OB Exam 3

18. What are the two reasons we give magnesium sulfate?

• To stop preterm labor Pg. 774 • To prevent seizures associated with preeclampsia pg.674

81. What are nursing interventions in the care of an infant with neural tube defects? p.916

• Use strict aseptic technique when caring for the defect to prevent infection. • Avoid trauma to the sac (to prevent leakage of CSF or damage to the nerve tissue) through prone or side-lying positioning. • Avoid placing a diaper over the sac to prevent rupture or infection by fecal contamination. • Apply a sterile dressing or protective covering over the sac to prevent rupture and drying, with frequent changes to prevent the dressing from adhering to the defect. • Frequently monitor the sac for signs of oozing fluid or drainage. • Preserve skin integrity on and around the spinal defect. • Meticulously clean the genital area to avoid contamination of the sac. • In addition, ensure a neutral thermal environment and avoid hypothermia. Heat can be lost through the defect opening, placing the newborn at increased risk for cold stress.

Labetalol hydrochloride-Normodyne

(Alpha 1 and beta blocker) Lowers blood pressure without lowering maternal heart rate or cardiac output. Administer 20-40mg every 15mins as needed and then IV infusion 2mg/min until desired pressure is achieved. Side effects: gastric pain, flatulence, constipation, dizziness, vertigo, and fatigue.

64. Where does drying the newborn fit into resuscitation efforts when there is a problem at birth?

1. Stabilization. Dry the newborn thoroughly with a warm towel; provide warmth by placing him or her under a radiant heater to prevent rapid heat loss through evaporation; position the head in a neutral position to open the airway; clear the airway with a bulb syringe or suction catheter; and stimulate breathing. At times, handling and rubbing the newborn with a dry towel may be all that is needed to stimulate respirations.

75. How is pulmonary hypertension diagnosed?

A newborn with persistent pulmonary hypertension demonstrates tachypnea within 12 hours after birth. Observe for marked cyanosis, grunting, respiratory distress with tachypnea, and retractions. Auscultate the heart, noting a systolic ejection harsh sound (tricuspid insufficiency murmur), and measure blood pressure for hypotension resulting from both heart failure and persistent hypoxemia. Measure oxygen saturation via pulse oximetry and report low values. Prepare the newborn for an echocardiogram, which will reveal right-to-left shunting of blood that confirms the diagnosis.

Furosemide-Lasix (Diuretic)

Administer via slow IV bolus at 10-40mg over 1-2mins. Monitor urine output. Adverse effects: dizziness, vertigo, vomiting, electrolyte imbalance, muscle cramps, muscle spasms.

71. What are signs and symptoms of Down syndrome, and how are these different from hypothyroidism and fetal alcohol syndrome? FAS

CLINICAL PICTURE OF FETAL ALCOHOL SYNDROME • Microcephaly (head circumference <10th percentile)* • Small palpebral (eyelid) fissures* • Abnormally small eyes • Intrauterine growth restriction • Maxillary hypoplasia (flattened or absent) • Epicanthal folds (folds of skin of the upper eyelid over the eye) • Thin upper lip* • Missing vertical groove in median portion of upper lip* • Short upturned nose • Short birth length and low birth weight • Joint and limb defects • Altered palmar crease pattern • Prenatal or postnatal growth ≤10th percentile* • Congenital cardiac defects (septal defects) • Delayed fine and gross motor development • Poor eye-hand coordination • Clinically significant brain abnormalities* • Intellectual disability • Narrow forehead • Performance substantially below expected level in cognitive or developmental functioning, executive or motor functioning, and attention or hyperactivity; social or language skills* • Inadequate sucking reflex and poor appetite • *Diagnosis of fetal alcohol syndrome requires the presence of three findings: 1. Documentation of all three facial abnormalities 2. Documentation of growth deficits (height, weight, or both below 10th percentile) 3. Documentation of central nervous system abnormalities (structural, neurologic, or functional)

50. VBAC—which women should be cautious about it?

Contraindications to VBAC include a prior classic uterine incision, prior transfundal uterine surgery (myomectomy), uterine scar other than low-transverse cesarean scar, contracted pelvis, and inadequate staff or facility if an emergency cesarean birth in the event of uterine rupture is required. The use of cervical ripening agents increases the risk of uterine rupture and thus is contraindicated in VBAC clients.

Zavanelli's Maneuver

Sandwiching in the head and neck in both hands and using a sort of corkscrew motion to get shoulders past the pubic arch

77. What are epispadius and hypospadias? p. 926-927

Epispadias is a rare congenital genitourinary defect occurring in 1 in 10,000 to 50,000 male births. The male-to-female ratio is 2:1. In boys with epispadias, the urethra generally opens on the top or side rather than the tip of the penis. In females, the urinary meatus is located between the clitoris and the labia. This anomaly often occurs in conjunction with exstrophy of the bladder (Foster & Kolaski, 2016). Surgical correction is necessary, and affected male newborns should not be circumcised. Hypospadias is a relatively common malformation of the male genital organ. It is an abnormal positioning of the urinary meatus on the underside of the penis. Hypospadias is a relatively common malformation of the male genital organ. It is an abnormal positioning of the urinary meatus on the underside of the penis. (SEE FIGURE 24.17)

79. When is ECMO used? What sort of diagnoses are treated by it?

Extracorporeal membrane oxygenation, a process that mimics the gas exchange process of the lungs, may be ordered when the surgery is undertaken. Congenital diaphragmatic hernia (CDH) is a severe anomaly of failure in the development of the diaphragm that results in an abnormal insertion onto the inner chest wall, allowing some or all of the abdominal organs/contents to protrude into the thoracic cavity, impeding fetal lung development. CDH is characterized by pulmonary hypoplasia and decreased pulmonary vasculature. Newborns with CDH often require prompt treatment of severe respiratory distress and pulmonary hypertension to prevent death. CDH is associated with other anomalies, including congenital cardiac defects, genital or renal anomalies, NTDs, choanal atresia, or chromosomal anomalies, such as trisomy 13 and 18. The survival rate of newborns with a diaphragmatic hernia varies widely

72. What are dietary restrictions of infants with galactosemia and PKU?

Galactosemia - lifelong lactose-restricted diet to prevent intellectual disability, liver disease, and cataracts Phenylketonuria (PKU) - lifelong dietary restriction of phenylalanine (such as protein - beef, poultry, pork, fish, milk, yogurt, eggs, cheese, soy products; certain nuts and seeds, aspartame)

82. What are S/S of hyperbilirubinemia? How is it treated, and how do nurses administer phototherapy?

Hyperbilirubinemia is a total serum bilirubin level above 5 mg/dL resulting from unconjugated bilirubin being deposited in the skin and mucous membranes o Hyperbilirubinemia is exhibited as jaundice (yellowing of the body tissues and fluids). o For the newborn receiving phototherapy, place the newborn under the lights or on the fiber-optic blanket, exposing as much skin as possible. Cover the newborn's genitals and shield the eyes to protect them from becoming irritated or burned when using direct lights. Assess the intensity of the light source to prevent burns and excoriation (Fig. 24.8). Turn the newborn every 2 hours to maximize the area of exposure, removing the newborn from the lights only for feedings. Maintain a neutral thermal environment to decrease energy expenditure, and assess the newborn's neurologic status frequently o AAP Guidelines for Prevention and Management of Hyperbilirubinemia in Newborns o Promote and support successful breastfeeding practices to make sure the newborn is well hydrated and stooling frequently to promote elimination of bilirubin. o Advise mothers to nurse their infants at least 8 to 12 times per day for the first several days. o Avoid routine supplementation of nondehydrated breast-fed infants with water or dextrose water because that will not lower bilirubin levels. o Ensure that all infants are routinely monitored for the development of jaundice and that nurseries have established protocols for the assessment of jaundice. Jaundice should be assessed whenever the infant's vital signs are measured but no less than every 8 to 12 hours. o Before discharge, complete a systematic assessment for the risk of severe hyperbilirubinemia. o Provide early and focused follow-up based on the risk assessment o When indicated, treat newborns with phototherapy or exchange transfusion to prevent acute bilirubin encephalopathy

80. What are S/S of sepsis in the neonate?

Hypotension Cyanosis Jaundice Apnea and bradycardia Hypoglycemia Tachycardia Poor weight gain Grunting Lethargy Irritability Hypotonia Seizures Nasal flaring Petechiae Rash Temperature instability Pallor or duskiness Respiratory distress Abdominal distention

70. What effects do the different illegal drugs cause to fetuses and neonates? TOBACCO/NICOTINE

Impaired oxygenation of mother and fetus due to nicotine crossing placenta and carbon monoxide combining with hemoglobin Increased risk for low birth weight (risk almost doubled), small for gestational age, and preterm birth Increased risk for sudden infant death syndrome (SIDS) and chronic respiratory illness

70. What effects do the different illegal drugs cause to fetuses and neonates? METHADONE

Improvement in many of the detrimental fetal effects associated with heroin use Withdrawal symptoms are common in newborns. Possible low birth weight due to symmetric fetal growth restriction Increased severity and longer period of withdrawal (due to methadone's longer half-life) Seizures (commonly severe) do not usually occur until 2-3 weeks of age, when the newborn is at home. Increased rate of SIDS (3-4 times higher)

70. What effects do the different illegal drugs cause to fetuses and neonates? METHAMPHETAMINES

Little research on use during pregnancy because its use is less common than cocaine or narcotics Fetal effects similar to cocaine (suggesting vasoconstriction as possible underlying mechanism) Possible maternal malnutrition, leading to problems with fetal growth and development Increased risk for preterm birth and low-birth-weight newborns Infants may have withdrawal symptoms, including dysphoria, agitation, jitteriness, poor weight gain, abnormal sleep patterns, poor feeding, frantic fist sucking, high-pitched cry, respiratory distress soon after birth, frequent infections, and significant lassitude. Long-term effects are not known.

70. What effects do the different illegal drugs cause to fetuses and neonates? HEROIN

Newborns of heroin-addicted mothers are born dependent on heroin. Increased risk for transmission of hepatitis B and C and HIV to newborns when mothers share needles Significantly increased rates of stillbirth, IUGR, preterm birth, and newborn mortality (3-7 times greater) Small-for-gestational-age newborns, meconium aspiration, high incidence of SIDS, and delayed effects from subacute withdrawal (restlessness, continual crying, agitation, sneezing, vomiting, fever, diarrhea, seizures, irritability, and poor socialization [possibly persisting for 4-6 months]) Intrauterine death or preterm birth is possible with abrupt cessation of heroin use.

70. What effects do the different illegal drugs cause to fetuses and neonates? MARIJUANA

Not shown to have teratogenic effects on fetus; no consistent types of malformations identified Fetal growth restriction is common due to delivery of carbon monoxide to fetus Increased risk for small for gestational age Altered responses to visual stimuli, sleep-pattern abnormalities, photophobia, lack of motor control, hyperirritability, increased tremulousness, and high-pitched cry noted in infants of mothers who smoked marijuana Research on long-term effects is continuing

70. What effects do the different illegal drugs cause to fetuses and neonates? COCAINE

Preterm birth and lower birth weight Unclear impact on later development Speculation that cocaine interferes with infant's cognitive development, leading to learning and memory difficulties later in life Associated congenital anomalies: GU, cardiac, and CNS defects, and prune belly syndrome Other typical newborn characteristics: smaller head circumference, piercing cry (indicative of neurologic dysfunction), limb defects, ambiguous genitalia, poor feeding, poor visual and auditory responses, poor sleep patterns, decreased impulse control, stiff, hyperextended positioning, irritability and hypersensitivity (hard to console when crying), inability to respond to caretaker

McRobert's Maneuver

Pull knees to head to open up pelvis in cases of shoulder dystocia

73. How is RDS manifested and treated? Ch 24 pg 873.

Respiratory Distress syndrome results from lung immaturity and a lack of alveolar surfactant. Without the surfactant, the alveoli collapse at the end of expiration. The newborn with RDS usually demonstrates signs at birth or within a few hours of birth. Observe the infant for expiratory grunting, shallow breathing, nasal flaring, chest wall retractions, see-saw respirations, and generalized cyanosis. Auscultate the heart and lungs, noting tachycardia (rates above 150 to 180), fine inspiratory crackles, and tachypnea (rates above 60 breaths per minute). The diagnosis is made based on the clinical picture, a lung ultrasound or x-ray (will show hypoaeration and "ground glass" pattern) and ABGs which show hypoxemia and acidosis. Surfactant replacement is the primary treatment, which can be given prophylactically within minutes of birth and then again a few hours later. The others are supportive, and an include nasal ventilation, CPAP, or mechanical ventilation with PEEP if warranted, maintenance of a normal body temperature, proper fluid management, good nutritional support, and support of the circulation to maintain adequate tissue perfusion

27. Women who take illegal drugs are exposing their infants to which risks? Pg. 29

Substance abuse for any person is a problem, but when it involves a pregnant woman, substance abuse can cause preterm birth, placenta abruption, poor weight gain, low birth weight, stillbirth, spontaneous abortion, a variety of behavioral and cognitive problems in exposed children, and fetal injury, and thus has legal and ethical implications.

74. What are S/S of NEC?

The onset of Necrotizing Enterocolitis is heralded by the development of feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock (respiratory distress, temperature instability, lethargy, hypotension, and oliguria). Nurses need to be suspicious of this condition in caring for this type of preterm infant. Also observe the newborn for common signs and symptoms, which may include: • Cardiorespiratory baseline changes • Feeding intolerance • Abdominal distention and tenderness • Bloody or hemoccult-positive stools • Diarrhea As the disease worsens, the infant develops signs and symptoms of septic shock (respiratory distress, temperature instability, lethargy, hypotension, and oliguria). Nurses need to be suspicious of this condition in caring for this type of preterm infant.

14. What distinguishes preeclampsia from eclampsia?

The onset of seizure activity identifies eclampsia. Preeclampsia= no seizures

49. Which assessment must be carried out immediately when the membranes rupture?

When membranes rupture, the priority focus should be on assessing fetal heart rate (FHR) first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. If the membranes are ruptured when the woman comes to the hospital, the health care provider should ascertain when it occurred.

30. What is the risk that vaginal Strep B can pose to mom and fetus?

a. GBS is the most common cause of sepsis and meningitis in newborns and is a frequent cause of newborn pneumonia. Newborns with early-onset (within a week after birth) GBS infections may have pneumonia or sepsis, whereas late-onset (after the first week) infections often manifest with meningitis. b. GBS colonization in the mother is thought to cause chorioamnionitis, endometritis, and postpartum wound infection.

76. How is intraventricular hemorrhage manifested? p.882 & 931

intraventricular hemorrhage is bleeding that usually originates in the subependymal germinal matrix region of the brain with extension into the ventricular system Assess for risk factors such as Acidosis, asphyxia, unstable blood pressure, meningitis, seizures, acute blood loss, hypovolemia respiratory distress with mechanical ventilation/ intubation, apnea, hypoxia, suctioning, use of hyperosmolar solutions rapid volume expansion Evaluate the newborn for an unexplained drop in hematocrit, pallor, and poor perfusion as evidenced by respiratory distress and oxygen desaturation. Note seizures, lethargy or other changes in level of consciousness, bulging fontanel, weak sucking, metabolic acidosis, high-pitched cry, or hypotonia/flaccidity. Palpate the anterior fontanel for tenseness. Assess vital signs, noting bradycardia and hypotension. Evaluate laboratory data for changes indicating metabolic acidosis or glucose instability (Annibale, 2015). Frequently a bleed can progress rapidly and result in shock and death. Prepare the newborn for cranial ultrasonography, the diagnostic tool of choice to detect hemorrhage.

Those occurring during the second trimester

more likely related to maternal conditions, such as cervical insufficiency, congenital, or acquired anomaly of the uterine cavity (uterine septum or fibroids), hypothyroidism, diabetes mellitus, chronic nephritis, use of crack cocaine, inherited and acquired thrombophilias, lupus, polycystic ovary syndrome, severe hypertension, and acute infection such as rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis, and toxoplasmosis.

Gaskin Maneuver

turning the woman to her hands and knees for shoulder dystocia

63. How are postpartum women whose babies have died in birth (or are stillborn) different from those who have living babies?

• A common reaction by many people when learning that a newborn is not going to survive is one of avoidance. • In a time of crisis or loss, individuals are often more sensitive to other people's reactions. • The death of an infant will more than likely be one of the toughest moments in a family's life

(What exam should NOT be done on cases of previa? How will women with previa deliver?)

• Avoid doing vaginal examinations in the woman with placenta previa because they may disrupt the placenta and cause hemorrhage. (661)

78. Be able to select the signs and symptoms of an infant whose mother had gestational diabetes from a line-up of manifestations.

• Cord prolapse secondary to polyhydramnios and abnormal fetal presentation • Congenital anomaly due to hyperglycemia in the first trimester (cardiac problems, neural tube defects, skeletal deformities, and genitourinary problems) • Macrosomia resulting from hyperinsulinemia stimulated by fetal hyperglycemia • Birth trauma due to increased size of fetus, which complicates the birthing process (shoulder dystocia) • Preterm birth secondary to polyhydramnios and an aging placenta, which places the fetus in jeopardy if the pregnancy continues • Fetal asphyxia secondary to fetal hyperglycemia and hyperinsulinemia • Intrauterine growth restriction secondary to maternal vascular impairment and decreased placental perfusion, which restricts growth • Perinatal death due to poor placental perfusion and hypoxia • Respiratory distress syndrome resulting from poor surfactant production secondary to hyperinsulinemia inhibiting the production of phospholipids, which make up surfactant • Polycythemia due to excessive red blood cell (RBC) production in response to hypoxia • Hyperbilirubinemia due to excessive RBC breakdown from hypoxia and an immature liver unable to break down bilirubin • Neonatal hypoglycemia resulting from ongoing hyperinsulinemia after the placenta is removed • Subsequent childhood obesity and carbohydrate intolerance

71. What are signs and symptoms of Down syndrome, and how are these different from hypothyroidism and fetal alcohol syndrome?

• Down Syndrome (Trisomy 21) o Small, low-set ears that may fold over a little at the pinna o Hyperflexibility o Muscle hypotonia o Small hands and feet o A short neck o Wide-spaced eyes that slant upward o Ulnar loop on the second digit o Deep crease across palm (termed a simian crease) o Flat facial profile o Short stature in childhood and adulthood o Small white, crescent-shaped spots on irises o Small mouth with protruding tongue o Broad, short fingers • HYPOTHYROIDISM o Large protruding tongue, slow reflexes, distended abdomen, large, open posterior fontanel, constipation, hypothermia, poor feeding, hoarse cry, dry skin, coarse hair, goiter, and jaundice o If untreated, irreversible cognitive and motor impairment occurs. o Decreased levels of thyroid hormone (T4) and elevated levels of TSH

Sodium nitroprusside

(Rapid vasodilation-arterial and venous- severe hypertension requiring rapid reduction) Administer continuous IV infusion and titrate according to blood pressure levels, wrap in foil or opaque material. Adverse effects: apprehension, restlessness, retrosternal pressure, palpitations, diaphoresis, abdominal pain.

Hydralazine hydrochloride-Apresoline

(Vascular smooth muscle relaxant, improves renal, uterine, and cerebral perfusion, reduces blood pressure) Administer 5-10 mg by slow IV bolus every 20mins as needed, withdraw drug slowly to prevent rebound hypertension, monitor for side effects: palpitations, headache, tachy, anorexia, nausea, vomit, and diarrhea.

60. What are S/S of hypoglycemia in neonates?

(often subtle) lethargy, tachycardia, respiratory distress, jitteriness, drowsiness, poor feeding, feeble sucking, hypothermia, temperature instability, diaphoresis, weak cry, seizures, hypotonia

12. How do we treat mild preeclampsia? Home

***Home Management: • Bed rest in lateral recumbent position (to improve uteroplacental blood flow, reduce her blood pressure, and promote diuresis) • antepartal visits and diagnostic testing—such as CBC, clotting studies, liver enzymes, and platelet levels—increase in frequency • monitor her blood pressure daily (every 4 to 6 hours while awake) and report any increased readings; • measure the amount of protein found in urine using a dipstick • weigh herself • take daily fetal movement counts, and if there is any decrease in movement, she needs to be evaluated by her health care provider that day • balanced, nutritional diet with no sodium restriction is advised

12. How do we treat mild preeclampsia? Hospital

***Hospital admission for failed home management: • monitored closely for signs and symptoms of severe preeclampsia or impending eclampsia (e.g., persistent headache, hyperreflexia) • Blood pressure • Fetal Surveillance (daily fetal movement counts, nonstress testing, and serial ultrasounds to evaluate fetal growth and amniotic fluid volume to confirm fetal well-being)

12. How do we treat mild preeclampsia? Prevention

***Prevention of disease progression is the focus of treatment during labor. • BP checked frequently • quiet environment is important to minimize the risk of stimulation and to promote rest. • IV magnesium sulfate is infused to prevent any seizure activity • antihypertensive if blood pressure values begin to rise • Calcium gluconate is kept at the bedside in case the magnesium level becomes toxic • monitor neurologic status is warranted to detect any signs or symptoms of hypoxemia, impending seizure activity, or increased intracranial pressure. • An indwelling urinary (Foley) catheter usually is inserted to allow for accurate measurement of urine output.

Nifedipine-procardia

(Calcium channel blocker/dilation of coronary arteries, arterioles, and peripheral arterioles *lowers blood pressure and stops preterm labor*) Administer 10-20mg orally for 3 doses every 4-8 hrs. Adverse effects: dizziness, peripheral edema, angina, diarrhea, nasal congestion, cough.

23. Why should pregnant women stay away from sources of toxoplasmosis, and what are strategies for doing this? Pg. 730

A pregnant woman that contracts toxoplasmosis for the first time has an approximately 40% chance of passing the infection to her fetus. Toxoplasmosis acquired during pregnancy means high risk of damage for the fetus. Although the woman typically remains asymptomatic, transmission to her fetus can occur throughout pregnancy. A fetus that contracts congenital toxoplasmosis typically has a low birth weight, enlarged liver and spleen, chorioretinitis, jaundice, IUGR, hydrocephalus, microcephaly, neurologic damage, and anemia. Severity varies with gestational age; usually, the earlier the infection, the more severe the effects. Treatment of the woman during pregnancy to reduce the risk of congenital infection is a combination of pyrimethamine and sulfadiazine. Treatment with sulfonamides during pregnancy has been shown to reduce the risk of congenital infection. Although there is much to learn about the best approach to the identification and treatment of toxoplasmosis, it is known that early treatment leads to the best neurodevelopmental outcomes in infants. Prevention is the key to managing this infection. Nurses play a key role in educating the woman about measures to prevent toxoplasmosis.

How do we treat severe preeclampsia—know dosages.

A woman with severe preeclampsia requires hospitalization. The patient will maintain bed rest in the left lateral lying position, in a dark and quiet room. Sedatives are administered and seizure precautions are established. Monitor their blood pressure closely, assess vision and level of consciousness. • Magnesium sulfate (Blockage of neuromuscular transmission, vasodilation, prevention of seizures)- loading dose 4-6g IV in 100ml of fluid over 15-20mins. Follow with 2g as continuous IV infusion. Monitor serum magnesium, assess DRTs and ankle clonus, have calcium gluconate ready in case of toxicity (signs: flushing, sweating, hypotension, and cardiac and central nervous system depression).

51. What is amnioinfusion and what precautions must be taken when women have this procedure done?

Amnioinfusion is a technique in which a volume of warmed, sterile, normal saline or Ringer's lactate solution is introduced into the uterus transcervically through an intrauterine pressure catheter to increase the volume of fluid when oligohydramnios is present. It is a procedure used during labor. It is used to change the relationship of the uterus, placenta, cord, and fetus to improve placental and fetal oxygenation. Instilling an isotonic glucose-free solution into the uterus helps to cushion the umbilical cord to prevent compression or dilute thick meconium. This procedure is commonly indicated for severe variable decelerations due to cord compression, oligohydramnios due to placental insufficiency, postmaturity or rupture of membranes, preterm labor with premature rupture of membranes, and thick meconium fluid. However, it does not prevent meconium aspiration syndrome. Contraindications to amnioinfusion include vaginal bleeding of unknown origin, umbilical cord prolapse, amnionitis, uterine hypertonicity, and severe fetal distress. *Overdistention of the uterus is a risk, so the amount of fluid infused must be monitored closely. Amnioinfusion should reach therapeutic result or increase the amniotic fluid volume in approximately 30 minutes

54. How can we teach women to treat their own preterm labor (teaching guidelines 21.1). Remember, dehydration will start preterm labor "from scratch" even in women who are at low risk. They MUST drink a lot of water!

Avoid traveling for long distances in cars, trains, planes, or buses. Avoid lifting heavy objects, such as laundry, groceries, or a young child. Avoid performing hard, physical work, such as yard work, moving of furniture, or construction. Mild to moderate levels of exercise are permitted such as walking daily. Achieve an appropriate prepregnancy weight. Achieve adequate iron stores through balanced nutrition. Wait at least 18 months between pregnancies. Visit a dentist in early pregnancy to evaluate and treat periodontal disease. Enroll in a smoking cessation program if you are unable to quit on your own. Curtail sexual activity until after 37 weeks if experiencing preterm labor symptoms. Consume a well-balanced nutritional diet to gain appropriate weight. Avoid the use of substances such as marijuana, cocaine, and heroin. Identify factors and areas of stress in your life, and use stress management techniques to reduce them. If you are experiencing intimate partner violence, seek resources to modify the situation. Recognize the signs and symptoms of preterm labor and notify your birth attendant if any occur: Uterine contractions, cramping, or low back pain Feeling of pelvic pressure or fullness Increase in vaginal discharge Nausea, vomiting, and diarrhea Leaking of fluid from vagina If you are experiencing any of these signs or symptoms, do the following: Stop what you are doing and rest for 1 hour. Empty your bladder. Lie down on your side. Drink two to three glasses of water. Feel your abdomen and make note of the hardness of the contraction. Call your health care provider and describe the contraction as Mild if it feels like the tip of the nose Moderate if it feels like the tip of the chin Strong if it feels like your forehead

Which methods can be used to ripen a cervix? What precautions should be taken when doing it?

d. Surgical Methods: i. Stripping of the membranes or performing an amniotomy. Risks associated with these procedures include umbilical cord prolapse or compression, maternal or neonatal infection, FHR deceleration, bleeding, and client discomfort. Amniotic fluid characteristics and the FHR pattern must be monitored closely.

57. How should nurses promote bonding in parents of preemies?

Reviewing with them the events that have occurred since birth; Providing simple relaxation and calming techniques (visual imagery, breathing;) Exploring their perception of the newborn's condition and offering explanations; Validating their anxiety and behaviors as normal reactions to stress and trauma; Providing a physical presence and support during emotional outbursts; Exploring the coping strategies they used successfully in the past and encouraging their use now; Encouraging frequent visits to the NICU; Providing individualized support to parents while in NICU; Encouraging parental involvement with their newborn in NICU; Addressing their reactions to the NICU environment and explaining all equipment used; Identifying family and community resources available to them

Threatened abortion

Vaginal bleeding (often slight) early in a pregnancy No cervical dilation or change in cervical consistency Mild abdominal cramping Closed cervical os No passage of fetal tissue Vaginal ultrasound to confirm if sac is empty Declining maternal serum hCG and progesterone levels to provide additional information about viability of pregnancy

31. When do we check for Strep B, and how do we treat it? (There is a vSim with this.)

a. According to the CDC guidelines, all pregnant women should be screened for GBS at 35 to 37 weeks of gestation and treated. Vaginal and rectal specimens are cultured for the presence of the bacterium. Both pregnant women and women during labor who have positive cultures are treated with a penicillin-based anti-infective agent. b. Penicillin G is the treatment of choice for GBS infection because of its narrow spectrum. Alternative antibiotics can be prescribed for clients with a penicillin allergy. The drug is usually administered intravenously at least 4 hours before birth so that it can reach adequate levels in the serum and amniotic fluid to reduce the risk of newborn colonization.

44. Why would betamethasone be given in pregnancy, and what precautions will be needed?

a. Promotes fetal lung maturity by stimulating surfactant production; prevents or reduces risk of respiratory distress syndrome and intraventricular hemorrhage in the preterm neonate less than 34 weeks of gestation b. Nursing implications/precautions: i. Administer two doses intramuscularly 24 h apart. ii. Monitor for maternal infection or pulmonary edema. iii. Educate parents about potential benefits of drug to preterm infant. iv. Assess maternal lung sounds and monitor for signs of infection.

41. Using a vacuum extractor during birth puts the baby at risk for which problems? P. 791

a. ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum

42. What if forceps are used in delivery—what are risks to the baby? P. 791

a. ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum

Missed abortion (nonviable embryo retained in utero for at least 6 weeks)

Evacuation of uterus (if inevitable abortion does not occur): suction curettage during first trimester, dilation and evacuation during second trimester

70. What effects do the different illegal drugs cause to fetuses and neonates? ALCOHOL

Fetal alcohol syndrome (one of the most common known causes of intellectual disability) Fetal alcohol spectrum disorders Alcohol-related birth defects: Facial features—flattened philtrum (groove in upper lip up to nose), thin upper lip, short palpebral; growth deficit—in weight, height, and BMI; structural/functional CNS dysfunction—microcephaly, intellectual disability, psychiatric conditions, language, motor, and memory disorders. Symptoms of alcohol withdrawal: Hyperactivity, jitteriness, hyperreflexia, hypertonia, poor suck, tremors, seizures, poor sleep patterns, and diaphoresis

38. What risks will face the neonate if his diabetic mother had uncontrolled glucose levels during pregnancy?

Gestational diabetes is associated with neonatal macrosomia, hypoglycemia, and birth trauma.

28. When are pregnant women with cardiovascular disease especially vulnerable?

Increased cardiac workload and greater myocardial oxygen demand during pregnancy place the woman's cardiovascular system at high risk for morbidity and mortality. Pregnancy causes cardiac output to rise as early as the first trimester, reaching peak values at 20 to 24 weeks, and continues to increase until it plateaus between 28 and 34 weeks of gestation. Common complaints of normal pregnancy, such as dyspnea, fatigue, palpitations, orthopnea, and pedal edema, mimic symptoms of worsening cardiac disease and create challenges when trying to evaluate pregnant women with cardiac disease. The pregnant woman is most vulnerable for this complication from 28 to 32 weeks of gestation and in the first 48 hours postpartum

55. How can we promote good developmental care for preemies?

Developmental care includes these strategies: Clustering care to promote rest and conserve the infant's energy Flexed positioning to simulate in utero positioning Environmental management to reduce noise and visual stimulation Kangaroo care to promote skin-to-skin sensation Placement of twins in the same isolette or open crib to reduce stress Activities to promote self-regulation and state regulation: Surrounding the newborn with nesting rolls/devices Swaddling with a blanket to maintain the flexed position Providing sheepskin or a waterbed to simulate the uterine environment Providing nonnutritive sucking (calms the infant) Providing objects to grasp (comforts the newborn) motion of parent-infant bonding by making parents feel welcome in the NICU Open, honest communication with parents and staff Collaboration with the parents in planning the infant's care Developmental care can be fostered by clustering the lights in one area so that no lights are shining directly on newborns, installing visual alarm systems and limiting overhead pages to minimize noise, and monitoring continuous and peak noise levels. Nurses can play an active role by serving on committees that address these issues. In addition, nurses can provide direct developmentally supportive care. Doing so involves careful planning of nursing activities to provide the ideal environment for the newborn's development. For example: Dim the lights and cover isolettes at night to simulate nighttime. Support early extubation from mechanical ventilation. Encourage early and consistent feedings with breast milk. Administer prescribed antibiotics judiciously. Position the newborn as if he or she was still in utero (a nesting fetal position). Promote kangaroo care by encouraging parents to hold the newborn against the chest for extended periods each day. Coordinate care to respect sleep and awake states.

34. Which women are at higher risk than average for having babies with congenital malformations?

Diabetics Most common anomalies: i. Coarctation of the aorta ii. Atrial and ventricular septal defects iii. Transposition of the great vessels iv. Sacral agenesis v. Hip and joint malformations vi. Anencephaly vii. Spina bifida viii. Caudal dysplasia ix. Hydrocephalus

37. Do insulin needs for type 1 diabetics go up or down during the various trimesters of the pregnancy?

Insulin doses are reduced in the first trimester to prevent hypoglycemia resulting from increased insulin sensitivity as well as from nausea and vomiting Increase after first trimester and fluctuate the greatest during third trimester

17. Know the signs and symptoms of hydatidiform mole/gestational trophoblastic disease and the treatment and the teaching that must be done to the woman experiencing it. pg.656-657

Gestational trophoblastic disease (GTD) comprises a spectrum of neoplastic disorders that originate in the placenta. There is abnormal hyperproliferation of trophoblastic cells that normally would develop into the placenta during pregnancy. GTDs encompass hydatidiform mole (complete and partial), invasive mole, gestational choriocarcinoma, placental-site trophoblastic tumor, and epithelioid trophoblastic tumor. Gestational tissue is present, but the pregnancy is not viable. Clinical manifestations of GTD are very similar to those of spontaneous abortion at about 12 weeks of pregnancy. Assess the woman for potential clinical manifestations at each antepartal visit. Be alert for the following: • Report of early signs of pregnancy, such as amenorrhea, breast tenderness, fatigue • Brownish vaginal bleeding/spotting • Anemia • Inability to detect a fetal heart rate after 10 to 12 weeks' gestation • Fetal parts not evident with palpation • Bilateral ovarian enlargement caused by cysts and elevated levels of hCG • Persistent, often severe, nausea and vomiting (due to high hCG levels) • Fluid retention and swelling • Uterine size larger than expected for pregnancy dates • Extremely high hCG levels present; no single value considered diagnostic • Early development of preeclampsia (usually not present until after 24 weeks) • Absence of fetal heart rate or fetal activity • Expulsion of grapelike vesicles (possible in some women) The diagnosis is made by very high hCG levels and the characteristic appearance of the vesicular molar pattern in the uterus via transvaginal ultrasound.

How is HELLP syndrome alike and different from preeclampsia?

HELLP= Hemolysis, elevated liver enzymes, low platelet count. It's a variant of preeclampsia/eclampsia. There is increased risk of hemorrhage, retinal detachment, hematoma/liver rupture, acute renal failure, DIC, placental abruption, and maternal death. HELLP and preeclampsia occur in the later stages of pregnancy and sometimes after childbirth HELLP is clinically progressive- early diagnosis is critical to prevent liver distention, rupture, and hemorrhage. HELLP occurs in up to 20% of women diagnosed with severe preeclampsia Lab values for those with HELLP are less abnormal than those with preeclampsia: a. Low hematocrit w/o blood loss b. Elevated LDH (liver impairment) c. Elevated AST (liver impairment) d. Elevated ALT e. Elevated BUN f. Elevated bilirubin g. Elevated uric acid and creatine levels h. Low platelet count

62. Be able to pick out signs and symptoms of SGA out of a line-up of possible symptoms.

Head disproportionately large compared to rest of body; wasted appearance of extremities; reduced subcutaneous fat stores; decreased amount of breast tissue; scaphoid abdomen (sunken appearance); wide skull sutures secondary to inadequate bone growth; poor muscle tone over buttocks and cheeks; loose and dry skin that appears oversized; thin umbilical cord

59. What are normal blood sugars in neonates, and how do we treat hypoglycemia?

Hypoglycemia is defined as a blood glucose level of less than 30 mg/dL or a plasma concentration of less than 40 mg/dL in the first 72 hours of life. The symptoms when present, are nonspecific and include jitteriness, lethargy, cyanosis, apnea, seizures, high-pitched or weak cry, hypothermia, and poor feeding. Treatment of hypoglycemia includes administration of a rapid-acting source of glucose such as sugar/water mixture or early formula feeding. In acute, severe cases, IV administration of glucose may be required.

5. Know the meds in Drug Guide table 19.2 (as much as it pains me to say it, 19.1 and 19.3 are more important than 19.2, however.) - Meds for hyperemesis gravidum

Promethazine, prochlorperazine, ondansetron

61. What is retinopathy of prematurity and how can it be prevented?

ROP is a potentially blinding eye disorder that occurs when abnormal blood vessels grow and spread through the retina, eventually leading to retinal detachment. Oxygen therapy must be used judiciously to prevent ROP.

36. How much caffeine can a woman safely consume in pregnancy without harm to herself or fetus?

Less than 300 mg/day

6. Know the first 4 meds in Drug Guide 19.3—the last 2 are not terribly important for OB because women using Nitroprusside are going to be in ICU (and you already know Lasix). - Meds used w/preeclampsia & eclampsia

Magnesium sulfate, Hydralazine, labetalol, Nifedipine

53. Be able to select tocolytic medications out of a list of drugs.

Medications commonly used for tocolysis include: Magnesium Sulfate (which reduces the muscle's ability to contract), Indomethacin (Indocin, a prostaglandin synthetase inhibitor), Atosiban (Tractocile, Antocin, an oxytocin receptor antagonist), and Nifedipine (Procardia, a calcium channel blocker)

4. Know the meds in the Drug Guide table 19.1—especially the nursing implications. (Nearly all will show up on either exam 3 or the HESI—count on it!) - Meds for Abortions

Misoprostol, Mifepristone, PGE2/dinoprostone, RhD immunoglobulin

52. A woman comes to the hospital because she says she is 42 weeks and wants to be induced. What would the admitting clinician want to establish first? (Think about this carefully!)

Obtain a thorough history to determine the estimated date of birth. Many women are unsure of the date of their last menstrual period, so the date given may be unreliable.

24. What makes pregnant women vulnerable to gestational diabetes? Pg. 367

Overt (pregestational diabetes) or high risk hx, physical inactivity, 1st degree relative w/diabetes, HTN, high risk race/ethnicity, obesity, PCO, hypercholesterolemia, previous large (>9lb) infant, smoker

56. How do preemies differ from term babies?

Physical characteristics of preterm infants may include: Birth weight of less than 5.5 lb Scrawny appearance Head disproportionately larger than chest circumference Poor muscle tone Minimal subcutaneous fat Undescended testes in males Prominent clitoris and labia minora in females Plentiful lanugo (soft, downy hair), especially over the face and back Poorly formed ear pinna, with soft, pliable cartilage Fused eyelids Soft and spongy skull bones, especially along suture lines Matted scalp hair, woolly in appearance Absent-to-a-few creases in the soles and palms Minimal scrotal rugae in male infants Thin, transparent skin with visible veins Breast and nipples not clearly delineated Abundant vernix caseosa

10. (Read my guides on preeclampsia in prep for this.) What is preeclampsia—what is happening and what are the signs/symptoms? Pg. 672-674

Preeclampsia can be described as a multisystem, vasopressive disorder that targets the cardiovascular, hepatic, renal, and central nervous systems (CNSs). Preeclampsia is a two-stage event;. the underlying mechanisms involved are vasospasm and hypoperfusion. In the first stage, the key feature is widespread vasospasm. In addition, endothelial injury occurs, leading to platelet adherence, fibrin deposition, and the presence of schistocytes (fragment of an erythrocyte). The second stage of preeclampsia is the woman's response to abnormal placentation, when symptoms appear, i.e., hypertension, proteinuria, and edema due to hypoperfusion. S/S: • Hypertension • Proteinuria • Edema (face, hands, and feet) • pulmonary edema • oliguria • headache • hyperreflexia • positive ankle clonus • seizures • thrombocytopenia • abnormal liver enzymes

58. What are risk factors for RDS?

Preterm birth, perinatal asphyxia regardless of gestational age, neonatal sepsis, cesarean birth in the absence of preceding labor (due to lack of thoracic squeezing), male gender, and maternal diabetes.

48. What is prolonged ROM and what risks does it pose?

Prolonged ruptured membranes (>24 hours) increase the risk of infection as a result of ascending vaginal pathological organisms for both mother and fetus. Signs of intrauterine infection to be alert for include maternal fever, fetal and maternal tachycardia, foul odor of vaginal discharge, and an increase in white blood cell count.

66. How can do neonates display over and under-hydration?

Sunken fontanels suggest dehydration; bulging fontanels suggest overhydration. • Under-hydration o More than 6 hrs. without a wet diaper o Urine that looks darker and smells stronger than usual o Lethargy o Dry, parched mouth and lips o No tears while crying o Sunken eye o Hands and feet that feel cold and look splotchy o Excessive sleepiness or fussiness o Sunken fontanels (soft spots on your baby's head) • Assess fluid status by monitoring weight; urinary output; urine specific gravity; laboratory test results such as serum electrolyte levels, blood urea nitrogen, creatinine, and hematocrit; skin turgor; and fontanels (Koletzko, Poindexter, & Uauy, 2014). Be alert for signs of dehydration, such as a decrease in urinary output, sunken fontanels, temperature elevation, lethargy, and tachypnea. • When assessing the fluid status of a preterm newborn, palpate the fontanels. Sunken fontanels suggest dehydration; bulging fontanels suggest overhydration.

32. How do we treat iron deficiency anemia, and how can women decrease unpleasant symptoms when they are being treated?

Taking prenatal vitamins and iron supplements consistently. Take iron with Vit. C. and on an empty stomach to promote absorption. Taking with food, increased fluids, and more fiber may decrease stomach discomfort and side effects.

47. What does a high vs. low Bishop's score mean?

The Bishop score helps identify women who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score: a score over 8 indicates a successful vaginal birth. Bishop scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction.

hydatidiform mole/gestational trophoblastic disease Therapeutic Management

Treatment consists of immediate evacuation of the uterine contents as soon as the diagnosis is made and long-term follow-up of the client to detect any remaining trophoblastic tissue that might become malignant. D&C is used to empty the uterus. The tissue obtained is sent to the laboratory for analysis to evaluate for choriocarcinoma. Serial levels of hCG are used to detect residual trophoblastic tissue for 1 year. If any tissue remains, hCG levels will not regress. In 80% of women with a benign hydatidiform mole, serum hCG titers steadily drop to normal within 8 to 12 weeks after evacuation of the molar pregnancy. In the other 20% of women with a malignant hydatidiform mole, serum hCG levels begin to rise. As a result of the increased risk for cancer, the client is advised to receive extensive follow-up therapy for the next 12 months. The follow-up protocol may include: • Baseline hCG level, chest radiograph, and pelvic ultrasound • Quantitative hCG levels every week until undetectable for 3 consecutive weeks; then serial hCG levels monthly for 1 year • Chest radiograph every 6 months to detect pulmonary metastasis • Regular pelvic examinations to assess uterine and ovarian regression • Systemic assessments for symptoms indicative of lung, brain, liver, or vaginal metastasis • Strong recommendation to avoid pregnancy for 1 year because the pregnancy can interfere with the monitoring of hCG levels • Use of a reliable contraceptive for at least 1 year

Inevitable abortion

Vaginal bleeding (greater than that associated with threatened abortion) Rupture of membranes Cervical dilation Strong abdominal cramping Possible passage of products of conception Ultrasound and hCG levels to indicate pregnancy loss

16. Absolutely KNOW all the signs of magnesium sulfate toxicity, and the blood levels. These will be on the exams. Also know that calcium gluconate is the antidote for mag sulfate—and is on all the crash carts in OB. Remember that most IV meds in OB are ordered by the clinician, but the nurse titrates them "to effect"—including mag sulfate to some extent. (There are protocols for it, with blood levels drawn at intervals.) If toxicity occurs, the nurse is expected to turn it off and go through a protocol, of course notifying the doc when it happens, but the clinician often will not be the one calling the shots—a protocol approved by the medical director/ACOG will be initiated, and then the clinician will weigh in. pg.767 & 768

With magnesium sulfate administration, the client is at risk for magnesium toxicity. Closely assess the client for signs of toxicity, which include a respiratory rate of less than 12 breaths per minute, absence of DTRs, and a decrease in urinary output (<30 mL/hr). Also monitor serum magnesium levels. Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic. As levels increase, the woman is at risk for severe problems: • 10 mEq/L: Possible loss of DTRs • 15 mEq/L: Possible respiratory depression • 25 mEq/L: Possible cardiac arrest

35. Be able to identify the signs and symptoms a neonate presents when his mother abused heroin

Withdrawal, or neonatal abstinence syndrome (NAS) • CNS Dysfunction o Tremors o Generalized seizures o Hyperactive reflexes o Restlessness o Irritability o Hypertonic muscle tone, constant movement o Shrill, high-pitched cry o Disturbed sleep patterns • Gastrointestinal Dysfunction o Poor feeding o Frantic sucking or rooting o Uncoordinated sucking o Poor weight gain o Loose or watery stools o Regurgitation or projectile vomiting • Metabolic, Vasomotor, and Respiratory Disturbances o Fever o Frequent yawning o Mottling of the skin o Sweating o Nasal stuffiness o Temperature instability o Frequent sneezing o Nasal flaring o Tachypnea >60 bpm o Apnea

46. What is a ripe cervix?

a. A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm. Cervical ripening usually begins prior to the onset of labor contractions and is necessary for cervical dilation and the passage of the fetus.

45. KNOW how to administer oxytocin—know the reasons it is given, why we might stop it, the benefits and risks.

a. Acts on uterine myofibrils to contract/to initiate or reinforce labor b. Administer as an IV infusion via pump, increasing dose based on protocol until adequate labor progress is achieved. c. Assess baseline vital signs and FHR and then frequently after initiating oxytocin infusion. d. Determine frequency, duration, and strength of contractions frequently. e. Notify health care provider of any uterine hypertonicity or abnormal FHR patterns. f. Maintain careful I&O, being alert for water intoxication. g. Keep client informed of labor progress. h. Monitor for possible adverse effects such as hyperstimulation of the uterus, impaired uterine blood flow leading to fetal hypoxia, rapid labor leading to cervical lacerations or uterine rupture, water intoxication (if oxytocin is given in electrolyte-free solution or at a rate exceeding 20 mU/min), and hypotension. i. After delivery, oxytocin secretion continues, causing the myometrium to contract and helping to constrict the uterine blood vessels, decreasing the amount of vaginal bleeding after delivery j. It is responsible for milk ejection during breast-feeding. k. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity. l. It may lead to jaundice in newborn.

43. What is the difference between caput succedaneum and cephalhematoma? P. 427 & 601

a. Caput succedaneum - edema of the scalp at the presenting part. This swelling crosses suture lines and disappears within 3 to 4 days. Pitting edema and overlying petechiae and ecchymosis are noted. Newborns who were delivered via vacuum extraction usually have a caput in the area where the cup was used. b. Cephalhematoma - a collection of blood between the periosteum and the bone that occurs several hours after birth. Can be caused by prolonged labor and obstetric interventions such as low forceps or vacuum extraction. clinical features include a well-demarcated, often fluctuant swelling with no overlying skin discoloration. The swelling does not cross suture lines and is firmer to the touch than an edematous area. Hyperbilirubinemia can occur d/t breakdown of RBC from the hematoma (occurs later than class hyperbilirubinemia); usually appears on 2nd or 3rd day after birth and disappears in weeks or months

29. How do we treat pregnant women with HIV to prevent transmission to the fetus? (You may also see a question on the HESI asking if women with HIV and with HepB can breastfeed).

a. Early identification of maternal HIV seropositivity allows early antiretroviral treatment to prevent mother-to-child transmission, allows a provider to avoid obstetric practices that may increase the risk for transmission, and allows an opportunity to counsel the mother against breast-feeding (also known to increase the risk for transmission). Women who elect to continue with the pregnancy should be treated with ART regardless of their CD4 count or viral load. b. Interventions to reduce HIV transmission include antiretroviral therapy to the mother and the newborn, consideration of elective cesarean section in women with elevated plasma viral load, and the avoidance of breastfeeding. With these interventions, the risk of HIV transmission is now less than 1%. Drug therapy is the mainstay of treatment for pregnant women infected with HIV. The standard treatment is oral antiretroviral drugs given twice daily until giving birth, intravenous administration during labor, and oral zidovudine (AZT) for the newborn within 6 to 12 hours of birth. The goal of therapy is to reduce the viral load as much as possible, which reduces the risk of transmission to the fetus. c. Decisions about the birthing method to be used are made on an individual basis based on several factors involving the woman's health. Some reports suggest that cesarean birth may reduce the risk of HIV infection. Efforts to reduce instrumentation, such as avoiding the use of an episiotomy, fetal scalp electrodes, and fetal scalp sampling, will reduce the newborn's exposure to body fluids.

8. What are the risks for ectopic pregnancy and why is it so dangerous? How do we treat it?

a. Ectopic pregnancy is any pregnancy in which the fertilized ovum implants outside the uterine cavity, including in the fallopian tubes, cervix, ovary, and the abdominal cavity. This abnormally implanted embryo grows and draws its blood supply from the site of abnormal implantation; as the embryo grows, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development; this can lead to massive hemorrhage, infertility, or death b. Risks fators: i. Usually result from conditions that obstruct or slow the passage of the fertilized ovum through the fallopian tube to the uterus; including physical blockage of the tube or failure of the tubal epithelium to move the zygote (cell formed after the egg is fertilized) down the tube to the uterus ii. Most cases are the result of tubal scarring secondary to pelvic inflammatory disease (PID) iii. Organisms such as Neisseria gonorrhea and Chlamydia trachomatis preferentially attack the fallopian tubs producing silent infection iv. Twofold increased risk in women with a history of a chlamydia infection, secondary to tubal damage v. Other risk factors include previous pregnancy loss (induced or spontaneous, sterilization, history of multiple sexual partners, vi. In addition to patient hx: 1. Previous ectopic pregnancy 2. Hx of STIs 3. Fallopian tube scarring from PID 4. In utero exposure to DES (diethylstilbestrol) 5. Endometriosis 6. Previous tubal or pelvic surgery 7. Infertility & infertility treatments including use of fertility drugs 8. Uterine abnormalities such as fibroids 9. Presence / use of intrauterine contraception 10. Use of progestin-only mini pill (slows ovum transport) 11. Postpartum or post abortion infection 12. Altered estrogen and progesterone levels (interferes with tubal motility) 13. Increasing age (older than 35 YO) 14. Cigarette smoking (which alters tubal motility) 15. Douching c. Therapeutic Management: i. Diagnosis of ectopic pregnancy can be challenging because many women are asymptomatic before tubal rupture; the classic clinical triad of ectopic pregnancy includes abdominal pain, amenorrhea, and vaginal bleeding; unfortunately, only about half of women present w/ all 3 symptoms ii. Diagnostic procedures used for a suspected ectopic pregnancy include a urine pregnancy test to confirm pregnancy, beta-hCG concentrations to exclude a false-negative urine test, and a transvaginal ultrasound to visualize the misplaced pregnancy iii. The therapeutic management depends on whether the tube is intact or has ruptured, creating a medical emergency; in the event of surgical intervention, preservation of the affected fallopian tube is attempted iv. Ectopic pregnancy is a potentially life-threatening condition and involves pregnancy loss

39. What is hyperemesis gravidarum and how is it treated?

a. First line - conservative management at home, including dietary and lifestyle changes b. Hospitalization - blood tests to assess for severity of dehydration, electrolyte imbalance, ketosis, and malnutrition. Parenteral fluids (usually NS, with vitamin B6 and electrolytes added) to rehydrate are given. Withhold oral food and fluids for 24-36 hours. Antiemetics can be given rectally or through an IV. If the condition still doesn't improve, you may need to give TPN or feeding through a percutaneous endoscopic tube. Antiemetics are still given (Phenergan and Compazine are tried first, then Zofran) c. Some women may choose to try acupressure, massage, therapeutic touch, ginger, and Sea-Bands.

9. How does gestational HTN differ from chronic HTN?

a. Gestational HTN is a temporary diagnosis for hypertensive pregnant women who don't meet the criteria for preeclampsia (both HTN and possibly proteinuria) or chronic HTN (HTN first detected before the 20th week of pregnancy) b. Characterized by HTN (>140/90) w/o proteinuria after 20 weeks gestation resolving by 12 weeks postpartum c. Is defined as a systolic blood pressure >140 mm Hg and/or a diastolic blood pressure >90 mm Hg on at least 2 occassions at 4 - 6 hours apart after the 20th wk of gestation, in women known to be normotensive prior to this time and prior to pregnancy

33. How are chlamydia and gonorrhea treated in pregnancy? (I disagree with the textbook on treatment of chlamydia. The CDC says azithromycin 1 gram in a single dose is first-line treatment. Erythromycin is what my teachers called a "wimpy" antibiotic!)

a. Gonorrhea- dual therapy treatment of a single IM dose of ceftriaxone (Rocephin) 250 mg plus a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice a day for 7 days b. Chlamydia- doxycycline (Vibramycin) 100 mg PO BID for 7 days or azithromycin (Zithromax) 1 g PO in a single dose.

40. What is the management of prolapsed cord?

a. Prevention and identifying who is at risk is the key to managing a cord prolapse. b. Recognition of cord prolapse - first sign is often sudden fetal bradycardia or variable decels. c. Call for help. Do not leave the woman. d. Inform the woman and discuss options. e. Assist with measure to relieve compression. f. Reposition pt - SIMS, trendlenberg, or knee chest position g. Do not attempt to replace the cord into the uterus. h. Monitor fetal heart rate, maintain bed rest, and administer oxygen if ordered. i. Provide emotional support and explanations as to what is going on to allay the woman's fears and anxiety. j. If not fully dilated, prepare for possible cesarean. k. Cord prolapse is when the cord precedes the fetus and the cord is occluded depriving the fetus of oxygen. It is an obstetrical emergency. It requires prompt recognition and intervention. It is rare and occurs mostly in breech or vertex positions.

Which methods can be used to ripen a cervix? What precautions should be taken when doing it?

b. Alternative or non-pharmacological methods (risks/benefits are unknown): i. Herbal agents (i.e. evening primrose oil, black haw, black and blue cohosh, and red raspberry leaves), sexual intercourse, or breast stimulation.

Which methods can be used to ripen a cervix? What precautions should be taken when doing it?

c. Mechanical Methods: i. Application of local pressure stimulates the release of prostaglandins to ripen the cervix. Potential advantages of mechanical methods, compared with pharmacologic methods, may include simplicity or preservation of the cervical tissue or structure, lower cost, and fewer side effects. The risks associated with these methods include infection, bleeding, membrane rupture, and placental disruption.

Which methods can be used to ripen a cervix? What precautions should be taken when doing it?

e. Pharmacologic Methods: i. Prostaglandins 1. A drawback of prostaglandins is their ability to induce excessive uterine contractions, which can increase maternal and perinatal morbidity ii. dinoprostone gel (Prepidil), dinoprostone inserts (Cervidil), and 1. It is important to note that only dinoprostone is approved by the FDA for use as a cervical ripening agent, although ACOG acknowledges the apparent safety and effectiveness of misoprostol for this purpose. iii. misoprostol (Cytotec). 1. Misoprostol (Cytotec), a synthetic PGE1 analog, is a gastric cytoprotective agent used in the treatment and prevention of peptic ulcers. It can be administered intravaginally or orally to ripen the cervix or induce labor. 2. A major adverse effect of the obstetric use of Cytotec is hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism. Furthermore, it is contraindicated for women with prior uterine scars and therefore should not be used for cervical ripening in women attempting a vaginal birth after cesarean.

most common cause for first-trimester abortions

fetal genetic abnormalities, usually unrelated to the mother

Mifepristone (RU-486)

i. Acts as progesterone antagonist, allowing prostaglandins to stimulate uterine contractions; causes the endometrium to slough; may be followed by administration of misoprostol within 48 hours. 1. Nursing Interventions: a. Monitor for headache, vomiting, diarrhea, and heavy bleeding. b. Anticipate administration of antiemetic prior to use to reduce nausea and vomiting. c. Encourage client to use acetaminophen to reduce discomfort from cramping.

Prochlorperazine (Compazine)

i. Acts centrally to inhibit dopamine receptors in the CTZ and peripherally to block vagus nerve stimulation in the gastrointestinal tract. ii. Controls severe nausea and vomiting. 1. Nursing Interventions: a. Be alert for abnormal movements and for neuroleptic malignant syndrome such as seizures, hyper/hypotension, tachycardia, and dyspnea. b. Assess mental status, intake/output. c. Caution client not to drive as a result of drowsiness or dizziness. d. Advise to change position slowly to minimize effects of orthostatic hypotension.

Labetalol hydrochloride (Normodyne)

i. Alpha-1 and beta blocker ii. Reduction in blood pressure 1. Nursing Interventions: a. Be aware that drug lowers blood pressure without decreasing maternal heart rate or cardiac output. b. Administer IV dose of 20 to 40 mg every 15 minutes as needed and then administer intravenous V infusion of 2 mg/min until desired blood pressure value achieved. c. Monitor for possible adverse effects such as gastric pain, flatulence, constipation, dizziness, vertigo, and fatigue.

Magnesium sulfate

i. Blockage of neuromuscular transmission, vasodilation ii. Prevention and treatment of eclamptic seizures 1. Nursing Interventions: a. Loading dose of 4 to 6 g by IV in 100 mL of fluid administered over 15 to 20 minutes, followed by a maintenance dose of 2 g as a continuous intravenous infusion. b. Monitor serum magnesium levels closely. c. Assess DTRs and check for ankle clonus. d. Have calcium gluconate readily available in case of toxicity. e. Monitor for signs and symptoms of toxicity, such as flushing, sweating, hypotension, and cardiac and central nervous system depression.

Ondansetron (Zofran)

i. Blocks serotonin release, which stimulates the vagal afferent nerves, thus stimulating the vomiting reflex 1. Nursing Interventions: a. Monitor for possible side effects such as diarrhea, constipation, abdominal pain, headache, dizziness, drowsiness, and fatigue. b. Monitor liver function studies as ordered.

Nifedipine (Procardia)

i. Calcium channel blocker/dilation of coronary arteries, arterioles, and peripheral arterioles ii. Reduction in blood pressure, stoppage of preterm labor 1. Nursing Interventions: a. Administer 10 to 20 mg orally for three doses and then every 4 to 8 hours. b. Monitor for possible adverse effects such as dizziness, peripheral edema, angina, diarrhea, nasal congestions, cough.

Promethazine (Phenergan)

i. Diminishes vestibular stimulation and acts on the chemoreceptor trigger zone (CTZ) ii. Symptomatic relief of nausea and vomiting, and motion sickness. 1. Nursing Interventions: a. Be alert for urinary retention, dizziness, hypotension, and involuntary movements. b. Institute safety measures to prevent injury secondary to sedative effects. c. Offer hard candy and frequent rinsing of mouth for dryness.

Misoprostol (Cytotec)

i. Stimulates uterine contractions to terminate a pregnancy; to evacuate the uterus after abortion to ensure passage of all the products of conception. 1. Nursing Interventions: a. Monitor for side effects such as diarrhea, abdominal pain, nausea, vomiting, and dyspepsia. b. Assess vaginal bleeding and report any increased bleeding, pain, or fever. c. Monitor for signs and symptoms of shock, such as tachycardia, hypotension, and anxiety.

PGE2, dinoprostone (Cervidil, Prepidil Gel, Prostin E2)

i. Stimulates uterine contractions, causing expulsion of uterine contents; to expel uterine contents in fetal death or missed abortion during second trimester, or to efface and dilate the cervix in pregnancy at term. 1. Nursing Interventions: a. Bring gel to room temperature before administering. b. Avoid contact with skin. c. Use sterile technique to administer. d. Keep client supine for 30 min after administering. e. Document time of insertion and dosing intervals. f. Remove insert with retrieval system after 12 hours or at the onset of labor. g. Explain purpose and expected response to client.

Rh(D) immunoglobulin (Gamulin, HydroRho-D, RhoGAM, MICRhoGAM)

i. Suppresses immune response of nonsensitized Rh-negative clients who are exposed to Rh-positive blood; to prevent isoimmunization in Rh-negative women exposed to Rh-positive blood after abortions, miscarriages, and pregnancies. 1. Nursing Interventions: a. Administer intramuscularly in deltoid area. b. Give only MICRhoGAM for abortions and miscarriages <12 weeks unless fetus or father is Rh negative (unless client is Rh positive, Rh antibodies are present). c. Educate woman that she will need this after subsequent deliveries if newborns are Rh positive; also check lab study results prior to administering the drug.

Hydralazine hydrochloride (Apresoline)

i. Vascular smooth muscle relaxant, thus improving perfusion to renal, uterine, and cerebral areas ii. Reduction in blood pressure 1. Nursing Interventions: a. Administer 5 to 10 mg by slow intravenous bolus every 20 minutes as needed. b. Use parenteral form immediately after opening ampule. c. Withdraw drug slowly to prevent possible rebound hypertension. d. Monitor for adverse effects such as palpitations, headache, tachycardia, anorexia, nausea, vomiting, and diarrhea.

3. What are the signs and symptoms of abruption placenta? (Know the differences between previa and abruptions).

• Abruptio placentae is the premature separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage. It is a significant cause of third-trimester bleeding, with a high mortality rate. • Classic manifestations of abruptio placentae include painful, dark-red vaginal bleeding (port-wine color) because the bleeding comes from the clot that was formed behind the placenta; "knife-like" abdominal pain; uterine tenderness; contractions; and decreased fetal movement.

1. Know the causes and types of spontaneous abortion. How can a clinician tell the difference been a threatened abortion and one that has already happened? What are the options for a missed abortion? (Table 19.1 pg. 651)

• An abortion is the loss of an early pregnancy, usually before week 20 of gestation. Abortion can be spontaneous or induced. A spontaneous abortion refers to the loss of a fetus resulting from natural causes, that is, not elective or therapeutically induced by a procedure.(649) • A stillbirth is the loss of a fetus after the 20th week of development, whereas a miscarriage refers to a loss before the 20th week.

TEACHING TO PREVENT TOXOPLASMOSIS

• Avoid eating raw or undercooked meat, especially lamb or pork. Cook all meat to an internal temperature of 160° F (71° C) throughout. • Clean cutting boards, work surfaces, and utensils with hot soapy water after contact with raw meat or unwashed fruits and vegetables. • Peel or thoroughly wash all raw fruits and vegetables before eating them. • Wash hands thoroughly with warm water and soap after handling raw meat. • Avoid feeding the cat raw or undercooked meats. • Avoid emptying or cleaning the cat's litter box. Have someone else do it daily. • Keep outdoor sandboxes covered to prevent cat feces contamination • Keep the cat indoors to prevent it from hunting and eating birds or rodents. • Avoid uncooked eggs and unpasteurized milk. • Wear gardening gloves when in contact with outdoor soil. • Avoid contact with children's sandboxes, because cats can use them as litter boxes.

68. What is the cause of club foot?

• Clubfoot, or talipes equinovarus o Complex, multifactorial deformity with genetic and intrauterine factors. Heredity and race seem to factor into the incidence, but the means of transmission and the etiology are unknown. Extrinsic (supple) type- a severe positional or soft tissue deformity Intrinsic (rigid) type- manual reduction is not possible o Most NB with clubfoot have no ID genetic, syndromal or extrinsic cause o It is bilateral in about half of the cases and affects boys twice as girls. o Characterized: an excessive turned in foot, limitation of extension of the ankle and subtalar joint and internal rotation of the leg. o 4 components: Inversion of the forefoot Adduction of the forefoot Inversion of the heel Hindfoot o Reducing or eliminating all of the components of the deformity is the goal to ensure that the NB has functional, mobile, painless foot that does not require the use of special or modified shoes.

26. What meds can a woman with rheumatoid arthritis use if she is pregnant—and which is category X and cannot be used? Pg. 723

• During pregnancy, medications are limited to hydroxychloroquine, glucocorticoids, and NSAIDs. • Methotrexate is contraindicated during pregnancy

25. Know the desired fasting and 1 hour post-prandial (and post GTT) values. pg. 377 & 698

• Fasting blood glucose level: Less than 92 mg/dL • At 1 hour: Less than 180 mg/dL • At 2 hours: Less than 153 mg/dL • At 3 hours: Less than 140 mg/dL

11. What are the risk factors of preeclampsia? You will be asked to select which patient has the most of them.

• First pregnancy • Previous Hx of preeclampsia • Multiple gestation • Hx of chronic high BP, diabetes, kidney disease or organ transplant • Obesity • Family Hx of preeclampsia (mother, grandmother, aunt or sister) • Over 40 or under 18 • SLE • In-vitro fertilization • Polycystic ovarian syndrome

19. Why is Why is HELLP syndrome such a serious problem? (Remember that among other reasons, it may occur without any visible signs and symptoms.)

• HELLP syndrome is an acronym for hemolysis, elevated liver enzymes, and low platelet count. Women with HELLP syndrome are at increased risk for complications such as cerebral hemorrhage, retinal detachment, hematoma/liver rupture, acute renal failure, disseminated intravascular coagulation (DIC), placental abruption, and maternal death. It is a life-threatening obstetric complication considered by many to be a severe form of preeclampsia involving hemolysis, thrombocytopenia, and liver dysfunction. Early diagnosis is critical to prevent liver distention, rupture, and hemorrhage and the onset of DIC. If the condition presents prenatally, morbidity and mortality can affect both mother and baby. • It can present prior to the presence of an elevated blood pressure. HELLP syndrome leads to an increased maternal risk for developing liver hematoma or rupture, stroke, cardiac arrest, seizure, pulmonary edema, DIC, subendocardial hemorrhage, adult respiratory distress syndrome, renal damage, sepsis, hypoxic encephalopathy, and maternal, or fetal death.

21. What factor drives the decision to allow delivery to occur in PPROM?

• If the fetal lungs are mature, induction of labor is initiated.

22. Know the patient teaching for PPROM. Pg. 688

• Monitor your baby's activity by performing fetal kick counts daily. • Check your temperature daily and report any temperature increases to your health care provider. • Watch for signs related to the beginning of labor. Report any tightening of the abdomen or contractions. • Avoid any touching or manipulating of your breasts, which could stimulate labor. • Do not insert anything into your vagina or vaginal area—no tampons, avoid vaginal intercourse • Do not swim in pools or in the ocean or sit in a hot tub or Jacuzzi. • Take showers for daily hygiene needs; avoid sitting in a tub bath. • Maintain any specific activity restrictions as recommended. • Wash your hands thoroughly after using the bathroom and make sure to wipe from front to back each time. • Keep your perineal area clean and dry. • Take your antibiotics as directed if your health care provider has prescribed them. • Call your health care provider with changes in your condition, including fever, uterine tenderness, feeling like your heart is racing, and foul-smelling vaginal discharge.

69. Be able to select the nursing care for exstrophy of the bladder out of a line-up of interventions.

• Nursing management of the newborn with bladder exstrophy includes the following activities:' o Identify the genitourinary defect at birth so that immediate treatment can be provided. o Cover the exposed bladder with a sterile clear nonadherent dressing to prevent hypothermia and infection. o Irrigate the bladder surface with sterile saline after each diaper change to prevent infection. o Assist with insertion and monitoring of a suprapubic catheter to drain the bladder and prevent obstruction. o Administer antibiotic therapy as ordered to prevent infection. o Schedule diagnostic tests to assess for additional anomalies. o Assess the newborn frequently for any signs of infection. o Inspect skin surfaces frequently to ensure skin integrity. o Maintain modified Bryant traction for immobilization after surgery. o Administer antispasmodics, analgesics, and sedatives as ordered to prevent bladder spasm and provide comfort. o Educate the parents about the care of the urinary catheter at home if applicable. o Support the parents throughout. o Promote bonding by encouraging the parents to visit and touch the newborn. o Refer the parents to a support group to enhance their coping ability. o Be a therapeutic listener to the family

67. What is nursing care for an infant with omphalocele?

• Omphalocele- defect of the umbilical ring that allows evisceration of the abdominal contents into an external peritoneal sac. Defects vary in size, they may be limited to bowel loops or may include the entire GI tract and liver. o Note the appearance of the protrusion on the abdomen and evidence of a sac. o Inspect the sac closely for the presence of organs, most commonly the intestines but sometimes the liver. o Inspect the contents for any twisting of the intestines. o Note the color of the organs within the sac and measure the size of the omphalocele. • Mngm: Preventing hypothermia, maintaining perfusion to the eviscerated abdominal contents by minimizing fluid loss, and protecting the exposed abdominal contents from trauma and infection. Place the infant in a sterile drawstring bowel bag that maintains a sterile environment for the exposed contents, allows visualization, reduces heat and moisture loss and allows heat from radiant warmers to reach the NB. NB is placed feet-first into the bag and the drawstring is secured around the torso. An orogastric tube attached to low suction is used to prevent intestinal distention. IV therapy: maintain F&E balance and provide abx. Monitor NB fluid stat. frequently. Closely observe the exposed bowel for vascular compromises, such as changes in color or a decrease in temperature, and report these ASAP. Surgery: pain mngm, respiratory and cardiac status, monitor I&O, assess vascular compromise maintain orogastric tube to suction, document the amount and color of drainage, adm. Meds and tx. BE ALERT FOR SHORT BOWEL SYNDROME. • Encourage the parents to touch the NB and participate in care as much as possible.

65. What are signs and symptoms of neonatal overstimulation?

• Overstimulation may have negative effects by reducing oxygenation and causing stress. • When overstimulated (e.g., by noise, lights, excessive handling, alarms, and procedures) and stressed, heart and respiratory rates decrease and periods of apnea or bradycardia may follow • The NICU environment can be altered to provide periods of calm and rest for the newborn by dimming the lights, lowering the volume and tone of conversations, closing doors gently, setting the telephone ringer to the lowest volume possible, clustering nursing activities, and covering the isolette with a blanket to act as a light shield to promote rest at night.

2. What are the signs and symptoms of placenta previa?

• Placenta previa is a bleeding condition that occurs during the last two trimesters of pregnancy. In placenta previa (literally, "afterbirth first"), the placenta implants over the cervical os. It may cause serious morbidity and mortality to the fetus and mother (660) • The classical clinical presentation is painless, bright-red vaginal bleeding occurring during the second or third trimester. The initial bleeding usually is not profuse and it ceases spontaneously, only to recur again. The first episode of bleeding occurs (on average) at 27 to 32 weeks' gestation. • A cesarean birth will be planned. (661)

20. What is PPROM, and what are the goals of treatment?

• Preterm premature rupture of membranes (PPROM), which is defined as rupture of membranes prior to the onset of labor in a woman who is less than 37 weeks' gestation. Perinatal risks associated with PPROM may stem from immaturity, including respiratory distress syndrome, intraventricular hemorrhage, patent ductus arteriosus, and necrotizing enterocolitis. Eighty-five percent of neonatal morbidity and mortality is a result of prematurity. PPROM is associated with 30% to 40% of preterm deliveries and is the leading identifiable cause of preterm delivery. Goals of tx: infection prevention & identifying uterine contractions PROM (Premature rupture of membranes) = ROM that occurs after 37 weeks, but before labor has started

7. Really understand the Rh negative situation—who gets Rhogam, when and why.

• Rh neg women receive RhoGAM at some point between 28-32 weeks and then again within 72 hours after giving birth • RhoGAM is given to suppress the immune response of nonsensitized Rh-negative pts who are exposed to Rh-positive blood; to prevent isoimmunization in Rh-neg women exposed to Rh-pos blood after abortions, miscarriages, and pregnancies • Nursing implications: o Administer IM in deltoid o Give only MICRhoGAM for abortions and miscarriages <12 weeks unless fetus or father is Rh neg (unless pt is Rh-pos, Rh antibodies are present) o Educate woman that she will need this after subsequent deliveries if newborns are Rh-pos; also check lab study results prior to administering the drug