WH Final Review Flashcards
A substance which causes damage to a pregnancy leading to physical or functional defects
Teratogen
ETOH, cocaine, radiation, hyperthermia, malnutrition, hyperglycemia, thyroid disorders, rubella, herpes, syphilis, toxoplasmosis
Examples of teratogens
creating of the zygote
Conception
Conception - week 2
Day 5: blastocyst (able to implant)
Pre-embryonic stage
implantation- week 8
Pregnancy most vulnerable to teratogens at this stage
Spontaneous abortion is common due to chromosomal errors
Week 3: neural tube fuses at the center and heart beings to beat, visible on ultrasound
Embryonic stage
Week 9 and onward
Fetal stage
Uterus enlarges, menstrual cycles cease, cervix softens and enlarges, cervix, vaginal and labia may have purple-blue discoloration. Breasts enlarge, areola may darken. Blood volume increase by 50%, blood vessels dilate, diastolic drops mid pregnancy (24-32 weeks) and then returns to normal. Heart rate and cardiac output increase. Supine hypotensive syndrome. Respirations may increase slightly. Posture changes, lordosis increases, joints relax later in pregnancy. Skin changes: striae gravidarum, chloasma, linea nigra. Hair grows longer and thicker. Diastasis recti may form in third trimester. Reduced peristalsis. Metabolic rate increases. White blood cell count increases. Increase in fibrinogen and other blood clotting factors.
Maternal physiologic changes
fetal movement begins
9-12 weeks
lungs begin to form surfactant
26 weeks
gas exchange in the lungs may be possible
28 weeks
enough surfactant to support lung function
35-40 weeks
Eat crackers and toast before getting out of bed. Avoid an empty stomach; spicy, greasy of gas-forming foods. Encourage fluids between meals
Comfort measures for nausea and vomiting
Wear a supportive bra
Comfort measures for breast tenderness
Encourage adequate rest including naps
Comfort measures for fatigue
Eat small frequent meals, use antacids as recommended by a provider, sit upright after eating
Comfort measures for heartburn
Increase fluid, increase fiber intake, exercise regularly
Comfort measures for constipation
Void frequency. Decrease fluid intake before bedtime. Perform kegel’s exercises. Reinforce usual recommendations to reduce risk of UTI: void after coitus, void frequently, cleanse perineal area from front to back, avoid bubble baths, wear cotton underwear, avoid tight fitting pants, increase fluid intake
Comfort measures for increased urinary frequency (especially first and third trimesters) and risk of UTI
Avoid sudden movements
Comfort measures for round ligament pain
Warm sitz bath, witch hazel pads, topical hemorrhoid ointments
Comfort measures for hemorrhoids
Exercise regularly, perform pelvic tilt exercises, use proper body mechanisms (use your legs!)
Comfort measures for backache
Maintain good posture, sleep with extra pillows, report worsening symptoms
Comfort measures for shortness of breath
Doriflex the foot on affected leg, extend the leg and dorsiflex if possible, apply heat
Comfort measures for leg cramps
Elevate hips and legs while resting. Avoid constricting clothing. Wear support hose. Avoid prolonged sitting or standing. Avoid crossing legs while sitting. Sleep in left-lateral position. Maintain moderate exercise.
Comfort measures for varicose veins and lower extremity edema
Use humidifier, saline nose drops or spray
Comfort measures for nasal congestion and epistaxis (nosebleed)
Acute nausea and vomiting in pregnancy leading to weight loss, dehydration, malnutrition and electrolyte imbalances. For some women this lasts throughout entire pregnancy. Cause of most first trimester pregnancy hospitalizations and a large portion of later pregnancy hospitalizations
Hyperemesis gravidarum
Evaluate for: Weight loss
Ketonuria
Dry mucous membranes
Skin tenting
Hyperemesis gravidarum Nursing Interventions
Pregnancy loss before 20 weeks, generally due to chromosomal abnormalities. 20%-50% of all pregnancies. Reduces to 6% at 6 weeks gestational age. Women may need emotional support, feel guilt, have conflicting feelings, may or may not grieve, and often have anxiety about future pregnancy outcomes
Spontaneous abortion/miscarriage
Bleeding, cramping, passing tissue, loss of early pregnancy symptoms
Spontaneous abortion/miscarriage S/S
Ovum implants in the fallopian tubes or abdominal cavity. Incompatible with successful outcome. As ovum grows, the fallopian tube can rupture, often leading to internal hemorrhage and one sided intense abdominal pain. This requires immediate surgical management with the loss of the affected tube. Identification of an ectopic before a tube ruptures may be managed by surgical removal or medical treatment with methotrexate to dissolve the pregnancy
Ectopic pregnancy
Slowly rising hCH levels. Absence of expected pregnancy in uterus. One sided abdominal pain. Vaginal bleeding.
Ectopic pregnancy S/s
This happened prior, pelvic infection, pelvic surgery, advanced maternal age, smoking, IUD in place, history of gonorrhea or chlamydia (especially if associated with pelvic inflammatory disease)
Increased risk of repeat and infertility
Risk factors for ectopic pregnancy
Nagele’s rule
LMP - 3 months + 7 days = EDD
Only works with 28 days menstrual cycles
After 14 weeks. Transabdominal needle into amniotic sac. Sample of amniotic fluid can be tested for AFP level and fetal DNA analysis
Administer Rhogam after procedure if mother is R negative
Amniocentesis
Risks: Bleeding, infection, preterm labor, or rupture of membranes
Risks of amniocentesis
10-13 weeks. Transvaginal or transabdominal needle into placental bed. Sample of chorionic villi can be tested for genetic disorders.
Administer Rhogam after procedure if mother is Rh negative
Chorionic villus sampling (CVS)
Risks: Bleeding, fetal limb loss, miscarriage, infection, rupture of membranes
Risks for Chorionic villus sampling (CVS)
Help for nausea, cravings, food aversions (first trimester). Weight gain expectations (25-35lbs). Caloric need increases (340 cal/day, increase to 452 cal/day third trimester)
Avoidance of mercury contaminated seafood, undercooked meat, highly-processed “food products”, soft cheeses, cold cuts and hot dogs, non-pasteurized mild products, alcohol. Limit caffeine intake, increase protein. Prenatal vitamins and DHA supplements recommended generally. If not taking a prenatal vitamin, encourage intake of folic acid 400mcg/day
Nutrition in pregnancy
Avoid supplements and medications unless approved. Review OTC medications considered safe for common discomforts. Exercise and sexual activity recommendations: maintain routine exercise unless extreme training or risk of injury/trauma, may introduce 30 min moderate exercise daily (unless advised otherwise), sexual intercourse is safe unless high risk for preterm labor or bleeding is present, HSV transmission precautions. Hydrate 8-10 glasses of water. Avoid overheating, hot tubs and saunas
Teaching points in pregnancy
The maternal blood type and antibody screen (indirect Coombs test) are determined upon presentation to care. RH- mothers may react to fetal Rh+ blood and develop antibodies to the Rh factor (isoimmunization). The greatest risk for this exposure is at delivery. Future pregnancies can then be attacked by the maternal immune system if that fetus is Rh+, this can lead to fetal hydrops or hemolytic disease of the newborn (fetal anemia, jaundice, hydrops and heart failure).
A blood product that cloaks the Rh+ marker on fetal cells and prevents exposure and isoimmunization
Cannot reverse prior isoimmunization
Is given to Rh- mothers with any pregnancy loss, abdominal trauma, invasive uterine procedure in pregnancy, or following delivery
Is also given at 28 weeks to Rh- mothers to prevent isoimmunization in late pregnancy
Lasts 12 weeks
Babies can be tested with the direct Coomb’s test which would identify maternal antibodies attached to their RBCs. This is normally done after birth from a cord blood sample.
Rhogam and RH factor
rhythmic contractions resulting in progressive dilation
First stage of labor
0-3cm
Latent labor
4-7cm
Active labor
8-10cm
Transition labor
Pushing and delivery of infant. Women usually notice rectal pressure or an urge to push. Exam must confirm full dilation before pushing. Can last from 20 min (or less!) to 3 (or more) hours. Nursing care is focused on coaching pushing efforts and monitoring FHR
Second stage of labor
Delivery of the placenta. A gush of blood may signal that the placenta has separated and is ready to deliver. Failure of continued contracting is termed uterine atony: primary cause of postpartum hemorrhage. Close assessment of uterine tone and ongoing bleeding is essential, at least every 15 mins. Normal blood loss at a vaginal delivery is 500 mL. Nursing care is focused on uterine tone, maternal VS and bleeding
Third stage of labor
Recovery, maternal stabilization of vital signs and bleeding. Uterine involution occurs here. Urinary retention can increase uterine atony; monitor return of bladder function and encourage voiding. The first attempt to stand or ambulate to the bathroom should be attempted when sensation has returned and vitals are stable; women are often syncopal. Closely monitor after a vaginal delivery for 2 hours, VS q 15 min
Fourth stage of labor
= normal FHR
FHR that is reassuring
= associated with poor outcomes, hypoxemia
Non-reassuring
Normal 110-160
Baseline FHR
irregular pattern of fluctuations within the baseline
Variability
An abrupt increase above baseline of at least 15 beats
Accelerations
Decrease in baseline FHR
Decelerations
mirrors the contraction in timing, caused by pressure on fetal head
Early decelerations
decrease in FHR with nadir just after peak of contraction, poor placental function
Late decelerations
Abrupt drop in FHR of more than 15 beats for up to 2 mins
Variable decelerations
Change maternal position (usually to left lateral)
oxygen administration (outdated practice)
IV hydration
Correction of maternal hypotension
turning off IV pitocin
Administering tocolytics to reduce contractions
Expedite delivery (forceps, vacuum, stat cesarean section)
Intrauterine resuscitation for NRFHR
Uterus is at the umbilicus after delivery, it shrinks 1 fingerbreadth per day
Uterine Involution
Fetal kick counts
Ultrasound to estimate fetal growth, wellbeing, and adequate amniotic fluid
Non stress trest
How to assess fetal well being
Maternal reports of “normal” fetal movement indicate wellbeing (decreased fetal movement warrants further eval with u/s or NST)
Fetal kick counts
Usually diagnosed at 28 weeks with glucose screening or with glycosuria in routine urine sample
Screening test:
Fasting BS should be below 95. 1 hour glucose should be below 130-140
Gestational Diabetes
Educate following diet plan and strict BS monitoring, encourage exercise
Complications include macrosomia, polyhydramnios, fetal demise
Gestational Diabetes Nursing Interventions and Complications
HTN and proteinuria. 300mg protein or greater in 24h urine collection sample. Protein: creatinine ratio 0.3 or higher. Urine dipstick reading of 2+ protein (if other testing not available)
Severe HTN 160/110
RUQ abdominal or epigastric pain can be a sign
Diagnosis of mild preeclampsia
HTN and abnormal lab finding indicating end-organ-dysfunction. Platelets less than 100,000. Serum creatinine over 1.1 mg/dL. Doubled liver transaminases. Pulmonary edema. New onset visual or cerebral symptoms (blurred vision, severe headache, flashing lights
Severe HTN 160/110
RUQ abdominal or epigastric pain can be a sign
Diagnosis of severe preeclampsia
Tonic-clonic seizure or coma (treated with magnesium sulfate IV bolus and maintenance infusion and oxygen therapy)
Eclampsia
Magnesium toxicity: resp depression (respiration less than 12/min, SOB) absent DTRs, lethargy, oliguria (less than 30mL urine/hr, hypotension, respiratory arrest. Reverse effects with calcium gluconate 1g IV
Magnesium Sulfate nursing considerations
Common side effects: Sweating, flushing, drowsiness, lethargy, headache
Common side effects of Magnesium Sulfate therapy
Rupture of membranes prior to the onset of labor.
Evaluation is by visible amniotic fluid, evidence of fluid on pH paper (Nitrazine paper), microscopic visualization of ferning, commercial testing swab (ROMplus)
Fluid collection is usually performed using a speculum and sterile swabs.
Monitor women for signs of infection; fever, chills, or fetal tachycardia
Premature Rupture of Membranes (PROM)
Onset of labor prior to 37 weeks gestation
Preterm labor
Risk factors:
Multiple pregnancy, co-morbidity with HTN or diabetes, uterine malformation, substance abuse (cocaine), infection, history of preterm birth, maternal stress
Risk factors for preterm labor
Before 34 weeks: corticosteroids are given to mother to promote fetal lung maturity. Treat with tocolytic medications to delay delivery, usually effective for only 2-7 days
Treatment of preterm labor
Indomethacin
Nifedipine
Terbutaline (significant maternal side effects)
Magnesium sulfate
Tocolysis Medications
Less effective at stopping labor than the others, but can offer neuroprotection to babies under 32 weeks gestation, reducing their risk of cerebral palsy
Overdose can cause toxicity, reducing their risk of cerebral palsy
Magnesium Sulfate
Less effective at stopping labor than the others, but can offer neuroprotection to babies under 32 weeks gestation, reducing their risk of cerebral palsy
Overdose can cause toxicity, reducing their risk of cerebral palsy
Magnesium Sulfate
Detachment of placenta prior to delivery
Significant maternal and fetal morbidity and mortality. The leading cause of maternal death.
Abruption
Risk Factors: trauma, severe hypertension, smoking, cocaine
Risk factors for abruption
Maternal pain: constant, abdominal, severe vaginal bleeding, NRFHR, uterine hypertonicity
Abruption S/S
Usually move to stat cesarean section, providing uterine resuscitation until OR is ready, call for blood for potential transfusion, call for neonatal team and prepare for neonatal resuscitation
A blood test for fetal cells in the maternal circulation is Kleihaure-Betke
Abruption Nursing Interventions
Labor and delivery in under 3 hours. Can be frightening for families as they may not make it to a safe delivery location.
At increased risk for: postpartum hemorrhage
perineal trauma if delivery is uncontrolled
Precipitous labor
Descent of the umbilical cord into the vagina. Treat as an emergency: compression on this cord will obstruct fetal oxygenation
Umbilical cord prolapse
Whoever identifies the prolapse must maintain upward pressure on the presenting part. Call for help. Care team makes preparation for cesarean delivery, usually urgent or stat. Monitor FHR continuously. Provide maternal oxygen. Maintain maternal IV access and given IV fluid bolus. Can reposition knee-chest, Trendelenburg or to side if this improves FHR. If cord is exposed to air, maintain warm moisture
Umbilical Cord Prolapse Nursing Interventions
Assess EBL (estimated blood loss). Normal lochia: rubra (red, day 1-3) serosa (pink-brown, day 4-10), alba (pink-yellow-white)
Post partum Nursing Care
Notify provider. Monitor vital signs. Start IV if no current access. Administer mediations as ordered.
Nursing Interventions with Excessive Bleeding
Colostrum “early milk” is present before delivery. Transitions to mature milk on day 3-4, turns white, “comes in” with breast filling and engorgement, may be quite uncomfortable and dramatic with erythema and beast firmness. Cabbage leaves to the breasts can relieve engorgement. If not breastfeeding: wear a supportie bra, apply cold packs and avoid nipple stimulation.
Breastfeeding: feed “on demand” but at least 3-4 hours in the first
To encourage milk production, feed frequently, eat and hydrate well, get rest, decrease pain and stress
Postpartum breast care
The way that the baby attaches at the breast, if inadequate can damage the nipple and feedings are painful, the infant needs a wide open mouth before latching in order to get the entire nipple and areola into its mouth
Latch
An infection within the breast tissue
Mastitis
S/S: Unilateral pain, erythema, warmth, fever and general malaise (flu-like symptoms)
Continue breastfeeding to prevent milk stasis. The infection will NOT hurt the baby.
Mastitis S/s and Nursing Interventions
A blockage of flow of the milk in that duct, a firm mass with discomfort and pressure, the mother can apply heat and try to massage towards the nipple to free the blockage
Plugged milk duct
Tachycardia: once recovered, pulse can be as low as 40 due to increased stroke volume, so a resumption of tachycardia is a red flag
Fever: Over 100.4
Postpartum danger signs
Wide range of emotions can be “normal”; can be tearful but quickly returning to normal affect.
Observe for bonding, demonstrating desire to care for infant and to learn, asking questions
Postpartum Psychological
Talking to infant, face to face, eye contact. Naming the infant, identifying family characteristics, touching, physical contact, feeding, diapering, responding to infant cries
Good signs of bonding
Ignoring cries, irritation with spitting up, wet diapers or stools, leaving the infant across the room, not holding or touching, interpreting infant behaviors as uncooperative or as if the infant dislikes the parent. “he does not like me, thats why he wont let me sleep” “she poops after I clean the diaper just to upset me”
Warning signs of poor bonding
Rubella vaccine should be given postpartum if not immune. Varicella may also be given. TDAP should be given if not already given during prenatal care.
Rhogam given within 72 hours of birth to RH negative mother with Rh positive babies.
CBC usually ordered for excessive bleeding, PPH or post c section
Tests and Vaccines
Important to understand the level of support at home and any housing or safety issues. Avoid strenuous activity until bleeding has stopped (could be 6-8 weeks). Limit stair climbing and walks, shopping, etc until bleeding has slowed and sleep schedule has improved. Review infant care. Sexual activity: wait until bleeding is stopped and perineum is healed, varies depending on laceration. Recommend lubrication. Arousal for the mother is diminished by fatigue, fear of pain, anxiety about getting pregnant, lactation hormones and the constant presence of a little human.
Discuss contraceptive options.
Discharge teaching and planning
Infection: malaise, fever 100.4 or higher, body aches, excessive fatigue, chills, foul odor
Hemorrhage: increasing bleeding, steady heavy flow, passage of large clots
Mastitis: pain, erythema, hard lump in one breast, fever, malaise, chills
Incision or wound infection: increasing pain, opening of incision, pus, erythema, edema
DVT: pain in one calf, localized lump or mass, unilateral leg edema, localized warmth or tenderness
Depression or psychosis: unable to perform infant care or ADL, persistent sadness or crying, desire for self harm or thoughts of harming the baby, acts of self harm
Warning Signs of Late Complications
Blood loss of more than 1000mL for either vaginal or c/sec delivery; although blood loss of more than 500mL warrants close monitoring” ACOG
Postpartum Hemorrhage
Causes: uterine atony, uncontrolled bleeding from a laceration or rupture, placental abruption or previa, retained placenta or placental fragments
Causes of postpartum hemorrhage
Prior hemorrhage or coagulopathy, high parity, overdistended uterus (multiples, polyhydramnios), long labor, dystocia, prolonged Pitocin augmentation, precipitous labor, magnesium sulfate adminstration
Risk factors for atony and PPH
Overt bleeding (saturating pads, pooling blood) or passage of large clots Uterine atony "boggy" Constant trickling of bright red blood Tachycardia and hypotension Pallor, cool, and clammy skin Oliguria
S/S of PPH
Call for help! You will likely need several team members to handle this emergency. Uterine massage. Assess vital signs. Assess for source of bleeding. Catheterize bladder if distended. Ensure IV access, replace fluid loss with NS or LR. Quantify bleeding. Monitor O2 saturation, supply oxygen if needed
Nursing Interventions during severe PPH
Oxytocin: WATER INTOXICATION, N&V, headache, malaise, lightheadedness
Methylergonovine: HYPERTENSION (DO NOT give to hypertensive patients), N&V, headache
Carboprost: fever, HYPERTENSION, chills, headache, N&V, diarrhea
Misoprostol: fever (if given high dose)
Medications for uterine atony and their side effects
Monitor uterine tone and vaginal bleeding. Monitor VS. Maintain IV fluids. Maintain empty bladder. Express clots from uterus. Assess for medication side effects
Nursing Interventions for Uterine Atony
Breathing is fast and shallow initially as the alveoli expand (30-60 breaths/minute) and irregular Babies may pause breathing for 15 seconds and then begin again
When using bulb suction, suction the mouth first, then nares
Newborn Breathing
Retractions, apnea, cyanosis, tachypnea, grunting, nasal flaring, gasping, stridor, seesaw breathing, crackles
Signs of respiratory distress
“cold stress” caused by heat loss (via evaporation, conduction, convection, & radiation) Increases oxygen demand and glucose metabolism
Signs: skin pallor, mottling, cyanotic trunk, tachypnea
Normal newborn temp 97.7-99.5
Dress infant same layers as adult, plus one blanket, protect from drafts, dry quickly after bath
Hypothermia General and Teaching
Banding and footprints
Alarm system activation
Teaching parents/caregivers about safety:
“Back to sleep”
Infant transport in crib whenever outside the room
Infant must be band matched whenever taken from or returned to the room
No co-sleeping in hospital, not recommended at home
No pillows or stuffed toys in crib, no loose blankets
Hospital security measures to prevent abduction
Safety Identification for Newborns
Erythromycin eye ointment within the first hour to prevent ophthalmic infection from gonorrhea or chlamydia.
Vitamin K IM injection is given routinely within 6 hours of birth to increase clotting factors and prevent pathologic bleeding
Hepatitis B vaccine offered & routinely given before discharge
“eyes and thighs”
Newborn medications
Vitals, weight, measurements (length, head/chest/abdomen circumferences) Initial head-toe exam for deformities, reflexes and maturity assessments
Vitals (HR, RR, temp) q 15-30min to assess transition, then q 4-8 hours Close assessment of nutrition and elimination including daily weight
Q shift nursing assessment and daily pediatrician exam
Completed before discharge for hearing, cardiac defects, PKU and metabolic disease (must eat 24h before being tested), jaundice.
Routine newborn assessment
first stools, thick & green, transitioning to brown by day 3
Diapers should be checked and changed prior to each feeding to protect the skin, clean with wipes or soap & water
Infants may void 2-6 times per day initially and then up to 8 times per day. They lose up to 10% of birth weight in the first few days
Meconium and elimination
once home, baby should void at least 6 times/ day,
newborns fed breastmilk should stool 3 or more times per day
formula fed infants will stool less often, as little as once every 1-2 days.
Keep skin clean and dry to prevent skin breakdown.
Leave the umbilical cord open to air. Fold the diaper to sit below it.
Infants can be tub bathed once the cord has fallen off (before then, sponge bath only) wipe from front to back to keep stool away from urethra
petroleum and gauze with every diaper change to the circumcised penis until healed leave the uncircumcised penis alone (do not attempt to retract the foreskin)
Teaching for newborn elimination
Blood sugar less than 40 by heel stick
S/S: jitteriness, twitching, weak cry, irregular respiratory effort, cyanosis, lethargy, eye rolls, seizures
Treatment: immediate feeding, oral sucrose gel or IV management per protocol
Hypoglycemia
Prematurity, gestational diabetes, cold stress, respiratory distress, SGA, LGA Routine monitoring of blood sugars: follow protocols for high-risk infants
Risk factors for Hypoglycemia
Elevation of serum bilirubin leading to jaundice
Hyperbilirubinemia
Yellowing of skin and sclera caused by deposits of unconjugated bilirubin. Appears first in face then descends to body as the bilirubin levels rise
Jaundice
Common, especially in breastfed babies. Presents after 72 hours of life and resolves day 5-10
Physiologic Jaundice
Jaundice from underlying disease. Presents before 24 hours of life or persists beyond day 14. Usually caused by blood incompatibility or infection
Pathologic jaundice
