Test Three Flashcards
Preterm labor management: what kinds of things do we do for preterm labor?
Give tocolytics: Mag sulfate, turbutiline, nifedipine, and Indocin
What are the complications of gestational diabetes: in regards to fetal size
LGA, C-section, shoulder dystocia
How do we treat shoulder dystocia:
McRobert’s maneuver or suprapubc pressure
Mag Sulfate: what do we worry about? Toxicity:
less than 12 RR, absent DTR
CNS depressant- relaxes smooth muscle, (not IM- controls seizures and convulsions)
->10 = toxic
-If mom is on, limit IV fluids to 100 mL/hr
- When to give and when to DC-
- Look at fetal kick counts
- S/S- relaxed, warm, flushed at IV site
- Toxic s/s- absent reflexes, slurred speech, lethargy, hypotension, bradycardic, low resp, cardiac arrest
- Decreases CNS and cardiac conduction
Anemias: what types?
Iron deficiency and thalassemia
What is the most common type of anemia?
Iron deficiency
What do we give moms to prevent anemia?
Iron supplements and nutritional eduation
When does a mom have iron deficiency anemia (What levels)? What can cause it?
also caused by ulcer, polyps, colon cancer, UTIs
o <10.5g/dl = 2nd trimester
What is thalassemia?
inherited blood disorder involving hemoglobin
What is the difference between chronic HTN and PIH?
- Chronic is something you had prior to pregnancy
- the placenta is what is causing PIH (they think), so once the placenta is removed, the condition should go away
- You can have chronic and PI
What is PIH?
- Onset of hypertension without proteinuria after week 20 of pregnancy
- Gestational hypertension- around 37th week, goes to normal 6th week postpartum
- The earlier it starts, more severe it can be à precclampsia
What is chronic HTN?
Present before pregnancy or diagnosed before week 20 of gestation
What is the difference between HTN in pregnancy and preeclampsia?
HTN you have HTN but no protein spill: 1+-2+ is okay (mild), any more than that is preeclampsia
What level of protein spill is preeclampsia?
3+ or more protein in the urine is preeclampsia
What are the s/s of preeclampsia?
pitting edema, headache, epigastric pain, blurred vision
What is preeclampsia
- Disease of reduced organ/placental perfusion with presence of hypertension and proteinuria
- Main pathogenic factor is not increase in BP but poor perfusion resulting from vasospasm
- Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to all organs and increases BP
-What are the symptoms we’d expect to see with abrupto placenta:
painful bleeding, rigid/board like abdomen (abrupto placenta could be caused by blunt trauma to the abdomen)
What are the causes and risk factors for placental abruption?
congenital anomalies, congential tube defects, SGA,
Risk factors- cocaine, HTN, trauma, hx of smoking, more common with twins
Can you take any oral meds for gestational diabetes? Why? How do you take it?
Glyburide.
-Because only a minute amount will cross the placenta barrier, can use with insulin, take 30-60 min before meal, make sure mom has good source of sugar in case drops down
•Metformin- type 2 only
-Diabetic mom: what happens in the beginning of pregnancy?
Their insulin needs decrease so they are at risk for hypoglycemia
Diabetic mom in the 2nd trimester:
they become more insulin resistant, fetus is growing and needs more sugars, so they are more at risk for hyperglycemia (we want more sugar in the blood to be available to the fetus)
-insulin needs gradually increase from 18ish-36 weeks
Diabetic mom in the 3rd trimester:
their insulin needs will triple or quadruple to what they were in the beginning
-gradually increase up to 36 weeks
Diabetic mom after delivery:
Baby at risk for:
Maternal insulin requirements drop drastically to prepregnancy levels
- the mom’s insulin needs will gradually return to normal in 7-10 days (will have some residual needs if breastfeeding)
- baby is at risk for hypoglycemia
Diabetic moms and breastfeeding:
- Breastfeeding mother maintains lower insulin requirements
- Weaning breastfeeding infant, mother’s insulin need returns to prepregnancy levels
Mag sulfate: what do we do as nurses when giving mag sulfate?
Watch their urine output! And listen to their lungs! Strict I&O! Usually on fluid restrictions
-Make sure they don’t have crackles and don’t have pulmonary edema. It is a smooth muscle relaxant and you’re not breathing too much and you’re not contracting your heart as well.
What do you do if a pt has a prolapsed cord?
call for help, then push up on presenting part, put patient in knee to chest position (if you can’t see the cord)
What are some risk factors for preterm labor?
Smoking, dehydration, infection, nutritional status, drugs, age (adolescents), low socioeconomic status
What is HELLP syndrome?
Hemolysis (jaundice and anemia), Elevated Liver enzymes, Low Platelet
What do we give routinely to prevent PPH?
Oxytocin, misoprostil, methergine, hemabate
Sickle cell anemia:
for these women it is very painful, stay hydrated (their blood is very viscous)
What is the effect(s) of asthma in pregnancy?
unpredictable.
1/3 the severity is unchanged
1/3 the condition is improved
1/3 the condition worsens
What are prostaglandins E1 and E2 used for?
used before induction to “ripen” (soften and thin) the cervix
-reduces amount and time of oxytocin administration
What are the advantages and disadvantages to using prostaglandin E1?
Pros: less expensive and more effective than E2
Cons: increased risk of hyperstimulation of the uterus w/ FHR changes and meconium-stained amniotic fluid
What other names does Prostaglandin E1 go by?
Misoprostol (Cytotec)
What other names does Prostaglandin E2 go by?
Dinoprostone (Cervidil Insert, Prepidel Gel)
What does oxytocin do? When is it used?
stimulates uterine contractions and ids in milk let-down
-either to induce labor or to augment a labor that is progressing slowly because of inadequate contractions
What are the adverse reactions to oxytocin?
Maternal: pain, abruptio placentae, uterine rupture, unnecessary C sections caused by nonreassuring FHR patterns, PPH, and infection, water intoxication
Fetal: too long/too many contractions can cause fetal hypoxemia and acidemia –> late decels and absent variability
What is the ideal contraction pattern for active labor?
One contraction every 2-3 minutes, lasting 80-90 seconds, and strong to palpation
What is the definition of PPH?
loss of more than 500 mL of blood after vaginal birth and 1000 mL after cesarean birth
-also 10% change in Hct or need for erythrocyte transfusion
What is early/acute/primary PPH?
occurs within 24 hours of the birth
What is late/secondary PPH?
occurs after 24 hours and up to 6-12 weeks PP
How do we treat PPH?
1) Fundal massage (evaluate contractility of the uterus)
2) Express clots, void, and Pitocin IV
3) ergonovine (Ergotrate or methylergonovine (Methergine) IM or Prostaglandin F2a IM
4) PGE2 (Dinoprostone suppository) or misoprostol (suppository)
5) Rapid crystalloid solutions, blood, or blood products given to restore intravascular volume
6) Oxygen, urinary catheter, Labs
7) Bimanual compression (fist), manual exploration for retained placental fragments
8) surgery: vessel ligation, arterial embolization, and hysterectomy
If a pt has HTN or cardiovascular disease, which PPH drugs are contraindicated?
ergonovine or methylergonvine (Methergine)
Which drug should be use cautiously in women with cardiovascular disease or asthma?
Prostaglandin F 2a
How do prostaglandins affect pregnant women with asthma?
negatively affects women’s respiratory staus
What is the most common pulmonary disorder in pregnancy
asthma
Mom’s w/ asthma have increased risk for …..?
-First drug of choice?
PPH
-first drug of choice is oxytocin/pitocin
What drugs are used for preterm labor?
Tocolytics like... Nifedipine Mag Sulfate Tubutaline Indocin
At what gestational age would we not give Indocin meds? Why?
32 weeks!
Only give less than 32 weeks
-will close ductus arteriosis
Which tocolytic is this?
CNS depressant; relaxes smooth muscle
Adverse: RR
Mag sulfate
Which tocolytic is this?
beta-adrenergic agonist
Relaxes smooth muscles, inhibiting uterine activity, and causing bronchodilation
Adverse: tachycardia > 130, BP
Terbutaline (Brethine)
Which tocolytic is this?
CCB, relax smooth muscles
Maternal: hypotension, HA, flushing, nausea, dizziness
Fetal: hypotension
Nifedipine (adalat, Procardia)
Which tocolytic is this?
NSAIDs, relaxes uterine smooth muscle by inhibiting prostaglandins
Maternal: Gi bleeding, prolonged bleeding time, thrombocytopenia, asthma in aspirin sensitive pts
Fetal: constriction of ductus arteriosus, oligohydramnios, neonatal pulmonary hypertension
Indomethacin (Indocin)
What is the therapeutic levels for magnesium?
4-7.5 mEq/L or 5-8 mg/dl
What is the reversal agent for mag sulfate?
calcium gluconate
What is the fluid restriction for mag sulfate?
IV intake should be limited to 125ml/hr to decrease risk for pulmonary edema
Which tocolytic should not be used in women with history of cardiac disease, diabetes (DM or GDM), preeclampsia or eclampsia, hyperthytoidism, or hemorrhage?
Terbutaline, watch mom’s sugars, increased risk of hyperglycemia
What GA do we give Terbutaline?
over 20 weeks and less than 35 weeks
Do not use ______ if you have renal/hepatic disease, active peptic ulcer disease, poorly controlled HTN, asthma, or coagulation disorders
Indocin
HELLP syndrome is a laboratory diagnosis for…?
a variant of severe preeclampsia that involves hepatic dysfunction
What is the max rate for giving mag? Why do we give it?
max 125 ml/hr
-prevent convulsions, treat HTN, and stop preterm labor
What are the normal lab values for hemoglobin and hematacrit? How do these change in preeclampsia and HELLP?
Normal: 12-16, 37-47%
Preeclampsia: may increase
HELLP: decrease
What is the normal lab vale for platelets? How do these change in preeclampsia and HELLP?
Normal: 150,000-400,000
Preeclampsia: unchanged or <100,000
What is the normal PT and PTT? How do these change in preeclampsia and HELLP?
Normal: 12-14 sec, 60-70 sec
Preeclampsia: Unchanged
HELLP: unchanged
What is the normal fibrinogen level? How does it change in preeclampsia and HELLP?
Normal: 200-400
Preeclampsia: 300-600
HELLP: decreased
What is the normal BUN? How does it change with preeclampsia and HELLP?
Normal: 10-20
Preeclampsia: increased
HELLP? increased
What is the normal creatinine level? How does is change with preeclampsia and HELLP?
Normal: 0.5-1.1
Preeclampsia: >1.2
HELLP: increased
What is the normal AST level? How does it change with preeclampsia and HELLP?
Normal: 4-20
Preeclampsia: unchanged to minimal increase
HELLP: increase >70
What is the normal ALT? How does it change with preeclampsia and HELLP?
Normal: 3-21
Preeclampsia: unchanged to minimal increase
HELLP: increased
What lab values are changed with HELLP syndrome?
Low platelets, but PT and PTT remain normal
decreased H&H, increased BUN, increased AST and ALT, increased uric acid, and increased bilirubin
-Know the difference between reactive vs nonreactive NST results (number of accelerations in a certain period of time)
Reactive: 2 accelerations in a 20-minute period (each lasting 15 seconds and peaking at least 15 bpm above baseline, <32 weeks numbers are 10 and 10)
Nonreactive: does not produce two or more qualifying accelerations in a 20 minute period
Hypoglycemia: during first trimester, what is the cause of that?
The baby is using it to grow
- Mom’s metabolic status is influenced by increased estrogen and progesterone (increase insulin production)
- Increase in tissue glycogen stores and a decrease in hepatic glucose production
What causes hyperglycemia during the 2nd and 3rd trimesters?
hormonal changes decrease glucose tolerance, increase insulin resistance, decrease hepatic glycogen stores, and increases hepatic production of glucose
-all to ensure an abundant supply of glucose for the fetus
What GA is betamethasone/dexamethasone used?
fetus between 24-34 weeks of gestation
What are the adverse reactions to betamethasone/dexamethasone?
Pulmonary edema or may worsen maternal conditions (diabetes, HTN)
-so assess blood glucose levels and lung sounds
Methergine is contraindicated in…
HTN and cardiac disease
Hemabate is a _______ and is contraindicated in…
Prostaglandin F2
-asthma, HTN
Misoprostil is a __________
Synthetic Prostaglandin E-1
What are the 3 criteria to be considered preterm labor?
1) Gestational age between 20 and 37 weeks
2) Contractions
3) Progressive cervical change
- Effacement of 80%
- Cervical dilation of 2 cm or greater
What’s the difference between PROM and PPROM?
PROM: Rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of labor at any gestational age
PPROM: Membranes rupture before 37 weeks of gestation
What are the risk factors associated with the development of preeclampsia?
nulliparity, family history of preeclampsia, obesity, multifetal gestation, previous preeclampsia, poor outcome in previous pregnancy (IUGR, abruption, death), preexisting medical/genetic conditions (HTN, renal dx, DM, thrombophilias)
-**early on in pregnancy (1st trimester) hypoglycemic in first trimester due to
estrogen and progesterone
Increased beta cell production of insulin
Promotes increased use of peripheral glucose
-increased glucose consumption by baby
Fetus creates it own glucose at…
10 weeks
Insulin does/does not cross the placenta
does not
When will a GDM mom need to start taking insulin?
2nd and 3rd trimester
If mom has RHD, mitral valve stenosis, mitral valve prolapse, ineffective endocarditis, or and MI, you will give her _____ during labor
antibiotics
What contraceptives are recommended for lupus women?
Oral you have to be cautious because of the vascular complications. Lupus will have more vascular disease. IUDs are not recommended due to infection. Recommend: progestin only injection **
What are the 4 ways to inherit chromosomal mutations?
Autosomal dominant
Autosomal recessive
X-linked dominant (occurs in males or heterozygous females)
X-linked recessive (only 1X needed to have dx)
What is standard of care?
The level of practice that a reasonable nurse would provide
What is risk management?
Systems of checks and balances to minimize the risk of injury
What are sentinel events?
Joint Commission
Unexpected outcomes involving death / serious injury
Respect for Autonomy
Beneficence
Non-Maleficence
Justice
Autonomy:
Beneficence:An ethical principle that emphasizes doing what is best for the patient, Choosing to do good; acting kindly or charitably.
Non-Mal: The principle of not doing something that causes harm. Hippocrates felt this was the underpinning of all medical practice.
Justice:
What are the 4 most common types of natural family planning methods?
basal body temperature method, 2 day method, calendar rhythm (but not as effective), and symptothermal method
What are the 3 prostaglandins? What do they do?
PG-E1, PG-E2, and PG-F2a
-affect smooth-muscle contractility and modulation of hormonal activity
(ovulation, fertility, cervical changes, mucus)
What day is day #1 of the cycle?
the first day of bleeding
What route(s) can you give Pitocin for PPH?
IV or IM
What route(s) can you give Methergine for PPH?
IM, intrauterine, or orally
What route(s) can you give Hemabate for PPH?
IM or intrauterine
What route(s) can you give Dinoprostone for PPH?
vaginal or rectal suppository
What route(s) can you give Misoprostol for PPH?
rectally
