Antepartum and Intrapartum
What should you tell a pregnant woman asking if she can continue her active exercise habits including horseback riding?
"Continue all usual activities as long as you are comfortable."
What solution should the nurse offer to the pregnant pt with nausea throughout the day without vomiting?
"Eat small but frequent meals throughout the day" (The crackers thing is only for morning sickness. Otherwise the solution is small frequent meals)
A pregnant client @ 40 wks gestation seems upset and says that her health care provider told her she needs to have a nonstress test. The client asks you why she needs this test. What is the nurse's best response?
"This is a test to assess your baby's well-being now that you are to deliver soon."
A pregnant client in her 1st trimester is scheduled for an abdominal ultrasound. When explaining the reason for the early pregnancy ultrasound, what info should the nurse explain to the client?
"This test will help to determine how many weeks you have been pregnant."
What's a probable sign of pregnancy?
"Uterine souffle" (a blowing sound, synchronous with the cardiac systole of the mother, heard on auscultation of the pregnant uterus.)
A client who is to have amniocentesis for genetic testing asks the nurse if there are any possible complications with this procedure. The nurse's best response would be:
"Yes, but they occur in less than 1% of the cases. Do you have any other questions about the procedure?"
Define gestation:
# of weeks since 1st day of the last menstrual period
If a pregnant woman tells you her last period was on January 21st, what is her EDB using Nagele's rule?
(January 21st - 3 months=October 21st) (October 21st + 7 days=) OCTOBER 28TH
A pregnant client who is 1 wk past her due date is scheduled to have a nonstress test (NST) (aka fetal heart rate monitoring). After receiving an explanation of the test, which statement by the client indicated a need for further teaching? (no meds given, so client is in normal mental state)
-->1.) "I understand you will start an IV containing medicines that will cause me to have contractions."<---- (1 is correct. 2-4 are normal procedures) 2.) "During the test I will need to push a button when I feel the baby move." 3.) "I won't need to be admitted to the hospital for this test." 4.) "The test should take 20-30 minutes."
An anesthesiologist is preparing to administer a continuous epidural block using a combination local anesthetic and opioid analgesic as pain relief for a laboring woman. Nurisng measures related to this type of nerve block would include:
-Assist the woman into a modified SIMS position or an upright position with back curved for administration -Alternate her position from side to side every hour -Assist the woman to urinate Q2 hrs during labor to prevent bladder distension -Assess BP frequently bc severe hypotension can occur
Signs of pregnancy-probable, presumptive, positive
-Presumptive (aka subjective) changes of pregnancy are the symptoms the woman experiences and reports. Includes amenorrhea (loss of period), nausea and vomiting, QUICKENING (mother's perception of fetal movement @ 18 wks) -Probable (aka objective) changes are perceived by the examiner, but are not positive/confirming because they could have causes other than pregnancy. Includes changes in pelvic organs, abdomen enlargement, fetal outline pregnancy tests (detecting hCG, but not positive because other factors can cause increase in hCG) and uterine souffle. -Positive (diagnostic) changes are completely objective and offer conclusive proof. Include fetal heartbeat heard by doppler @ 10-12wks, fetal movement @ wk 20, and visualization of fetus by ultrasound
Common discomforts of pregnancy with measures for relief, special populations with concerns for pregnancy.
1st trimester: Nausea and vomiting- small, light, frequent meals, if in morning dry crackers before rising Urinary frequency- drink more during day, less at night to decrease nocturia Fatigue- schedule nap time, go to bed earlier, seek help with tasks not allowing you to go to bed early Breast tenderness- wear well-fitting supportive bra Increased vaginal discharge- bathe daily, powder + cotton undies Nasal stuffiness + nosebleed- cool air vaporizer 2nd + 3rd trimesters: Heartburn- small frequent meals, low sodium antacids, Ankle edema- frequent dorsiflexion and leg elevation Varicose veins- elivate legs frequently, avoid cutting off circulation including crossing legs Flatulence- avoid gassy food, chew thoroughly, exercise Backache- pelvic tilt exercise, Leg cramps- dorsiflexion, diet, heat, rise slowly Dyspnea- use proper posture when sitting and standing, sleep propped up with pillows Carpal tunnel- elevate arm, avoid painful movements
A pregnant client who is 11 wks gestation comes to the office reporting flu-like symptoms. Lab studies indicate she has contracted toxoplasmosis (most commonly associated w/ foodborne illness). From which of the following was the infection probably contracted?
1.) Poor handwashing after handling infected cat litter 2.) Eating raw or poorly cooked meat (One of the possible answers said contact with toxoplasmosis-contaminated droplets in the air, which sound like a viable answer, but it comes from undercooked meat, cat litter and wherever cats go 2 BR
Highlights of organ system development
2-3 weeks(2mm): beginning of blood circulation, <3 begins to form, liver begins to function, pigment in eyes 4th wk(4-6mm): brain+spinal cord formed, noticable limb buds, tubular heart beats @ 28 days, tummy forms 8th week(2.5-3cm) heartbeat detectable with ultrasound/doppler @8-12wks, digits formed, heart development essentially complete 10 wks(5-6cmCR) nails start to grow, intestines developing, bladder sac formed, male physical characteristics + testosterone production 12 wks(8cm) ossification process established throughout fetal body, completion of mouth palate, skin is pink and delicate, hormone secretion from thyroid gland, 16 wks(13.5) teeth beginning to form, appearance of scalp hair, eyes ears nose formed, Sex Determination Possible!! 20 wks(19cm) sucking reflex, swallowing, peristaltic movements begin, 24 wks(23 cm) gas exchange becomes possible 28wks(27cm) adipose tissue starts to form, eyelashes and eyebrows, eyelids open, 38wks (40cmCR)full term!
The results have been returned from a complete blood count for a pregnant client who came to the clinic for her initial prenatal visit. Which problem would indicate a possible problem with her O2 carrying capacity? 1.) Decreased white blood cell count 2.) Decreased red blood cell count 3.) Decreased platelet count
2.) Decreased red blood cell count
A 42 year old client who is 6 weeks pregnant has requested genetic testing. During the session, the client asks the nurse about the advantages of chorionic villus sampling (CVS) over amniocentesis. What is the nurse's best response?
Advantages: CVS can be done earlier in the pregnancy and the results are available more quickly (Disadvantages: it's less safe than amniocentesis and amniocentesis provides more info)
Discuss the development and function of structures-Amniotic Fluid
Amniotic fluid floats between the amnion membrane and the embryo. The primary functions of amniotic fluid are to: -act as a cushion to protect the embryo against mechanical injury -help control the embryo's temp. (relies on the mother to release heat) - Permit symmetrical external growth and development -prevent adherence of fetus to amnion to allow freedom of movement so that the fetus can change position, thus aiding musculoskeletal development -allow umbilical cord to be basically free of compression -act as an extension of fetal extracellular space -act as a wedge during labor -provide fluid for analysis to determine fetal health and maturity. Is slightly alkaline. 770mL @ full term.
The nurse should explain to the newly pregnant primigravida that the fetal heartbeat will first be heard with...
An Electronic Doppler at 10 to 12 weeks
Define antepartum, intrapartum, postpartum, and preterm
Antepartum- time between conception and onset of labor (Duration of pregnancy, normally 38-42 wks) Intrapartum- time from onset of labor to birth of infant and placenta Postpartum- time from birth until woman's body returns to an essentially pre-pregnant condition. Preterm- (aka premature) labor that occurs after 20 wks, but before completion of 37 wks' gestation
Following admin. of fentanyl (Sublimaze) IV for labor pain, a woman's labor progresses more rapidly than expected. The physician orders that a stat dose of naloxone (Narcan) 1mg be administered IV to the woman to reverse respiratory depression in the newborn after birth. In fulfilling this order the nurse would:
Assess the woman's level of pain because it will return abruptly.
A nurse is caring for a client in active labor. When last examined 2 hrs ago client was 3cm dilated 100% effaced, and the fetus was at a +2station when the client states "my water broke!" (etc...) What action does the nurse perform first? (FIRST)
Call for assistance!
What develops a mucous plug during pregnancy?
Cervix
Physiological changes and alterations in body systems with pregnancy
Cervix- endocervical glands secrete a thick, sticky mucus that accumulates and forms a mucous plug which seals the endocervical canal and prevents the ascent of microorganisms into the uterus. Increased cervical vascularity causes softening of the cervix (Goodell's sign) and its bluish discoloration (Chadwick's sign). Breasts- nipples become more erect, areolas dargen, colostrum (antibody rich yellow secretion) may leak in 3rd trimester but convert to mature milk during first few days after childbirth. Lungs- air volume increases per breath 30-40% and progesterone decreases airway resistance increasing O2 consumption 15-20%. Chest circumference can expand by up to 6cm, however difficulty breathing may still occur as the baby grows. Nasal stuffiness and nosebleeds may occur bc of estrogen induced edema. <3: Increased cardiac output(by25-30wks, increases 30-50%), increased blood flow, pulse increases. Should sleep on side as opposed to supine. Smooth muscle relaxation causes heartburn, gum bleeding, constipation and bloating, predisposition to gall stones. Hyperpigmentation of skin, and sweat and sebacious gland hyperactivity are common. nausea and vomiting in 1st trimester because of elevated HCG hormone levels and changed carb metabolism. Posture troubles, esp lordosis
After induction of a spinal block in preparation for an elected cesarean birth, a woman's BP drops from 124/76 to 96/60. The nurse's initial reaction would be:
Change woman's position from supine(back) to lateral(side)
A nurse has just administered promethazine to a woman in labor. Which of the following would be an expected effect of this medication?
Decrease in anxiety and apprehension. Sedation Potentiation (increase effect) of opioid analgesics
Urinary frequency in the first trimester is influenced by...
the enlarging uterus, still contained in the pelvis.
Describe different cardinal movements(baby positions):
Descent- The head enters the occiput transverse or oblique position bc the pelvic inlet is widest from side to side Flexion- the fetal head descends and meets the resistance from the soft tissues of the pelvis, Internal rotation- fetal head must rotate (L to R) to fit the diameter of the pelvic cavity, which is the widest in the anteroposterior diameter. Extension- the resistance of the pelvic floor and the mechanical movement of the vulva opening anteriorly and forward assist with extension of the fetal head as it passes through the symphysis pubis. This change allows baby's head to emerge from the vagina Restitution- the shoulders of the fetus enter the pelvic inlet obliquely and remain oblique when the head rotates to the anteroposterior diameter through internal rotation, twisting the neck. Once the head is born the neck turns to one side untwisting(restitution). Extra terms: Station- downward movement of baby's head through woman's pelvis Engaged- baby's head at narrowest part of ischial spines
What is the average maternal weight gain distribution and pattern of weight gain?
Distribution: 11lbs- fetus, placenta, amniotic fluid(5kg) 2lbs- uterus(0.9kg) 4lbs- increased blood volume(1.8kg) 3lbs- breast tissue (1.4kg) 5-10lbs- maternal stores(2.3-4.5kg)
What type of twins are fraternal twins? (Derived from 2 separate ova and not identical)
Dizogotic
What happens to the cervix during pregnancy and delivery?
During pregnancy: turns blue due to increased blood flow to uterus, called Chadwick's sign. It also develops a mucous plug which functions to lubricate the vaginal canal, act as a bacteriostatic agent, and to provide an alkaline environment to shelter deposited sperm from the acidic vaginal secretions. During delivery: cervix should thin (effacement) and dilate (1-10cm) simultaneously
What is detected in Serum 24-48 hours after fertilization?
Early Pregnancy Factor (a protein with immunosuppresive and growth factor properties).
What does EDD stand for? How do you calculate it?
Estimated Date of Delivery. Date of first day of last period, minus 3 months, plus 7 days.
What hormones are involved in pregnancy? Delivery?
Estrogen- secreted mainly by the ovaries and some by the adrenal cortex and fat cells. Contributes to "femaleness" and the growth of secondary sex characteristics. Also causes uterus to increase in size and weight. Inhibits FSH production and stimulates LH. Responsible for boob stuff. Progesterone-Secreted by corpus luteum. Often called the pregnancy hormone bc it decreased uterine motility and contractility caused by estrogens and relaxes smooth muscle causing vasodilation which prepares the fetus for implantation after fertilization, and maintains pregnancy. Also responsible for preventing lactation during pregnancy. Temporarily blocks estrogen's boob responsibilities. Gonadotropin-releasing hormone (GnRH)- released by anterior pituitary to stimulate release of FSH & LH. Follicle stimulating hormone (FSH)- maturation of ovarian follicle Leuteinizing hormone (LH)- increases production or progesterone, and inadvertently reduces estrogen production. Relaxin- inhibits uterine activity, diminishes strength of uterine contractions, aids in softening of cervix and long-term effect remodels collagen Human chorionic gonadotropin- stimulates progesterone and estrogen production by the corpus luteum to maintain the pregnancy until the placenta develops enough to assume that function. Human placental lactogen-increases the amount of circulating free fatty acids for maternal metabolic needs and decreases maternal metabolism of glucose to favor fetal growth.
What should you tell a pregnant woman at 10 weeks who is worried about her new frequent voiding?
Explain why this is expected during early pregnancy, when the growing uterus is still so close to, and pressing on the bladder.
Fertilization, implantation, and development
Fertilization: the process by which a sperm fuses with an ovum to form a new diploid cell, or zygote, with 23 chromosomes from each parent, resulting in 46 total. Occurs in outer 1/3 of fallopian tube. Implantation: when the blastocyst burrows itself into the uterine lining down toward the maternal capillaries until it's completely covered, then the surrounding endometrium thickens and gets renamed "decidua". Development: at about 1 1/2 to 2 wks, the blastycyst differentiates into 3 layers, ecto-, meso-, and endoderm which eventually form the tissues, organs, and organ systems. The chorionic villi form the fetal placenta. The umbilical cord is formed from the amnion. Pregnancy lasts an average of 40 weeks. 1st 14 days is "pre-embryonic". Day 15 thru week 8 is the "embryo" stage, and "fetus" stage starts week 9-birth.
Explain GTPAL
G=Gravida (# of pregnancies including current one) T=Term (# of full term infants born. Full term is 37wks+) P=Preterm (# of preterm infants born. 20-37wks) A=Abortion (# of pregnancies ending in abortion) L=Living (# of currently living children)
What's the name for the number of pregnancies?
Gravida (ex. Primigravida=1 pregnancy)
Define Gravida and Para:
Gravida- # of pregnancies, regardless of duration including present pregnancy. Para- # of births after 20 wks gestation, alive or not. *These terms are used in relation to pregnancies not to the # of fetuses, so twins, etc. count as one pregnancy and one birth.*
What is present in urine or serum 8-10 days after fertilization?
HCG (hCG stands for Human Chorionic Gonadotropin, a hormone naturally produced by the placenta in pregnant women that almost completely controls the metabolic function through the hypothalamus throughout the pregnancy.)
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment the fetus is said to be in posterior occiput position. Which labor position should the nurse suggest to facilitate normal labor progress?
Hands and knees
A pregnant client is experiencing nausea and vomiting. The nurse is aware that this discomfort may be related to:
Human chorionic gonadotropin- a hormone produced in the human placenta that maintains the corpus luteum (secretes hormones) during pregnancy.
Name the condition in which excess amniotic fluid (over 2,000mL) accumulates during pregnancy ?
Hydramnios
Reviewing all the nutritional requirements listed from p. 221-226 what needs to be increased during pregnancy and what not?
Increased: Vitamins A, C, B6, B12, Thiamine, Riboflavin, Niacin, Folate, Magnesium, Iron, Zinc, Iodine, Selenuim Remain same: Vitamins D, E, K, calcium, Phosphorus
What should the nurse tell the pregnant pt concerned with allergies/congestion?
It is an expected occurrence; the increased hormones are responsible for the congestion."
Emotional/psych changes in childbearing family, cultural factors
Physical changes can bring distress as well as whether or not the child is wanted, support, finances, child care and division of domestic tasks. Adapt plan of care for cultural diversity rituals surrounding pregnancy.
What is the phase from ovum fertilization to the 14th day?
Pre-embryonic
What hormone maintains pregnancy?
Progesterone
A nurse is caring for a client admitted to the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in breech presentation. For which complication should the nurse observe?
Prolapsed umbilical cord
What is the name for the downward passage of the fetus through the maternal pelvis?
Station
During the first prenatal visit, the client denies having had rubella or the rubella vaccine. What would be an appropriate action by the nurse based on this info?
Take a blood sample to assess the rubella titer.
What should you tell a pregnant pt who is concerned because she finds out her cervix is bluish purple, known as Chadwick's sign?
Tell her "It's a normal finding and is caused by increased blood flow to the uterus during pregnancy."
What should the nurse tell a pt. asking whether sex is ok or not during pregnancy?
Tell her "With an uncomplicated pregnancy, there are no limitations on sexual activity."
Discuss the female pelvis during delivery
The Pelvis is divided first by the false and true pelvis. The upper false pelvis serves to support the weight of the enlarged pregnant uterus and direct the presenting fetal part into the true pelvis below. The true pelvis lies below the pelvic brim. Here is where the baby descends for birth and adequate measurements here are critical for normal delivery. The size and shape of the true pelvis must be adequate for normal fetal passage during birth. It's important for the baby's head to be able to pass through the ischial spines, which is the narrowest diameter the baby has to pass. The bones move, and the ligaments stretch during birth primarily the symphysis pubis
The doctor has ordered meperidine (Demerol) 25mg q2-3 hrs prn for pain associated with labor. In fulfilling this order, the nurse should consider which of the following?
The newborn should be observed for respiratory depression if born within 4 hours of the dose.
Discuss the development and function of structures-Placenta
The placenta is formed from the endometruim, which is the uterine wall tissue surrounding where the zygote implanted, which is called the decidua after implanting. The decidua basalis (portion under the implanted blastocyst/egg) forms the maternal side of the placenta, and the chorionic villi form the fetal side. The placenta is the means of metabolic and nutrient exchange between the embryonic and maternal circulations. Development and circulations don't begin until 3 wks and expands until 20 wks covering 1/2 of uterus. Then becomes thicker until birth, but not wider. Placental blood flow is best when woman lies on her side.
Discuss the development and function of structures- Umbilical Cord
The umbilical cord forms from the amnion(membrane around amniotic fluid). The forming umbilical cord is called the "body stalk" and attaches the embryo to the yolk sac. It contains blood vessels that extend into the chorionic villi. The body stalk fuses with the embryonic portion of the placenta to provide a circulatory path from the chorionic villi to the embryo. As it elongates to become the umbilical cord, the blood vessels w/in the cord decrease to one large vein and 2 smaller arteries which are surrounded by Wharton's jelly (type of connective tissue that prevents compression of cord). At term, cord is average 2cm wide and 55cm long (22in) The cord appears twisted due to fetal movement and a "nuchal cord" is the term for when it encircles the fetal neck. :(
Where does the placenta most often attach to?
The upper uterus
1. What are the recommended weight gain levels during pregnancy for the underweight woman, normal weight woman, overweight woman, obese woman?
Underweight: 28-40lbs Normal weight:25-35lbs Overweight:15-25lbs Obese:11-20lbs
What is the single most important clinical method for dating a pregnancy in the 1st and 2nd trimesters? How is this measured?
Uterine size. Measured by fundal height. Tape measure from top of symphysis pubis to top of uterine fundus. Fundal height (cm) correlates well with the # of weeks gestation between 22-34 wks. (Eg. 26 cm fundal height = 26 wks gestation). Void-30 min prior to measurement
What are the female reproductive organs involved in pregnancy? Structures and functions, and how important in childbirth?
Vagina- connects the external genitals with the uterus. Aka the birth canal. Acidic during reproductive years (4-5pH, as opposed to 7.5 before and after these years). The vaginal walls are covered with ridges which allow the vagina to stretch during delivery Uterus- in the center of the pelvic cavity above the vagina. Holds the baby during pregnancy. Divided into corpus(uterine body) and cervix(lower cylindrical portion). Top rounded part of corpus is called fundus, which is palpated to measure uterine size in 1st & 2nd trimesters. Ovaries- primary source of 2 important hormones: estrogens and progesterone
The use of phenothiazines can potentiate the action of analgesics and reduce nausea. When preparing to administer a phenothiazine to a laboring woman, the nurse can expect to give which medication?
hydroxyzine (Vistaril)
Danger signs of pregnancy
multiparity > 3(up risk of maternal hemorrhage and fetal anemia), weight less than 100lbs(prolonged labor maternal, and fetal hypoxia) or more than 200lbs(maternal hypertn, decreased fetal nutrition), age less than 16(maternal preeclampsia, low birth weight) or greater than 35(cesarean birth, fetal congenital abnormalities), smoking a pack/day+, drugs/alcohol
If contractions are too long in duration and do not have complete relaxation of uterine tone in between contractions, the adverse effect will be:
reduced fetal O2 supply
A nurse should be aware that the following are risk factors for dysfunctional labor:
short stature, cephalopelvic disproportion(CPD), fetal malpresentation, maternal fatigue