OB exam 3

What do late preterm infants have an increased risk for?

(34 0/7 - 36 6/7) Respiratory distress Thermoregulation problems Nutrition issues Hypoglycemia Hyperbilirubinemia Infection

What do postterm infants have an increased risk for?

(>42 weeks) Meconium aspiration syndrome (MAS) Persistent pulmonary hypertension of the newborn (PPHN)

What are some risk factors for placental abruption?

*Cocaine use* HTN Trauma Cigarrette smoking Hx PPROM

S/S of preeclampsia

*Proteinuria must be present* Visual changes Headache Pulmonary edema Elevated LFTs Renal insufficiency RUQ pain

This infusion should be continued (not turned off and restarted in thePACU) and monitored through cesarean section

Mag sulfate

For parents of high risk/preterm newborns, what are important parental adaptation considerations?

- Anticipatory grief lasts from labor until either death of the infant or signs of survival - Must accomplish numerous tasks before effective relationships and parenting patterns evolve - Parental support and education is imperative - Maladaptation increases risk of abuse in preterm infants

Your patient is a 20-year-old, single, G0P0 who presents to the clinic as a walk-in. She appears upset. After you bring her to an examination room and take her vital signs, you ask her what the reason is for her visit today. She replies, "A couple of days ago, I noticed some painful, pimple-like bumps on the outside of my vagina. I don't know what to do." While you take her health history, what are some especially important questions to include?

- Sexual history? Orientation? Recent sexual activity? How many partners? - Hx of STIs or exposure to an infected person? - Hx of viral symptoms such as malaise, headache, fever, or myalgia or local symptoms such as vulvar pain, dysuria, itching or burning at the site of infection? - Hx of a primary infection, prodromal symptoms, vaginal discharge, and dyspareunia.

Number of minutes recommended to wait between identification and confirmation of elevated blood pressure.

15 minutes

Second bolus dose of IV magnesium sulfate administered for refractory eclampsia.

2 g

The amount of protein present in a 24 hour urine to be considered diagnostic for preeclampsia

300 g

How is mag run for preeclamsia? What does it do? What is the antidote?

46 g bolus over 20 min 2g/hr Anti-seizure Calcium gluconate

Preeclampsia effects this percentage of women in the US and Canada

5-8%

After a severe BP reading, how soon do we need to give antihypertensive medication?

60 minutes

Recommended follow up care for women diagnosed with gest. htn, preeclampsia or superimposed preeclampsia

72 hours and again 7-10 days postpartum

What should blood glucose be during labor

90-120 at al times

What is considered a severe preeclamptic BP?

>160/110

This should be completed and turned in for review when your patient has new onset severe hypertension

A preeclampsia debriefing sheet

What is an inevitable abortion? Treatment options?

Often accompanied by ROM, pain Heavy bleeding and/or infection is present, immediate termination is indicated.

Match the following classifications of diabetes to its definition: A1, A2, B, C, D, F, R, T Options: - has had a renal transplant - Onset prior to the age of 10 OR duration of illness >20years or both - GDM diet controlled - developed diabetic nephropathy - GDM - Insulin controlled - Onset after age 20 and duration less than 10 years - developed retinitis - Onset between 10-19 years old OR illness for 10-19 years. - or both

A1 - GDM diet controlled A2 - GDM - Insulin controlled B- Onset after age 20 and duration less than 10 years C- Onset between 10-19 years old OR illness for 10-19 years. - or both D - Onset prior to the age of 10 OR duration of illness >20years or both F - developed diabetic nephropathy R - developed retinitis T- has had a renal transplant

What is gestational hypertension?

Onset after 20 weeks of gestation without proteinuria, return of normal B/P in postpartum

What are health risks of menopause?

Osteoporosis Coronary artery disease - decreased estrogen Low libido Breast/colon cancer

What are some important assessments for a patient with preeclampsia?

Accurate BP Edema DTRs (hyperreflexic or hypo with mag toxicity) Lung sounds Q4, Q1-2 if severe Labs (LFTs) 24 hour urine Creatinine clearance and Proteinuria

How does pregnancy affect rheumatoid arthritis?

Although the reason is unclear, marked improvement is seen with rheumatoid arthritis. Most women relapse 6 weeks to 6 months postpartum.

A magnesium sulfate infusion requires this at the beginning of every shift, patient handover and at initiation.

An independent RN double check

Reflex tachycardia is aside effect of this medication.

Apresoline

IV antihypertensive medications administered over two minutes.

Apresoline and labetolol

What medication can be given to women with a history of preeclampsia with severe features in the first trimester to decrease the risk in the current pregnancy?

Aspirin (60-80mg)

Signs of asymmetric IUGR vs symmetric IUGR?

Asymmetric IUGR head is larger and has better potential for normal growth as the brain still developed to normal size. Symmetric/SGA can result in less brain capacity.

Women with hyperemesis gravidarum: A. Are a majority, because 80% of all pregnant women suffer from it at some time B. Have vomiting severe and persistent enough to cause weight loss, dehydration, ketonuria, and electrolyte imbalance C. Need IV fluid and nutrition for most of their pregnancy D. Often inspire similar, milder symptoms in their male partners and mothers

B. Have vomiting severe and persistent enough to cause weight loss, dehydration, ketonuria, and electrolyte imbalance Treatment for several days sets things right in most cases.

What are the 4 Ps of screening for perinatal substance abuse?

Parents: Did either of your parents ever have a problem with alcohol or drugs? Partner: Does your partner have a problem with alcohol or drugs? Past: Have you ever had any beer or wine or liquor? Pregnancy: In the month before you knew you were pregnant, how many cigarettes did you smoke? How much beer, wine or liquor did you drink?

Why do they use anti-infective prophylactically with people who have Mitral Valve Stenosis r/t rheumatic heart disease in pregnancy?

Because of vegetation on the leaflets of the mitral valve and the increased demands of pregnancy, the woman is at greater risk of bacterial endocarditis.

What are the two classifications of placental abruption? Clinical signs?

Partial- can clot itself off, still a lot of bleeding Complete- EMERGENCY, placenta fully detached (losing 500 cc every few minutes) Port wine bleeding, abdominal pain, and uterine tenderness and contractions. Boardlike abdomen; Couvelaire uterus

What are the intrapartum blood glucose goals? (fasting, post-meal 1hr, post-meal 2hr)

Pre-meal or fasting - 60-99 Post-meal (1-hr) - 100-129 Post-meal (2-hr) - less than or equal to 120

High risk infants are classified by which factors?

Birth weight, gestational age, predominant patho problems

What special environmental considerations are made in the NICU?

Blankets over isolets Quiet rooms Generally reduce stimulation due to underdeveloped nervous system

What are risk factors for developing a previa?

Previous c-birth Advanced age (more than 35 to 40 years of age) Multiparity Hx of suction curettage Living at a higher altitude Smoking

What is the most effective way of reducing STIs in women?

Primary prevention

1.When obtaining a reproductive health history from a woman, the nurse should: a. Limit the time spent on exploration of intimate topics b. Avoid asking questions that may embarrass the woman c. Use only accepted medical terminology when referring to body parts and functions d. Explain the purpose for the questions asked and how the information will be used

d. Explain the purpose for the questions asked and how the information will be used Explanation of the purpose for the questions asked while obtaining a reproductive health history will help to gather honest and relevant data.

What are the three types of placenta previa? Which ones can deliver vaginally? What are some risk factors?

Complete, Marginal, Low-lying Low-lying previas can deliver vaginally <19 or >40, multiple pregnancies, higher altitude

A nurse is providing instruction to a couple undergoing zygote intrafallopian transfer (ZIFT). The nurse is aware that instruction has been effective when the woman states: a. "My egg will be fertilized and then placed into my uterus." b. "My husband's sperm will be inserted into my uterus." c. "My husband's sperm and my egg will be placed into my fallopian tube." d. "A fertilized egg will be placed into my fallopian tube."

D. "A fertilized egg will be placed into my fallopian tube." A fertilized egg that is placed into the fallopian tube is known as ZIFT.

Presence of these types of cells on a blood smear would indicate hemolysis

Burr cells and schistocytes

What is HELLP syndrome? S/S? What complications are they at risk for?

Hemolysis, Elevated Liver enzymes, Low Platelets S/S: malaise, flu-like symtpoms, epigastric pain, worse at night Untreated develops into DIC, Placental abruption, renal failure, maternal and fetal death

A nurse is providing discharge instructions to a client who has just been diagnosed with human papillomavirus (HPV) on her cervix. What is the most important discharge instruction for this client? a. Take a multivitamin every day. b. Check for external lesions around the vagina every month. c. Have Pap tests done as recommended by her provider. d. Avoid using an intrauterine device (IUD).

C. Have Pap tests done as recommended by her provider. The link between HPV and cervical cancer should be discussed. The client should be instructed regarding regular follow-up after diagnosis and treatment of HPV. Annual Pap tests are essential to assess for disease recurrence.

An induced abortion client calls the nurse to report postprocedural symptoms. Which condition is not an indication for the nurse to ask her to come into the office for care? a. Abdominal tenderness when pressure is applied b. Chills and a fever of 101° F c. Return of her period in less than 6 weeks d. Foul-smelling vaginal discharge

C. Return of her period in less than 6 weeks A return of her period in 4 to 6 weeks is expected.

This syndrome is caused from damage to blood vessels, renal circulation, and pulmonary vasculature.

Capillary leak syndrome

What are the 3 types of previas? Biggest clinical manifestation?

Complete - whole cervix is covered Marginal - portion of the cervix is covered Low-lying - within 4 cm of os Bright red bleeding prior to delivery

What are some physiological problems that preterm/high risk infants need to overcome?

Low birth weight Decreased respiratory function and surfactant Cardiovascular function Thermoregulation CNS function Nutrition complications Immature renal function Hematologic problems Immature immune systen

1.Which findings would cause the nurse to suspect physical abuse in a pregnant client? a. The client has a history of sexually transmitted infections. b. The client has a mother who was physically abused. c. The client has a partner who accompanies her to all prenatal visits. d. Multiple bruises in various stages of healing are found on physical examination.

D. Multiple bruises in various stages of healing are found on physical examination. Multiple bruises in various stages of healing may be an indication of physical abuse.

What are some interventions for preeclampsia?

Low dose aspirin (can help prevent) Close mom and baby monitoring Activity restriction Diet (mild) Labetolol or nifedipine Mag sulfate Low stimulation Seizure precautions

What are treatment options for PMS/PMDD

Lower sodium, refined sugar, and caffeine before menstruation and don't smoke these reduce vasoconstriction and associated pain Oral birth control,

What is the treatment for preeclampsia?

Delivery of baby/placenta is only known treatment All other care is symptom management

What are some important things to assess and monitor during pregnancy for pregestational DM?

Diet Exercise Blood glucose Urine testing Hydration status Fetal monitoring

One would expect a hematocrit to be elevated in preeclampsia because of this process.

Endothelial damage - leaky blood vessels

What are genetic and environmental factors that can lead to cleft lip/ palate?

Exposure to alcohol and tobacco Folic acid or B vitamin deficiency Anti-epileptics (phenytoin, phenobarbital, sodium valproate, benzodiazepines, etc) Other medications (corticosteroids, methotrexate, isotretinoin) Advanced parental age Viral infection Maternal obesity

What is a missed abortion? Treatment options?

Fetus dies, if spontaneous evacuation doesn't occur but remains in uterus after 1 month - then termination by appropriate means based on gestational age.

This protein is the principal component of clotting. What medication prevents its breakdown?

Fibrinogen, TXA

What type of breast tumor is common in adolescence?

Fibroadenomas smooth and < 3 cm Recheck every 6 months for 2 years

Auscultation of all lung fields every two hours while on mag sulfate is to detect this complication of preeclampsia.

Flash pulmonary edema

What is the trump-all barrier to seeking OB care?

Gender identity

What is the relationship between insulin/glucose and the placenta in pregnancy?

Glucose crosses the placenta, insulin does not. Insulin needs increase during pregnancy but drop dramatically in 24 hours after birth

What are the primary risk factors for a placental abruption?

HTN Cocaine use Blunt external trauma Smoking Hx of abruptio PPROM

Definition of preeclampsia

HTN (>140/90) with proteinuria (>300mg over 24hrs) at gestational age >20wks. Caused by vasospasm and leaky vessels Severe = > 160/110

How is CPR and first aid rescue different in pregnancy?

Have to do chest thrusts instead of abdominal thrusts, defibrillation paddles must be placed 1 rib higher

A woman has a two fold risk for this over the next 5 - 15 years after preeclampsia

Heart disease and/or HTN

What is an incomplete abortion? Treatment options?

Heavy profuse bleeding but all parts are not expelled so a D&C may be necessary if medical management (cytotec) doesn't work or isn't an option

Define chronic essential hypertension

Hypertension present before pregnancy or diagnosed before week 20 of gestation

1st three antihypertensives we will try?

IV Labetalol, IV Apresoline, PO Nifedipine

What is the initial treatment for hyperemesis gravidarum?

IVF for fluids and electrolytes, medication, enteral/parenteral nutrition as last resort

S/S of mag toxicity?

Loss of patellar reflexes, slurred speech and muscular paralysis.

What are some maternal complications of pregestational DM? Fetal and neonatal complications?

Maternal: Hydramnios/polyhydramnios Ketoacidosis Hypoglycemia/hyperglycemia Neonatal/fetal: IUFD Congenital malformations Hypoglycemia at birth

What is the nursing care and education for previas?

May need early c-section at 36 weeks Rest Call 911 for bleeding, if 3 bleeds occur, will need to stay in hospital until delivery

Common risk factors for preeclampsia?

Multifetal gestation Hx of pre-e Chronic HTN <19 or >40 Diabetes or thrombophilias 1st pregnancy with new partner Men who have fathered a preeclamptic pregnancy are nearly twice as likely to father another preeclamptic pregnancy with a different woman

Can a HELLP patient get an epidural? Why not?

NO - they will bleed and form a hematoma, could be paralyzed

What is NEC and what are risk factors associated with NEC?

Necrotizing enterocolitis, an acute inflammatory disease of GI mucosa 30% mortality rate Risk Factors: RDS Asphyxia Polycythemia Anemia Congenital heart disease Shock Having an umbilical artery catheter Exchange transfusion Early enteral feedings Spina bifida IUGR GI infection

How is pain assessed in a newborn? What are the consequences of untreated pain in infants?

Nonverbal scales, high-pitched cry, grimace, brow furrowing Stress response, immune system suppression, neurological impairment, future increased pain sensitivity

How often should you get VS after BP threshold is achieved?

Q 10 min x 1 hour Q 15 min x 1 hour Q 30 min x 1 hour Q 1 hour x 4 hours

Decreased surfactant in a premature lung causes what problem?

Respiratory distress syndrome (RDS) - progressive atelectasis, loss of functional residual capacity, and ventilation-perfusion imbalance

What is the first line medication for perinatal anxiety?

SSRIs because most anti-anxiety meds are category D or X. Benzos are associated with abuse, physical dependence, cleft palate, floppy infant syndrome

Biggest complication risks for a patient with preeclampsia?

Seizure (eclampsia) Stroke Abruptio placentae Precipitous labor

How does pregnancy affect epilepsy?

Seizures may increase, decrease, or remain the same

In the absence of proteinuria, what lab tests indicates a worsening renal function (and is considered diagnostic for Pre-e with severe features)

Serum creatinine concentrations greater than 1.2 mg/dl (or doubling of serum creatinine concentration in absence of other renal disease)

What is the major concern of a patient with ectopic pregnancy? What are early signs? Treatment?

Severe bleeding and risk of hemorrhage if fallopian tube bursts!! Three most classic s/s: Abdominal pain Delayed menses Abnormal vaginal bleeding (spotting) Treatment: Methotrexate or surgery

What is a complete abortion? Treatment options?

Slight bleeding and tissue expelled on its own - no further interventions needed.

What is a threatened abortion? Treatment options?

Slight bleeding but cervix remains closed Progesterone may be an option, close monitoring, consider bedrest although it hasn't been proven, further treatment depends on whether the pregnancy is sustained

When a cardiovascular anomaly is suspected, what is a priority within the first hours of life?

Start prostaglandin therapy to keep the ductus arteriosis patent

RUQ or epigastric pain in preeclampsia originates in this organ.

The liver

The difference between preeclampsia and gestational hypertension

The presence of proteinuria

How does pregnancy affect SLE?

The woman with SLE can have a normal pregnancy but must be treated as high risk because half of all deliveries will be premature. Pregnancy can exacerbate SLE

5 T's of postpartum hemorrhage

Tone Tissue Trauma Thrombin Traction

Leading cause of PPH/passing clots and what to do

Tone (uterine atony) - High parity - big baby - multifetal gestation - infection Massage fundus, have them pee, call code white, can use meds, Bakri tamponade or Jada, give fluids, get blood ready

How does BP cuff size affect BP readings?

Too small = falsely high Too big = falsely low

How long are developmental milestones corrected for a preterm infant?

Until 2 ½ years

What are the 4 C's of women's health/OB assessment?

What do you call your problem? What do you think caused your problem? How do you cope? What are your concerns?

In caring for an immediate postpartum patient, you note petechiae and oozing from the IV site. You monitor closely for which clotting disorder? a. Disseminated intravascular coagulation (DIC) b. Amniotic fluid embolism (AFE) c. Hemorrhage d. HELLP syndrome

a. Disseminated intravascular coagulation (DIC) The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman's arm. Excessive bleeding may occur from the site of a slight trauma such as venipuncture sites.

If a pregnant patient presents with abdominal pain that may require surgery, it is important for the nurse to understand that: a. The diagnosis of appendicitis may be difficult because the normal signs and symptoms mimic some normal changes in pregnancy. b. Rupture of the appendix is less likely in pregnant women because of the close monitoring. c. Surgery for intestinal obstructions should be delayed as long as possible because it usually affects the pregnancy. d. When pregnancy takes over, a woman is less likely to have ovarian problems that require invasive responses.

a. The diagnosis of appendicitis may be difficult because the normal signs and symptoms mimic some normal changes in pregnancy. The diagnosis of appendicitis may be difficult because the normal signs and symptoms mimic some normal changes in pregnancy.

In the past, women were told to choose between psychotropic medications and breastfeeding their infant. Current beliefs are that although most drugs will diffuse into breast milk, there are few instances in which breastfeeding must be discontinued. Several factors are known to influence the amount of drug an infant will receive via breast milk. Which is not one of these factors? a. Amount of milk produced b. Composition of the milk c. Concentration of the medication d. Offering of single or both breasts

d. Offering of single or both breasts Whether both breasts are offered at a feeding is not a factor related to the amount of a psychotropic medication found in breast milk. Whether the breasts are fully emptied during the previous feeding is a contributing factor.

A client at 36 weeks of gestation presents to labor and delivery complaining of a constant headache for the past 2 days. She also states that her face "seems more swollen than usual." What should be the nurse's first action? a. Obtain a urine sample b. Place the client on a fetal heart monitor c. Notify the physician of the client's concerns d. Take the client's blood pressure

d. Take the client's blood pressure Accurate measurement of BP is essential to detect hypertensive disorders including preeclampsia. Personnel caring for pregnant women need to be consistent in taking and recording BP measurements in a standardized manner. BP readings are easily altered by the cuff size and position of the client.

What is recurrent abortion? Treatment options?

this may be related to cervical insufficiency and cerclage may be appropriate intervention in future pregnancy to prevent miscarriage