210 Clotting

How should the uterus NORMALLY feel?

- contracted, size of grapefruit - easily located above the level of the umbilicus - lochia = dark red and scat to moderate

How to respond to the patient Hypovolemic Shock:

• Ensure a patent airway. • Insert an IV catheter or maintain an established catheter. • Administer oxygen. • Elevate the patient's feet, keeping his or her head flat or elevated to no more than a 30-degree angle. • Examine the patient for overt bleeding. • If overt bleeding is present, apply direct pressure to the site. • Administer drugs as prescribed. • Increase the rate of IV fluid delivery. • Do not leave the patient.

Butorphanol (Stadol) & Nalbuphine (Nubain) Interventions

*Monitor VS (*RR) = if 12 or less, withhold med and contact HCP *Monitor FHR and characteristics of contractions *Monitor for BP changes (Hypotension) *Maintain pt in recumbent position (elevate with a wedge pillow or other device) *Record level of pain relief *Monitor bladder for distension and retention *Have naloxone readily accessible - especially if deliery is expected to occur during peak medication absorption time

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean section

1. A normal test result

What happens during contractions with a Placenta Previa?

Effacement and dilation lead to tearing of the placenta - causing bleeding. Without a good placenta, perfusion to the baby is interrupted.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? 1. Feed the newborn less frequently. 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently.

2. Continue to breast-feed every 2 to 4 hours. Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.

What are the types of Placenta Previa?

Marginal Partial Total

How long is the Postpartum Period?

6 Weeks

What is the priority nursing goal for a newborn with FAS?

A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after birth. These newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help to establish appropriate sleep-rest cycles in the newborn as well.

Lumbar Epidural Block

Admin after labor is established or b/f c-section Relieves pain from contractions and numbs vag and perineum Adverse: hypotension, bladder distension, and prolonged 2nd stage - DOES NOT CAUSE HEADACHE *Monitor BP and assess bladder frequently *Maintain pt is side-lying position or place rolled blanket underneath hip *Admin IV fluids as perscribed *Increase fluids if hypotension occurs *Observe for adverse effects: N/V, pruritus, respiratory depression

How should you interpret a contraction stress test?

Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by 3 contractions of at least 40 seconds' duration in a 10-minute period.

What are the medications used to manage PPH?

Methylergonovine Oxytocin Carboprost Tromethamine

During their initial visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed? 1 Recent history of drug abuse 2 Family history of genetic abnormalities 3 A client history of more than three prior spontaneous abortions 4 Maternal age older than 30 years at the time of the first pregnancy

Family history of genetic abnormalities One of the specific reasons for performing amniocentesis is the diagnosis of genetic problems. A recent history of drug abuse is not a reason to perform this invasive procedure. A history of more than three prior spontaneous abortions is not a reason to perform this invasive procedure. Amniocentesis is no longer performed routinely if the client is an older primigravida; a sonogram is performed first.

What is Placenta Previa?

Implantation of the placenta in the lower uterus Can be evidenced by painless uterine bleeding in the later half of pregnancy

A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: A Breech B Transverse C Occiput anterior D Occiput posterior

Occiput Posterior A persistent occiput-posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.

How does the body to decreased perfusion?

Shunts all blood flow and O2 to vital organs - limiting blood to less vital areas and resulting in shock symptoms - can lead to death

Why is a Total Placenta Previa an issue?

The baby will not be able to get out.

What causes an Abruptio Placentae

Trauma! Anything that clamps down too hard on the uterus could force placenta to detach.

Local Anesthesia Use

Used for blocking pain during Episiotomy Used before the birth of an infant

Calcium Gluconate

Antidote for magnesium sulfate

Carboprost Tromethamine

Contracts the uterus Used in PPH Adverse: headaches, N/V, diarrhea, fever, tachycardia, and HTN DO not use if pt has asthma *Monitor VS *Monitor vag bleeding and uterine tone

What is the most common and potentially harmful maternal complication of epidural anesthesia?

Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure. Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic as it would be with a low spinal (saddle block) anesthesia; 2 is an effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially serious complication.

What is Early PPH?

First 24 Hrs Cumulative blood loss of 1000 mL or greater Most often caused by uterine atony - failure to contract Can also be caused by trauma, hematomas, retention of placental fragments, or coagulation abnormalities

What is Late PPH?

From 24 hrs up to 6 weeks postpartum Most common causes include Subinvolution (delayed return of uterus to normal size) of the uterus and retained placental fragments

How do we respond to Uterine Atony?

PPH Prophylaxis PPH: Oxytocin during 3rd stage IV or IM 1st Intervention = massage the fundus until firm then express clots that may have accumulated in uterus ***make sure its firm before trying to expel clots*** (( Pushing on a uterus that is not contracted could invert the uterus and cause massive hemorrhage and rapid shock)) 2nd Intervention = check for distended bladder 3rd Intervention = more drugs 4th Intervention = Bimanual compression by Physician Provide Fluid Replacement = Hemorrhage requires prompt replacement of intravascular fluid volume.

Nalaxone (Narcan)

Rapid reduces opioid toxicity (respiratory depressions) May have to be repeated every few hours until opioid levels are decreased to non-toxic levels Can cause with-drawl in opioid dependent pts

Why does the mother receive the Rubella Vaccine?

Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization or as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.

What type of contraceptives should be avoided by breast-feeding mothers?

Those that contain estrogen.

General Anesthesia

Used for surgical interventions Mother is not awake Presents a maternal danger of respiratory depression, vomiting, and aspiration

A woman at 22 weeks' gestation is admitted with heavy bleeding and severe abdominal cramping. When told that no fetal heart sounds can be detected, the client says to the nurse, "We wanted this baby so badly." How should the nurse respond? 1 "It must be difficult to lose this baby that was important to you both." 2 "This is nature's way of dealing with babies that may have problems." 3 "A curettage will give you a new start. I'll bet you'll get pregnant again soon." 4 "You must be disappointed, but don't feel guilty. These things sometimes happen."

"It must be difficult to lose this baby that was important to you both." The response "It must be difficult to lose this baby that was important to you both" acknowledges the loss and the grieving process. It also encourages the expression of feelings. Suggesting that "this is nature's way" minimizes the loss and may reflect the nurse's beliefs. Predicting that another pregnancy will occur soon does not acknowledge the loss and cuts off communication. Guilt feelings were never expressed by the client.

What are risk factors for DIC?

- Dead Fetus Syndrome - Missed abortion - Hemorrhage - Seve Preeclampsia

Ampicillin

Broad-spectrum antibiotic admin IV. Treatment for Chorioamnionitis. Adverse: GI effects (sore mouth and furry tongue), superinfections, hypersensitivity reactions like anaphylaxis

Gentamicin

Broad-spectrum antibiotic admin IV. Treatment for Chorioamnionitis. Aminoglycoside. Adverse: Neprho & Ototoxic

After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: A Above the umbilicus at the midline B Above the umbilicus on the left side C Below the umbilicus on the right side D Below the umbilicus near the left groin

C Below the umbilicus on the right side Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting), the back would be below the umbilicus and on the right side.

A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate? 1 Cesarean birth 2 Prolonged labor 3 Rapidly induced labor 4 Vacuum extraction vaginal birth

Cesarean birth Immediate birth is necessary to prevent fetal hypoxia and death. Allowing a prolonged labor, inducing labor, or using vacuum extraction in a vaginal birth will increase pressure on the cord, resulting in fetal hypoxia.

A nurse on the high-risk unit is caring for a client with severe preeclampsia. Which intervention is the most effective in preventing a seizure? 1 Providing a plastic airway 2 Controlling external stimuli 3 Having emergency equipment available 4 Keeping calcium gluconate at the bedside

Controlling external stimuli Reducing lights, noise, and stimulation minimizes central nervous system irritability, which can trigger a seizure. A plastic airway will not prevent a seizure. Available emergency equipment will not prevent a seizure, although oxygen and suction equipment may be useful after a seizure. Calcium gluconate is the antidote for magnesium sulfate toxicity; it does not prevent seizures.

A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response? 1 Taking exogenous insulin stimulates fetal growth. 2 Consuming more calories covers the insulin secreted by the fetus. 3 Extra circulating glucose causes the fetus to acquire fatty deposits. 4 Fetal weight gain increases as a result of the common response of maternal overeating.

Extra circulating glucose causes the fetus to acquire fatty deposits. It is difficult to maintain maternal normoglycemia throughout pregnancy; excess glucose passes into the fetus, where it is converted to fat. The problem is excess glucose, which is why exogenous insulin must be administered. Although all pregnant women consume extra calories to meet the increased metabolism associated with pregnancy, fetal insulin does not pass from the fetus to the mother. Stating that fetal weight gain increases because pregnant women commonly overeat is a stereotypical statement; not all clients with diabetes overeat.

Hepatitis B Vaccine

Given IM to newborn b/f discharge For all newborns to prevent Hep B Adverse: rash, fever, erythema, pain at injection site *Parental consent needed *Admin IM to middle 1/3 of vastus lateralis muscle *If mom is + for Hep B surface antigen, Hep B immune globulin should be given w/in 12 hours along with Hep B Vaccine. Then follow regular schedule *Document vaccination for parent records

The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client for? 1 Hemorrhage 2 Dehydration 3 Hypertension 4 Subinvolution

Hemorrhage Hemorrhage may result if placental tissue is retained or uterine atony occurs. There is no indication that the client has been deprived of fluids. Hypotension, not hypertension, may occur with postabortion hemorrhage. Subinvolution is more likely to occur after a full-term birth.

A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the nurse to intervene? 1 Hyperactive sensorium 2 Increase in respiratory rate 3 Lack of the knee-jerk reflex 4 Development of a cardiac dysrhythmia

Lack of the knee-jerk reflex Magnesium sulfate has a depressant effect on the central nervous system; therefore a toxic level will be reflected by the loss of the knee-jerk reflex. The level of consciousness is decreased with excessive magnesium sulfate. There is a deceleration in the respiratory rate with magnesium sulfate toxicity. Development of a cardiac dysrhythmia may be caused by increased potassium, not magnesium sulfate.

What is Hypovolemic Shock?

Loss of vascular volume, decreased mean arterial pressure, and sometimes loss of RBCs Results in decreased perfusion

The nurse is teaching a prenatal class regarding the risks of smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? 1 Low birthweight 2 Facial abnormalities 3 Chronic lung problems 4 Hyperglycemic reactions

Low birthweight Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in a SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition does the nurse suspect that this result indicates? 1 Cystic fibrosis 2 Phenylketonuria 3 Down syndrome 4 Neural tube defect

Neural tube defect Increased levels of alpha-fetoprotein in pregnant women have been found to reflect open neural tube defects such as spina bifida and anencephaly. Cystic fibrosis is a genetic defect that is not associated with the AFP level. A Guthrie test soon after ingestion of formula can determine whether an infant has phenylketonuria. Down syndrome is a chromosomal defect that is associated with a low AFP level.

Non-surgical Management of Hypovolemic Shock

O2 Therapy = self explanatory Fluid Replacement Therapy = Crystalloids and colloids used for volume replacement **Use only normal saline for infusion with blood or blood products because the calcium in Ringer's lactate induces CLOTTING of the infusing blood.** Drug Therapy = increase venous return, improve cardiac contractility, improve cardiac perfusion Monitor VS Q15min until shock controlled

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? 1 True labor 2 Placenta previa 3 Partial abruptio placentae 4 Abdominal muscular injury

Partial abruptio placentae Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.

Erythromycin

Prophylaxis against Gonorrhea and Chlamydia Required by law in the US *Clean newborn's eyes before instilling the medication *Do not flush eyes after instillation *Can be delyaed for 1 hr after birth to facilitate eye contact and parent-newborn attatchment/bonding

The nurse is providing care for parents who have experienced a stillbirth. What is the most appropriate intervention at this time? 1 Giving a detailed explanation of what may have caused the stillbirth 2 Providing the parents the opportunity to say goodbye to their newborn 3 Explaining that autopsy is not recommended in the setting of a stillbirth 4 Waiting to provide any information about follow-up care until the parents have had an opportunity to adjust to the grief

Providing the parents the opportunity to say goodbye to their newborn Parents should be given the opportunity to say goodbye to a stillborn baby. Because the parents may not think to ask to see the baby, the nurse should provide this opportunity. Giving a detailed explanation of possible causes of the stillbirth is nontherapeutic. An autopsy may be performed when there is a stillbirth. The decision is left to the parents. The procedure can be very important in answering the question "Why?" if there is a chance that the cause of death can be determined. Before the parents leave the hospital, arrangements for follow-up care should be made. This information should be provided immediately, because it can help the parents begin the grieving process. Many hospitals have a team consisting of a social worker, chaplain, and nurse that is called when a stillbirth occurs.

What is an Abruptio Placentae?

Separation of a normally implanted placenta before the fetus is born. Bleeding and formation of a hematoma on the maternal side of the placenta - may be visible or concealed

What condition can occur as a result of severe preeclampsia?

Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the health care provider if noted on assessment.

Methylergonovine (Methergine)

Stimulates uterine muscle Increases force and frequency of contractions Used for PPH Adverse: Nausea, uterine cramping, bradycardia, DYSRHYTHMIAS, myocardial infarction, severe HTN // peripheral vasospasm or vasoconstriction, confusion, respiratory depression, uterine tetany Do not use: CVD, PVD, HTN** *Check pts BP before admin - causes vasoconstriction and note an increase in BP *Notify HCP if chest pain occurs

Magnesium Sulfate

Stop preterm labor & prevent preterm birth Prevent and control seizures (preeclampsia) Adverse: Respiratory depression, decreased DTR, flushing, hypotension, extreme muscle weakness, elevated serum mag **high doses = loss of DTR, heart block, repiratory paralysis and cardiac arrest **used in caution in clients with Kidney impairment *Monitor VS (*RR) Q30-60min *Monitor Mg levels *Assess renal function & ECG for cardiac function *ALWAYS admin with infusion device *Keep calcium gluconate nearby *Monitor DTR *Monitor RR - call HCP if they fall below 12 breaths/per min *Monitor I/Os

Normal Postpartum Vital Signs

Temp = May increase to 100.4 during first 24 hr d/t dehydration; anything higher may be infection P = may decrease to 50 BPM. Pulse > 100 may indicate excessive blood loss or infection BP = should be normal, hypovolemia if decreased RR = rarely change; if increase suspect pulmonary embolism, uterine atony, or hemorrhage

What occurs with Uterine Atony and PPH?

The relaxed muscles allow rapid bleeding from arteries at the placental site. Continues until the uterine muscle fibers contract and stop flow of blood.

A client at 12 weeks' gestation arrives in the prenatal clinic complaining of cramping and vaginal spotting. A pelvic examination reveals that the cervix is closed. Which probable diagnosis should the nurse expect? 1 Missed abortion 2 Inevitable abortion 3 Incomplete abortion 4 Threatened abortion

Threatened abortion Because the cervix is closed, this is considered a threatened abortion. The lifeless products of conception are retained in a missed abortion. Once the cervix is dilated the abortion is inevitable. Portions of the products of conception will have to be passed for a diagnosis of incomplete abortion

Butorphanol (Stadol) & Nalbuphine (Nubain)

Used to relieve moderate to severe pain associated with labor Admin IV or IM May produce withdrawal symptoms in newborn with regular use (irritability, excessive crying, tremors, hyperactive reflexes, fever, vomiting, diarrhea, yawning. sneezing, and seizures) Adverse: Confusion, sedation, sweating, N/V, hypotension, and sinusoidal-like FHR Use caution when using with client who has preexisting opioid dependency - can cause withdrawl symptoms

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond? A Let the client get up to use the potty B Allow the client to use a bedpan C Perform a pelvic examination D Check the fetal heart rate Question 48 Explanation:

C Perform a pelvic examination A complaint of rectal pressure usually indicates a low presenting fetal part, signaling imminent delivery. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part.

A client in the thirty-eighth week of gestation exhibits a slight increase in blood pressure. The primary healthcare provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position? 1 "It increases blood flow to the fetus." 2 "It decreases intra-abdominal pressure." 3 "It increases the mean arterial pressure." 4 "It prevents the development of thrombosis."

"It increases blood flow to the fetus." The side-lying position decreases blood pressure and moves the gravid uterus off the great vessels of the lower abdomen, increasing venous return, improving cardiac output, and promoting kidney and placental perfusion. The side-lying position does not influence intra-abdominal pressure. While a pregnant woman is on bed rest the blood pressure decreases. The side-lying position does not prevent thrombosis; bed rest and immobility may increase the risk of thrombosis.

While observing a mother visiting her preterm son in the neonatal intensive care nursery, the nurse notes that she has not yet begun the bonding process. Which statement by the mother supports the nurse's conclusion? 1 "It's such a tiny baby." 2 "Do you think he'll make it?" 3 "Why does he need to be in an incubator?" 4 "My baby looks so much like my husband."

"It's such a tiny baby." By failing to acknowledge the infant as a person, the client indicates that she has not released her fantasy baby and accepted the real baby. Acknowledging the infant by using the word "he" denotes a relationship. Saying that the baby looks like her husband indicates that the mother has incorporated the infant into the family.

After an incomplete abortion, a client tells the nurse that although her primary healthcare provider explained what an incomplete abortion was, she did not understand. What is the best response by the nurse? 1 "I don't think you should focus on this anymore." 2 "It's when the fetus dies but is retained in the uterus for at least 2 months." 3 "It's when the fetus is expelled but other parts of the pregnancy remain in the uterus." 4 "I think it's best for you to ask your primary healthcare provider for the answer to that question."

"It's when the fetus is expelled but other parts of the pregnancy remain in the uterus." A correct and simple definition answers the question and fulfills the client's need to know. Telling the client not to focus on the topic any more denies the client's right to know. The definition of a missed abortion is when the fetus dies but is retained in the uterus for at least 2 months. Telling the client to ask her primary healthcare provider for the answer is an abdication of the nurse's responsibility; the nurse can independently reinforce information and correct misconceptions.

During a follow-up appointment, a client at 21 weeks' gestation is diagnosed with hyperemesis gravidarum. The client says, "Why is this happening to me? I don't know whether I can go on like this." What is the ideal response by the nurse? 1 "Are you saying that you want to schedule an abortion?" 2 "This must be physically and emotionally challenging for you." 3 "We're doing the best we can here, so please be patient with us." 4 "There are dietary changes and medications available that can ease the nausea."

"This must be physically and emotionally challenging for you." An open-ended statement validates what the client is experiencing and will encourage further client expression. It is not clear that the client has expressed a desire to have an abortion. It is important to open the lines of communication so the client may express her concerns. Becoming defensive is not in the best interest of the client. This would close down communication. It is true that there are dietary and medication options that can help, but validation of the client's feeling and encouraging open expression is the first priority; only after this is done will the client be ready to listen.

Interventions of Oxytocin

*Monitor VS Q15min *Monitor contractions Q15min *Monitor FHR Q15min - notify HCP if changes occur *Admin by IV infusion *Do not leave client unattended *Admin O2 if perscribed *Monitor for hypertonic contractions or non-reassuring FHR - notify HCP if this occurs *Stop meds if this occurs - turn her to side, increase IV rate of NS, and admin O2 *Monitor for S&S of water intoxication *Have emergency equipment available *Document *Keep family informed of progress

S&S of Uterine Atony

- Fundus difficult to locate - "Boggy" or soft feel to the fundus - Becomes firm when massaged, loses tone when stopped - Fundus located above expected level - Excessive lochia (especially bright red) and clots

S&S of Concealed Hemorrhage in Abruptio Placentae

- Increase in Fundal Height - Hard, board like abdomen - High uterine baseline tone or eletronic monitoring strip - Persistent abdominal pain - System signs: F&M tachycardia, falling BP, restlessness - Persistent late d'cels or decreasing variability - vaginal bleeding slight or absent

S&S of Hypovolemic Shock

- Increased P, falling BP, increased RR - Weak, diminished, thready pulses - Cool moist skin, pallor, cyanosis (late sign) - Decreased urinary output (<30 mL/hr) - Decreased Hgb & Hct - Change in LOC

What are the predisposing factors for PPH?

- Overdistention of uterus (multiple gestation, large infant, hydramnios [excessive amniotic fluid]) - Multiparity (>5) - Precipitate labor or delivery (baby came out too fast) - Prolonged Labor - Use of forceps or vacuum extractor (anytime you stick something up a mother you can cause trauma) - Ceasarean birth - Manual removal of placenta - Uterine Inversion - Placenta Previa, accreta, or low implantation - Drugs (oxytocin, prostaglandins, tocolytics, mag sul) - General anesthesia - Chorioamnionitis (infection) - Previous PPH or uterine surgery - DIC - Uterine Leiomyomas (Fibroids)

S&S of PPH

- Uterus that does not contract or does not remain contracted - BOGGY uterus - Large gush, or slow, steady trickle, ooze, or dribble of blood from the vagina - Saturation of one peripad per 15 min - Severe, unrelieved perineal or rectal pain - Tachycardia

A client has delivered her infant via cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day? 1 Providing oxygen therapy 2 Administering pain medication 3 Encouraging frequent ambulation 4 Recommending an increase in oral fluids

3 Encouraging frequent ambulation Ambulation involves muscle contractions that promote an increase in circulation in the legs. During pregnancy, hypercoagulation is associated with an increase in clotting factors and fibrinogen, which increases the risk for thromboembolism. Oxygen therapy will not prevent thromboembolism. Relieving pain does not prevent thromboembolism, but pain medication may be needed to help the client tolerate ambulation. Increasing fluid intake will not prevent thromboembolism.

The breathing technique that the mother should be instructed to use as the fetus' head is crowning is: A Blowing B Slow chest C Shallow D Accelerated-decelerated

A Blowing Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.

A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? A Swelling of the calf in one leg B Prolonged clotting times C Decreased platelet count D Petechiae, oozing from injection sites, and hematuria

A Swelling of the calf in one leg DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.

What is a nonstress test?

A nonstress test (NST) measures fetal heart rate and response to movement in the third trimester to ensure your baby's doing well and getting enough oxygen. A baby who moves a lot and has a normal heart rate is classified as "reactive" — i.e. healthy and not under any stress. A "nonreactive" baby is one who does not make a minimum number of movements during the 40-minute period or whose heart doesn't accelerate as much as expected when he does move. A nonreactive result does not necessarily mean your baby is in danger. However it could mean your baby isn't getting enough oxygen.

Which sign or symptom leads the nurse to suspect that a client is experiencing a tubal pregnancy? 1 A painful, tender area in the epigastric region after meals 2 Lower abdominal cramping of 1 week's duration with constipation 3 Leukorrhea or dysuria occurring a few days after the first missed menstrual period 4 A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder

A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder A fallopian tube is unable to contain and sustain a pregnancy to term; as the fertilized ovum grows, there is excessive stretching or rupture of the affected fallopian tube, resulting in pain. At this stage the products of conception are too small to form a mass; the pain is lateral, not centered. The pain is sudden, intense, and knifelike, not prolonged or cramping. Leukorrhea and dysuria may be indicative of a vaginal or bladder infection.

Subarachnoid Block

Admin just before birth Relieves uterine and perineal pain and numbs of the vagina, perineum, and lower extremities May cause maternal hypotension May cause postpartum headache *Must lie flat 8-12 hrs after spinal injection *IV fluids are perscribed

What occurs with an Amniotomy?

Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.

A pregnant client comes to the emergency department because of vaginal bleeding. The nurse asks the client to estimate how heavy the bleeding is. What is the best gauge for the client to use? 1 Number of clots that were passed 2 Changes in fetal activity when bleeding 3 Increased weakness since bleeding began 4 Amount of blood lost in relation to usual menstrual flow

Amount of blood lost in relation to usual menstrual flow Determining the amount of blood lost in relation to her usual menstrual flow gives the client a familiar gauge with which to estimate the amount of bleeding she is experiencing. The presence of clots does not indicate the amount of bleeding. Changes in fetal activity may indicate a problem, but there is no relationship to the amount of bleeding. Weakness is a subjective symptom and may not reflect blood loss.

During the postpartum period a client tells the nurse that she was very uncomfortable during her pregnancy because of large and painful varicose veins. In light of this information, what should the nurse's assessment include? 1 Monitoring daily clotting times 2 Assessing for peripheral pulses 3 Monitoring daily hemoglobin values 4 Assessing for signs of thrombophlebitis

Assessing for signs of thrombophlebitis Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency.

A client in the high-risk postpartum unit has had a precipitous labor and birth. Which maternal complication should the nurse anticipate? 1 Hypertension 2 Hypoglycemia 3 Chilling and shivering 4 Bleeding and infection

Bleeding and infection Precipitate birth is associated with an increased maternal morbidity rate, because hemorrhage and infection may occur as a result of the trauma of a rapid, forceful birth in a contaminated field. Hypertension is anticipated in a client with preeclampsia. There are not enough data to indicate that this client has preeclampsia. A low blood glucose level is not expected after a precipitous birth. Chilling and shivering are common maternal responses after all types of births because of cardiovascular and vasomotor changes.

A 24-year-old client is admitted at 40 weeks' gestation. The cervix is dilated 5 cm and is 100% effaced, and the presenting part is at station 0. The nurse assesses that the fetal heart tones are just above the umbilicus. Which fetal presentation does the nurse document? 1 Face 2 Brow 3 Breech 4 Shoulder

Breech In the breech presentation, the fetal head is in the fundal portion of the uterus; the chest or back is at or above the umbilicus, where fetal heart tones can be heard. In the vertex presentation the head is the presenting part; the chest and back are in lower quadrants, where the fetal heart is heard. The brow presentation is a type of cephalic presentation in which the fetal head is partially extended; the fetal heart is heard in the lower abdomen, not above the umbilicus. In the shoulder presentation the fetal heart usually is heard in the midabdominal region.

Which measure would be least effective in preventing postpartum hemorrhage? A Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered B Encourage the woman to void every 2 hours C Massage the fundus every hour for the first 24 hours following birth D Teach the woman the importance of rest and nutrition to enhance healing

C Massage the fundus every hour for the first 24 hours following birth The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.

Nifidepine

Calcium Channel Blocker Relaxes smooth muscles in uterus - may be FIRST LINE to halt Preterm Labor contractions Adverse: tachycardia, hypotension, dizziness, headache, nervousness, facial flushing & Newborn hypotension *Place on side to enhace placental perfusion and reduce pressure on cervix *Monitor VS *Do not mix with Mag Sulf - can cause severe hypotension *Monitor I/Os

The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? 1 Calling the primary healthcare provider 2 Checking the client's reflexes 3 Determining the client's blood type 4 Administering the prescribed intravenous (IV) normal saline

Checking the client's reflexes The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary healthcare provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary healthcare provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment; however, a more dilute saline solution will be prescribed.

A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect? 1 Hydatidiform mole 2 Vena cava syndrome 3 Marginal placenta previa 4 Complete abruptio placentae

Complete abruptio placentae Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.

Betamethasone

Corticosteroid increase production of surfactant to accelerate fetal lung maturity and reduce severity of respiratory distress syndrome Used for Preterm Labor Adverse: Decrease immunity, pulmonary edema & fluid retention, ELEVATED GLUCOSE in pts with DM *Monitor VS and lung sounds for edema *Monitor mother for S&S of infection *Monitor WBC *Monitor BG levels *Admin by deep IM injection

What is Postpartum Hemorrage?

Cumulative blood loss of ≥1000 mL or blood loss accompanied by sign/symptoms of hypovolemia within 24 hours following the birth process (includes intrapartum loss).

What is cystitis?

Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated.

At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: A Discontinue the catheter, if the reading is not above 80% B Discontinue the catheter, if the reading does not go below 30% C Advance the catheter until the reading is above 90% and continue monitoring D Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring

D Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.

How do you respond to a Placenta Previa?

Do NOT do an SVE (Sterile Vaginal Exam) = do not want to be poking the placenta Monitor for separation Prepare for c/s if total Previa

How should you measure fundal height?

During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

Rubella Vaccine

Given SubQ to a non-immune post-partum pt Admin of rubella titer is less than 1:8 Adverse: transient rash & hypersensitivity DO NOT given to client with hypersensitivity to eggs (made using duck eggs) *Assess for allergy to duck eggs and notify HCP *Do not admin if any other fam member is immunocompromised *Pt should avoid pregnancy for 1-3 months *Pt should be using contraceptives at this time

Several hours after delivery, a new mother expresses ambivalence regarding her infant. How will the nurse promote bonding between this mother and her newborn? 1 Having the mother feed the infant 2 Removing the infant from the mother's arms if it cries 3 Positioning the infant so its head rests on the mother's shoulder 4 Encouraging the mother to sleep for 4 to 6 hours before interacting with the infant

Having the mother feed the infant Feeding the infant promotes bonding through physical interaction, and positioning the infant in a face-to-face position facilitates eye contact. Removing the infant decreases the pair's time together. Positioning the infant on the mother's shoulder prevents the face-to-face contact that promotes bonding. It is important to have the parent and infant interact as soon as possible after birth to promote bonding.

During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's priority intervention? 1 Inserting a urine retention catheter 2 Administering oxygen by means of nasal cannula 3 Helping the client turn to the side-lying position 4 Encouraging the client to pant with her next contraction

Helping the client turn to the side-lying position Assisting the client to turn to the side-lying position will improve uterine blood flow, and fetal oxygenation will increase. Inserting a urine retention catheter is unnecessary; in addition, it requires a primary healthcare provider's prescription. Oxygen may be administered eventually if necessary, but this is not the first intervention. Encouraging the client to pant with her next contraction will not increase uterine blood flow or oxygen to the fetus.

The nurse is caring for a client in her third trimester who is scheduled for an amniocentesis. What should the nurse do to prepare the client for this test? 1 Instruct her to void immediately before the test. 2 Tell her to assume the high Fowler position before the test. 3 Encourage her to drink three glasses of water before the test. 4 Advise her to take nothing by mouth for several hours before the test.

Instruct her to void immediately before the test. The client is instructed to void immediately before the test to help prevent injury to the bladder as the needle is introduced into the amniotic sac. The supine position with a hip roll under the right hip is the preferred position for this procedure. Telling the client to assume the high Fowler position before the test will cause the bladder to fill, making it vulnerable to injury as the needle is inserted into the amniotic sac. Encouraging the client to drink three glasses of water before the test is advised if the amniocentesis is being performed early during pregnancy. There is no reason to withhold food or fluid, because the test does not involve the gastrointestinal tract.

A pregnant client with a history of preterm labor is at home on bed rest. Which instructions should be included in this client's teaching plan? 1 Place blocks under the foot of the bed 2 Sit upright with several pillows behind the back 3 Lie on the side with the head raised on a small pillow 4 Assume the knee-chest position at regular intervals throughout the day

Lie on the side with the head raised on a small pillow Bed rest keeps the pressure of the fetal head off the cervix. The side-lying position keeps the gravid uterus from impeding blood flow through major vessels, thus maintaining uterine perfusion. The Trendelenburg position is used when the cord is prolapsed or the client is in shock. Sitting up in bed increases pressure on the cervix and could lead to further dilation. Assuming the knee-chest position at regular intervals throughout the day may help relieve pressure of the fetus on the cervix; however, it will not enhance uterine perfusion.

Types of Abruptio Placentae

Marginal Partial Complete = baby dies

A 16-year-old primigravida at 32 weeks' gestation is admitted to the high-risk unit. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria. She has gained 50 lb (22.7 kg) during the pregnancy, and her face and extremities are edematous. Which complication is this client experiencing? 1 Eclampsia 2 Severe preeclampsia 3 Chronic hypertension 4 Gestational hypertension

Severe preeclampsia With severe preeclampsia, arteriolar spasms result in hypertension and decreased arterial perfusion of the kidneys. This in turn causes an alteration in the glomeruli, resulting in oliguria and proteinuria, retention of sodium and water, and edema. Eclampsia is characterized by seizures; there is no data to indicate that the client is having or has had seizures. Chronic hypertension is hypertension diagnosed before pregnancy or before 20 weeks' gestation. Hypertension that is first diagnosed during pregnancy that persists beyond the postpartum period is also considered chronic hypertension. Gestational hypertension is hypertension that first occurs during midpregnancy without proteinuria; it is definitively diagnosed when the hypertension resolves 12 weeks after delivery.

Oxytocin

Stimulates smooth muscle of uterus (^force, frequency, and duration) Promotes milk letdown For labor - admin IV *Mag sulfate should be accessible in case relaxation of the myometrium is necessary Used to: Induce/augment labor, control PPH, manage an incomplete abortion Adverse: Allergies, DYSRYTHMIAS, changes in BP, uterine rupture, and water intoxication May cause uterine hypertonicity High doses may cause hypotension PPH can occur and should be monitored Should NOT be used for clients who: do not have vagina delivery or who have hypertonic uterine contractions - contraindicated in clients with active genital herpes

Prostaglandin Gel

Used to ripen the cervix - making it softer and causing it to dilate and efface Admin vaginally Preinduction cervical ripening Induction of labor Induction of abortion Adverse: GI (diarrhea, N/V, stomach cramps), fever, chills, headache, hypotension, uterine tachysystole (contractions > or = 12 in 20 min w/o change in FHR), hyperstimulation of uterus, fetal passage of meconium *Monitor VS and FHR *Monitor for indications of cervical ripening or induction of labor *Have pt void before admin of medication *Have pt lay for 30-60 min after gen applied *Treatment is discontinued once true labor begins * Oxytocin can be started 6-12 hrs after discontinuation of prostaglandin gel

The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations? 1 Head compression 2 Maternal hypothyroidism 3 Uteroplacental insufficiency 4 Umbilical cord compression

Uteroplacental insufficiency Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency. Head compression results in early decelerations; this finding is considered benign. Hypothyroidism is unrelated to late decelerations. Umbilical cord compression results in variable decelerations.

Priority Problems for Hypovolemic Shock

• Hypoxia due to hypovolemia • Inadequate PERFUSION due to active fluid volume loss and hypotension • Anxiety due to potential for death and decreased cerebral PERFUSION • Decreased cognition due to decreased cerebral PERFUSION