OB-Exam 3 Flashcards
What is APGAR and when do we use it?
It is used immediately after the newborn is delivered It It is used to tell how well the newborn is adapting to extrauterine life. Given at 1 minute of delivery and then 5 minutes of life.
What does APGAR stand for
appearance, pulse, grimace, activity, respiration effort
What is the ballard score used for?
to calculate the approximate gestational age of the newborn. It can often be used if the mother doesn’t know when her last menstrual period etc.
What are typical medications a newborn would receive?
Erythromycin, Vitamin K, Hepatitis B
When and why would we give erythromycin to a newborn?
(eye ointment) applied within 1 hour after birth, eye prophylaxis to prevent gonorrheal conjunctivitis
When and why would we give Vitamin K to a newborn?
Administered within 1 hour after birth to prevent hemorrhage/ excessive bleeding.
(newborn GI tract is sterile at birth and unable to produce Vitamin K)
*especially in circumssion
When and why would we give Hepatitis B to a newborn?
First dose within 12 hours of birth, second dose at month, third dose at 6 months.
-If the mom is positive for hepatitis B surface antigen newborn will also receive hepatitis B immune globulin
Neonatal abstinence syndrome
- neonatal substance withdrawal, mother who took drugs while pregnant, and baby experiencing withdrawal symptoms after being born.
What drugs can cause NAS?
Opioids, narcotics,heroin,methadone,weed, amphetamines, alcohol
Neonatal Abstinence Syndrome expected findings
high pitch shrill cry, irritability, disturbed sleep, tremors, convulsions, hyperreflexia
tachypnea, congestion, sweating, frequent sneezing due to ^ acetylcholine, poor feeding, regurgitation, vomiting, diarrhea, excessive or uncoordinated sucking
NAS complications
risk for skin breakdown, vomiting/ diarrhea risk for dehydration and feeding issues, gaining weight, glucose control
-increase resp.> Hyper ventilation can cause resp. alk.
long-term effects, add, microcephaly, poor maternal bonding, learning/developmental delays
NAS nursing care
-urine/ meconium collection to determine what drugs
-Perform NAS assessment performed every 3-4 hours after baby eats
-monitor ability to feed, offer small frequent feedings
-tight swaddle and dark room little stimuli
- monitor fluid and electrolytes
What are the different categories of the Finnegan NAS Tool
- Central nervous system disturbances
- metabolic, vasomotor, & respiratory disturbance
-Gastrointestinal Disturance
When would treatment be warranted for the baby based on the Finnegan NAS Tool
If they are scoring an 8 or higher
Hypoglycemia in newborn
range: glucose level below 45 can get to as low as 40 in about 4 hours of life (the normal term can tolerate these levels)
What puts a newborn at risk for hypoglycemia
Preterm babies, SGA (small or gestational age) and LGA (large for gestational age) , and stressful birth and infants born of a diabetic mother
Physiological stress on the newborn
Cold stress or improper thermal regulation, asphyxia, or decreases in O2 -> at risk for experiencing hypoglycemia
Expected findings of hypoglycemic baby
initially, they will be jittery, after awhile they will become lethargic and flaccid and have a weak cry and weak suck, and can become poor feeders
Nursing care for hypoglycemic baby
-perform heel stick to monitor glucose
- make sure the baby has a good feeding and early feeding
-monitor feedings and glucose -glucose checked before baby eats Q 2-3 hours
-Skin-to-skin will help baby regulate temp.
What is considered a preterm infant?
an infant that is born before 37 weeks of gestation
- early preterm - 24-34 weeks
-late preterm 34-37 weeks
Risk factors for preterm births
Inadequate nutrition, smoking while pregnant, adolescent pregnancy, and alcohol abuse
preterm complications overview
-Early preterm is more likely to be affected.
-in pre-term overall more likely to be respiratory and cardiovascular issues
preterm complications
-RDS, decreased surfactant which will cause alveoli to collapse
-Aspiration, premature infant gag reflex not intact, therefore, can effectively suck or swallow
-Intraventricular Hemorrhage, bleeding into brain ventricles, due to fragile capillaries and immature development
-Retinopathy of prematurity ROP- due to vasoconstriction of retinal blood vessels
-Necrotizing enterocolitis-inflammatory disease of GI mucosa due to ischemia
-Ineffective thermoregulation, inadequate amount of brown fat
Prematurity Assessment and common labs and Dx procedures
Evaluate any risk factors involved,
Labs: CBC, urinalysis, PT/aPTT, glucose, bilirubin, ABG
Dx: chest x-ray, heart ultrasound, echocardiography
Expected findings for a premature baby
-Ballard assessment- will reveal <37
-Lanugo will be scant in very premature newborns and extensive in late preterm newborns
-Hypotonic muscles, decreased activity, weak cry
-apnea
-increased resp. effort
-head and ears appear larger
Premature infant nursing care
- Continuously monitor vital sings
- assess the ability to gag and suck will help determine ability to consume and digest nutrients
-Because immature infants can not sweat or shiver environmental temperature protection is important
-often on CPAP, intubated, or on O2, monitor resp. rate any signs of distress and monitor O2 levels
-bundle care to reduce stimulation
-Monitor ins and outs
Post-term infant
-born 42 weeks gestation or older
-main concern after 40 weeks placenta looses function and nutrients
-Can still be sga or lga
Complications for post-term newborn
-birth trauma
-Meconium aspiration
-Polycythemia
-Clavicle fracture
-fetal hypoxia
-hypoglycemia
-temperature instability
Post-term expected findings
- decrease in vernix and lack of amnio fluid so they may look dry with peeling skin
-thin due to lack of nutrients and diminished subcutaneous fat
-meconium stained (yellowish appearance)
-difficulty establishing respirations due to the possibility of meconium aspiration
Necrotizing enterocolitis
-happens in preterm babies more than post-term
-necrotic patches within intestines, which can lead to perforation, paralytic ileus, peritonitis
-usually caused by lack of blood flow
-less incidences found in those breastfed vs. formula
- usually can present as abdominal distension, apnea, hypotension, positive occult blood
What is bilirubin?
It is a substance that your body makes when there is a breakdown of red blood cells. An accumulation of bilirubin can cause jaundice.
Types of Jaundice
-Physiologic Jaundice is caused by the breakdown of fetal red blood cells and an immature liver. It is a normal process after the first few days of life. Elevation of unconjugated bilirubin typically peaks on days 3-5, rapidly declines, and then comes back to normal on days 5- 10. This bilirubin excretes through bile and urine.
-Pathological Jaundice: Result of an underlying disease and usually appears 24 hours before life. This could be due to blood group incompatibility, infection, or blocked bile duct, or red blood cell disorder, which excretes through the stool.
-Breastfeeding Jaundice: due to something in the breastmilk called preganalol, progesterone metabolite that interferes with converting indirect bilirubin to direct bilirubin. can be treated with an increase in breastfeeding
Hyperbilirubinemia risk factors
- ABO blood incompatibility If mom is O and baby is a or b blood. (the mother’s immune system can react and make antibodies that fight against baby blood cells)
-Increase in RBC production will lead to breakdown aka hyperbiirubin
-cephalohematoma and ecchymosis are a collection of RBCs that need to be monitored and may develop hyperbilirubinemia or jaundice
-The liver is responsible for converting fat-soluble bilirubin to water-soluble and due to the immature nature of newborns’ liver it can prevent the process and cause a build-up of bilirubin.
Hyperbilirubinemia expected findings
- yellowing tint to the skin (jaundice) usually starts in the head and works its way down. Blanch test, note the timing of onset.
Labs
-Bilirubin- if at risk monitored every 4 hours, if not tested at 24 hours
-Direct Coombs: detects the presence of antibodies due to rh + newborn and if mom is Rh- and there is an exposure then the test would be +
Hyperbilirubinemia Nursing Care
-Observe the newborn’s skin and note any signs of jaundice
-monitor vital signs
-one treatment option is phototherapy if levels are above 10-12 may vary and depend on age and baby-specific
-Education to parents is important (as much contact and time as possible
- monitor for dehydration: turgor, decreased urinary output, any signs of dry mucous membranes
Hyperbilirubinemia Complications
Acute Bilirubin encephalopathy (kernicterus)
-permanent brain cell damage if levels reach 20 or higher can cause developmental delays, hearing/vision loss, cognitive impairment
Developmental Hip Dysplasia and how do you assess it
-improper formation and function of the hip socket (socket of the hip is flat so the head of the femur won’t stay in the socket)
- Ortolani is done while a newborn is supine and flat place fingers over the greater trochanter and abduct the hips listen for a clicking sound, then keep hips and knees bent at 90 and apply downward pressure and apply towards the body feel for slipping
- if a positive finding ultrasound will be the preferred method of finding it. Needs to be found earlier rather than later.
What is considered a high risk pregnancy?
one in which a concurrent disorder pregnancy related complication or external factor jeopardize the health of the pregnant person, fetus or both
Cardiac disease in pregnancy
a disease that can affect the heart or blood vessels during pregnancy like coronary artery disease, high blood pressure, valvular disease
What happens with blood and cardiac output during pregnancy
blood volume and cardiac output increases about 30% and up to as much as 50%
what are the four categories of heart disease
class I, II, III, IV
I or II: heart disease can expect to experience a normal pregnancy and birth
III: can complete a pregnancy by maintaining special interventions like bed rest
IV: usually advised to avoid pregnancy because they are in cardiac failure even at rest and when they aren’t pregnant
What is the danger behind pregnancy in a person with cardiac disease
There’s an increased workload that can cause heart failure and then cause pulmonary edema. there is an increase in circulatory volume. it can be very dangerous in weeks 28-32 just after blood volume peaks.
Nursing care in cardiac disease in pregnancy
Monitor and get a baseline respiratory rate and blood pressure, pulse rate when they go in for visits. most likely an EKG and echo on file to monitor.
The biggest complication when they have cardiac disease during pregnancy is
Hypertension can result in poor perfusion to both mother and baby because they have damaged blood vessels. poor perfusion to heart kidneys and placenta (vary vascular)
What can be prescribed to help mothers with hypertension/ cardiac disease during pregnancy?
Betablocker, or calcium channel blocker like BB labetalol, CB Procardia
Gestational Hypertension
Vasospasms occur in both small and large arteries during pregnancy causing increased blood pressure
What is a vasospasm?
Its what happens when an artery is being constricted and narrowed
Risk factors for gestational hypertension
person of color, experiencing multiple pregnancies, a pregnancy before the age of 20 or after the age of 40, poor nutrition, gravida 5 or more
The most important thing when it comes to what causes gestational hypertension is what and what does it mean.
It is caused by a vasospasm which leads to a decrease in blood flow.
When would someone with gestational hypertension be induced
around 37 weeks to reduce further complications like preeclampsia.
When does gestational hypertension occur
20 weeks after gestation
blood pressure systolic 140 or greater
blood pressure diastolic 90 or greater
or both
If someone has gestational hypertension and proteinuria what could it be indicative of
preeclampsia
Preeclampsia without severe features- symptoms
Systolic 140 or greater or diastolic 90 or higher or both *
proteinuria*
excessive weight gain
mild facial edema or upper extremity edema
Preeclampsia Nursing Care
Monitor vital signs
monitor urine output
Labwork: CBC, PLT, Liver enzymes
Deep tendon reflexes
monitor for edema
Expected findings for preeclampsia
BP >140-90
+ proteinuria
1+ or 2+ upper extremity edema
>1lb weight gain (third trimester)
>2lb weight gain (9second trimester)
patellar reflex 3+ or 4+
Ways to detect proteinuria
Dipstick, 24-hour urine collection, urine PCR protein creatine area .3 or higher indicative
What is a treatment for preeclampsia
Magnesium sulfate
What is magnesium sulfate and how much should be given?
anticonvulsant, CNS depressant, 2-6 gram loading dose followed by continuous infusion
with a therapeutic range being 5-8mg
What is magnesium toxicity and how do we treat it
too much magnesium can lead to decreased/absent reflexes, respiratory depression, decreased output <30ml/hr, cardiac arrhythmia
stop infusion — the antidote is calcium gluconate
What should you be monitoring hourly when giving magnesium sulfate
Blood pressure, respiratory rate, FHR, intake/ output, LOC, patellar/ Bicept reflex
What is a process that can occur due to gestational hypertension with Mnemonic
HELLP
H-Hemolysis leads to anemia
EL-elevated liver enzymes lead to epigastric pain
LP- Low platelets lead to abnormal bleeding/ clotting
Risk factors in diabetes in pregnancy
Obesity, age over 25, hx. of large babies 10lbs<, hx. of unexpected fetal loss, hx. of congenital anomalies, hx. Of PCOS, family hx. of diabetes
What is gestational diabetes
a condition of abnormal glucose metabolism that arises during pregnancy
At what age are pregnant women screened with 50g glucose challenge test
24-28 weeks
How do you manage diabetes
-diet control with glucose monitoring (fasting should be <90, 1-hour post prandial should be <140)
-medicinal therapy for GDM, glyburide, metformin, and insulin are all appropriate treatment options
-Insulin therapy: shorter-acting insulin with or without intermediate-acting. may need to increase later in pregnancy
- insulin pump therapy: continuous rate of insulin
-Make sure to follow up postpartum to assess the development of type 2 diabetes.
What is important regarding education, monitoring, nutrition, and exercise in regard to GDM
The calorie diet is split into 3 meals and 3 snacks
-20% of intake should be protein, and 40%-50% of intake from carbohydrates, 30% of intake from fats
-daily walk, 30 minutes
-eat a snack before exercise
Hyperemesis gravidarum
sometimes called pernicious or persistent vomiting)
-nausea & vomiting of pregnancy prolonged past week 16 of pregnancy or that is so severe that dehydration, ketonuria, and significant weight loss occur within the first 12 weeks of pregnancy
Hyperemesis Gravidarum S&S
Nausea, vomiting, weight loss, elevated HCT(hemoconcentration), decreased sodium, potassium, chloride
Cervical insufficiency
premature cervical dilation, previously termed an incompetent cervix, refers to a cervix that dilates prematurely and therefore cannot retain a fetus until term. and its common at 20 weeks
cervical insufficiency S&S
painless, pink-stained vaginal discharge, pelvic pressure, ROM, contractions
what is a cervical cerclage
A surgical procedure that involves placing a stitch or band around the cervix to keep it closed during pregnancy
What happens if a woman has a hx. of premature cervical dilation
they will receive a cervical cerclage at 12-14 weeks gestation
How do you determine placental previa
ultrasound will determine placement
What is placental previa
a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus.
What is the most common cause of painless bleeding in the third trimester of pregnancy
placental previa
Placental previa risk factors
advanced maternal age, hx. of placenta Previa, multiple gestations, uterine scarring, smoking
placenta previa assessment and management
-during the second or third trimester abrupt painless bright red bleeding (comes out fast)
-bed rest, monitor vaginal blood loss, sonogram/ ultrasound, external FHR monitor (internal monitor is contraindicated)
-urinary output, labs, *no vaginal exams
Abruptio placentae
premature separation of the placenta. occurs late in pregnancy and during labor. Occurs later in pregnancy and there’s a concern for hemorrhage
Abruptio Placentae risk factors
maternal HTN, Blunt trauma, cocaine, cigarettes, chorioamnionitis
Placenta abruption assessment and management
-sudden localized uterine pain and tenderness
-Uterus becomes rigid, board like
-Dark red vaginal bleeding
-Closely monitor FHR
- checks slide25
DIC Disseminated Intravascular Coagulopathy
Occurs when there is extreme bleeding. Platelets and fibrin from general circulation rush to the site (where the placenta detached) body is left with none of these
Explain fibrinogen
glycoprotein which is synthesized by the liver , is a major structural component of clotting and hemostasis
Signs of DIC
Bruising, Bleeding from IV site/ incisions, petechiae, hematuria
What is an ectopic pregnancy?
Implantation occurs outside of the uterine cavity. Most common site is fallopian tube
Findings with ectopic pregnancy
-Unilateral stabbing pain in lower abdomen
-Missed/ delayed menses
-scant,dark red/brown, vaginal spotting
-signs of hypovolemic shocks
-you will have a positive pregnancy test or hGC
-Transvaginal U/S will reveal a ruptured fallopian tube and blood collecting in peritoneum
What qualifies as Precipitate labor
Cervical dilation that occurs at a rate of
-5cm or more per hour in a primipara , 1 cm every 12 min
-10 cm or more per hour in a multipart, 1 cm every 6 min
Amniotic fluid embolism
it is rare and an obstetrical emergency
-occurs when amniotic fluid is forced into an open uterine blood sinus, after a membrane rupture or partial premature separation of the placenta
What could cause an amniotic fluid embolism
could be due to fetal cells entering the mothers blood stream or an anaphylactic reaction from amniotic fluid in the maternal bloodstream
Amniotic fluid embolism assessment
anxiety, SOB, chest pain, pale/blue skin, unconsciousness, Cardiac collapse
Amniotic fluid embolism complications
pulmonary artery constriction, poor organ perfusion, poor placental perfusion, decrease in coagulation factors
AFE Nursing management
Monitor FHR, Cardiopulmonary Resuscitation, notify the MD, prepare for emergency C-section, transfer to ICU, blood transfusion
Shoulder Dystocia
A birth problem common in LGA (maternal diabetes) as well as postdate babies
-fetal head is born but shoulders are too broad to enter the pelvic outlet
*can be hazardous to the mother and fetus
Shoulder Dystocia Interventions
- McRoberts Maneuver to widen pelvic outlet.
- Suprapubic pressure to dislodge and rotate the fetal shoulder.
What is a clinical sign for shoulder dystocia and describe it
turtle sign - a clinical sign that occurs during childbirth when the fetal head is delivered but then retracts back into the birth canal
What fetal trauma happens during shoulder dystocia>
-fracture of the clavical
-brachial plexus injury, nerves between the neck & shoulder are stretched compressed, or torn during birth
Umbilical cord prolapse
when the cord slips out and the presenting part can compress and it can fall out and through the cervix or fall completely out of the vagina
How can a nurse help during an umbilical prolapse
they can move the presenting part off of the umbilical corn using their hands. It will relieve the compression so the baby can get blood supply and oxygen again. rotating wont help as much as lifting the pressure off the cord.
Risk factor for umbilical cord prolapse
-rupture of membranes
-fetal presentation other than cephalic: breech baby
-intrauterine tumors
-small fetus
-polyhydramnios: more fluid so more space cord can slip through the cracks
umbilical cord prolapse assessment
- could feel like she has something slipping out, the provider may be able to feel it or see it
-on the FHR monitor it may show variable or prolonged deceleration
umbilical cord prolapse interventions
-apply a sterile glove and manually elevate the presenting part to relieve pressure off the cord
-could be rushed to a c-section
-knee-chest position
- 8-10l oxygen via face mask
preterm labor
less than 37 weeks gestation
preterm labor risk factors
the true factor is unknown but associated with
-previous preterm birth
-short interval between pregnancy
-short cervical length
-drug use and illicit drug use
-perinatal infection
-placenta previa
-polyhydramnios
-fetal birth defects
-socioeconomic instability
-intimate partner violence
preterm labor assessment findings
-low backache
-pelvic pressure
-cramping
-vaginal spotting
preterm labor diagnostic procedures
-ultrasound to measure cervical length
-cervical cultures
-biophysical profile/ non-stress test (determines how well the baby is doing)
-vaginal swab to detect fetal fibronectin
How to manage preterm labor
-bed rest/ activity restriction
-vaginal swab, urine collection
-FHR monitor, contraction monitor
-IV hydration
-Identify/ treat any infections
How to manage preterm labor with medications
Terbutaline
- A beta-adrenergic agonist used as a tocolytic that relaxes smooth muscles and inhibits uterine activity
Betamethasone
-given 12-24 hours before birth to hasten fetal lung maturity if a fetus is less than 34 weeks gestation. helps prevent resp. distress syndrome in newborn
Terbutaline
medication used to delay preterm labor by relaxing the uterus and reducing contractions. (tocolytic)
-sub Q Q 4hr
-do not use or use cautiously in diabetes, hemorrhage, preeclampsia with severe features
Betamethasone
a glucocorticoid (steroid) given to enhance fetal lung maturity and surfactant
-intramuscular injection
- ventral gluteal or vastus lateralis, 2 injections 24 hours apart
-ideally 24 hours before delivery
lasts for 7 days
*monitor for maternal hyperglycemia
