm, SGA, stillbirth) - Marijuana (low academic performance, ADHD, LBW)

Answer 369

- Clustering of care to promote sleep (do not cluster painful interventions) - Limit stimuli-noise, lights, touch (Overstimulation impacts ability to grow) - Skin to skin with parents/kangaroo care - involve parents in care as much as possible

Answer 370

Hemolysis (RBC destruction via constricted vessels)- total bilirubin > 0.2, abnormal peripheral smear Elevated Liver Enzymes (Decreased blood flow and Damage to the liver)- AST > 70, RUQ pain, NV, malaise Low platelets (<100,000)- Platelets aggregate at the site of damaged endothelial vessels (platelet consumption and thrombocytopenia)-- easy bleeding, bruising

Answer 371

Onset: any time including postpartum Risks: placental abruption (PTL, death), renal failure, liver hematoma Treatment - Delivery but may worsen in first 48 hrs postpartum - platelet replacement

Answer 372

- parity (multiparity have more info but may grieve special bond w/ first child) - maternal age (adolescence and older have difficult time) - sexual orientation (social stigma, heteronormativity of care, legal implications for gender miniorites) - single parenting (legal and financial concerns) - hx of abuse (pregnancy can trigger or worsen IPV) - multigestational - military deployment (higher mental health disorders) - cultural and SES factors - planned vs unplanned