mother baby test 3

wound infection nursing care and teaching

-C & S cultures and sensitivity tells us which antibiotics the bacteria is sensitive to -Broad spectrum antibiotics -Warm compresses/sitz bath if on perineum -Analgesics for pain -Proper hand washing, fluids, rest, diet dehiscence: prevent this! make sure you are taking care of wound and encouraging mom to use support when she is moving around -Fluids, rest, healthy diet, proper handwashing, watch for s/s of infx

Nifedipine

-CA calcium channel blocker -PO - 10mg -Monitor for signs of low BP and hold it if its less than 60 diastolic and continue to monitor

DIC (Disseminated Intravascular Coagulation) aka Consumption Coagulopathy

-CLOT CLOT CLOT BLEED BLEED BLEED) -characterized by massive clotting response followed by hemorrhage -a secondary disease (Burns, sepsis, brain injury trauma) will cause release of tissue factor, there are high levels of it in the placenta so when there is placenta injury or any bleeding in pregnancy, we have a higher rate of DIC

Peripartum cardiomyopathy

-Change of fluid volume during pregnancy→ puts a lot of pressure on heart -Weakened heart diagnosed within Last month of pregnancy OR within 5 months of delivery without any other identified causes for dysfunction of heart -PP patients: increased cardiac workload→ Cardiomyopathy → heart does not work efficiently -Heart becomes an inefficient pump....congestive heart failure...pulmonary edema if it's left sided...decreased O2 to vital organs

What kind of complications could develop if a mom had PPROM/PROM for longer than 24 hours?

-Chorioamnionitis -Endometritis -SEPSIS (neonatal infxn) -prolapsed cord -abruptio placentae -preterm labor

Acceleration of Fetal Lung Maturity: drug, when, route, dosage

-Corticosteroid Betamethasone -indicated if between 24 and 34 weeks -12 mg X 2 doses IM z track 24 hrs apart -Steroid ↓ incidence and severity of RDS

what happens AFTER labor with a diabetic mom?

-Cured if shes gestational diabetic when she gets rid of the placenta -high risk for hypoglycemia -Lactation: need a lot of energy and burn a lot -we encourage the moms to breastfeed (helps lose weight and manage diabetes better, insulin does not pass through breast milk so there is no risk for baby)

Pre-gestational diabetes

-Diabetes is present BEFORE 20 weeks, or the client has a diagnosis prior to pregnancy -At higher risk for fetal anomalies

Ectopic Pregnancy Risk Factors

-Disorders that make the uterus less welcoming and comfy for a baby to bed -Endometriosis -Pelvic Inflammatory Disease -STDs -Pharmacologic treatment of infertility

clinical presentation of ectopic pregnancy

-Dizziness, syncope -Vaginal bleeding -Sharp abdominal pain, referred shoulder pain -Adnexal mass and tenderness -Pain when cervix is moved

role of the nurse in a molar pregnancy

-Emotional support -Education -Advocating for careful follow up: initially weekly -see oncologist -Wait a year before you try to get pregnant again.

IUGR and what causes it?

-Fetus growing less than 10% for growth -Problems with placenta, hypertension, poorly controlled diabetes, anything that affects vascularization signs placenta is a vascular organ

How do you screen for gestational diabetes and when is it done?

-Glucose Challenge Test (GCT/Glucola) -75 mg of CHO -not diagnostic, just screening -between 24 and 28 weeks -Normal results 140 mg/dl

Polyhydramnios (deep end of pool)

-Greater than 2,000 ml -Most causes are idiopathic (unknown) -Increased abdominal pain -Ineffective labor or prolapsed cord when membranes rupture -Why does this occur? Uterus can't contract well

How do elevated blood glucose levels and diabetes in general affect a baby during pregnancy?

-High maternal blood glucose passes the placenta, fetus releases insulin to metabolize the glucose = hyperinsulinemia -Fetus gains weight -IUGR -Malformation -Macrosomia -mal-presentation -Birth trauma (shoulder) -Hypoglycemia -Preterm birth -RDS -Risk for Perinatal death

carbopost for pph

-IM -250 mcg -diarrhea, n/v, fever, h/a -contraindicated in patients with ASTHMA

progesterone

-IM or PO -Quiets down uterus and makes everything comfy for baby to grow -Used early in pregnancy to help prevent aborted pregnancies -instruct pt on how to use

methylergonovine

-IM, IV PO- 0.2 mg -HTN, H/A, cramping -not for active pp hemorrhage, given to moms who may have already had pp hemorrhage and are still bleeding and being discharged but provider just wants to add that extra safety precaution, use it cautiously in hypertension and check it before whether they have BP or not because it can cause elevation

What are the 4 Tocolytic Agents?

-Indomethacin -Nifedipine -Magnesium Sulfate (no longer used in preterm practice though) -progesterone

med management for diabetes

-Insulin is used for type 1 and 2 that required medication when not pregnant -glyburide or metformin when diet and exercise are not working for gestational diabetics

Misoprostol

-It is a tiny pill, you only put 25-50mcg. It's inserted posterior to cervical os. -Ripens cervix to induce labor -Instruct patient about purpose and possible risks -Informed consent -Assess VS and FHR -Monitor reaction to drug -Initiate oxytocin at least 4 hours after last dose was administered -Contraindicated for women with prior uterine scars;VBAC -Cannot be removed

DIC nursing considerations

-Limit blood draws, IV sticks, and injections of any kind -IV route of med admin preferable -Apply 3-5 min pressure to puncture sites -Q1 hour VS - (for general ICU pts use of arterial line for BP) -Careful use of BP cuff -IV fluids and blood replacement as ordered -Strict I&O (in case kidney perfusion is less than adequate) -Thorough system assessments -Provide gentle skin and oral care -Monitor lab values -Provide restful environment

inevitable pregnancy

-Loss is unavoidable no matter what we do -want to follow up after to make sure HCG levels are dropping, bleeding is subsiding

Therapeutic management for a woman with mild preeclampsia during labor

-Maintain calm environment -meds as ordered -labor induction meds -cervical ripening agents if needed -oxytocin -antihypertensives meds as ordered -magnesium sulfate -limit to bedrest -Fetal surveillance

intrapartum nursing care for a pt with abrupto placentae

-Maintain hemodynamic status -Assess fetal well being -Assess maternal VS: ask yourself does pain correlate with bp?? Does this correlate with clinical picture? --Assess mucous membranes and cap. Refill -if pale→ blood loss -Palpate abdomen with care -IV access and obtain labs w/ 2nd IV if mom is bleeding heavily -Support of mother and family -Place your hand on mother's abdomen to relax the uterus between contractions!!

risk factors for preterm labor

-Maternal age less than 16 or over 40 -Maternal health status -Overextended uterus (poly, multiples, fibroids) -Low socioeconomic status -Race -ETOH tobacco illicit drug use -Fetal and placental factors

how to stop preterm labor?

-Mild symptoms treated with bed rest and hydration -Identify and treat infections -Tocolytic Agents

post delivery care for a mom with abrupto placenta

-Monitoring hemodynamic status -Maternal VS and post delivery labs -H&H trends -Monitoring kidney function -Replacement of fluids and blood as ordered -Monitor for signs of shock

risk factors for abrupto placenta

-Multiple gestations -Multiparity -Polyhydramnios: over expansion of the uterus and the tight tension, think of a balloon, this can cause a placental abruption -Diabetes (vascular issues) -Hypertension causes vasoconstriction of the vessels and a mother who is chronically hypertensive, placenta already isn't all that healthy so with hypertension you can get increased pressure -Preeclampsia/eclampsia -Cocaine use and abuse because of the vasoconstriction -Uterine hyperstimulation/tacky systole: because the uterus is contracting so much the placenta literally gets pushed off the uterine wall

missed pregnancy

-Non-viable embryo in uterus up to 6 weeks -No attempt of maternal body to expel it -if mom doesn't pass it on her own, she'll have to have -procedure (don't wait longer than 6 weeks) -Fetus begins developing but then stops developing so it is no longer alive

incomplete pregnancy

-Not all products of conception are passed -Infection -higher risk for bleeding -IV fluids -pain -Dilatation and curettage (D&C) for early in pregnancy or suction evacuation for later in pregnancy

misoprotel

-PO, PR, not vagianally with PPH -200-1,000 mcg -nausea, cramping, h/a -giving buccal mucosa as PO, we would not give this vagially because its just going to get washed out with the blood

symptoms and further risks for HELLP

-Petechiae because platelets are low -Malaise/Flu like symptoms -Headache /Visual changes -Nausea and vomiting due to liver and GI issues -Epigastric pain-liver -PP hemorrhage and DIC because platelets are low -Hypo-volemic shock if she were to hemorrhage

What is placenta previa and what is the problem with it?

-Placental implantation in the lower uterine segment over or near the cervical os (part that opens) -A normal placental attachment is up close to the fundal level of the uterus, with placenta previa when it implants very low, it can cover the os which is problematic because the baby needs to get out of it in order to be born

Threatened pregnancy

-Possibility of loss exist but not a definite -Interventions: limit activities for 24-48 hours, use of progesterone as prescribed, be on pelvic rest (nothing in vagina/no sex)

What are some maternal factors involved in preterm labor?

-Pre-eclampsia -Diabetes, cardiovascular or renal disease -Abdominal trauma or surgery -Cervical insufficiency -Uterine abnormalities

What are some risk factors for placenta previa?

-Previous uterine scar -Multi parity -Multi gestation -AMA -Short interval pregnancies

Indomethacin

-Prostaglandin inhibitor -100 mg, 2 doses, 6-12 hours apart -GI upset - premed with Carafate -not given past 33 weeks

Dinoprostone

-Stays in for 12 hours; after first 2 hours she can get up -Directly softens and dilates the cervix to ripen cervix and induce labor -Provide emotional support -Administer pain medications as needed -Assess effacement and dilation -Monitor uterine contractions -Assess maternal VS and FHR -Slow release; if infant gets in trouble with stress or Hypertonic ctx, you can pull it

What VASCULAR organ is affected by diabetes? and how?

-THE PLACENTA! -White spots (Calcification deposits) resulting from high blood glucose levels

nursing care for a patient with gestational diabetes

-Ultrasound eval at 16-18 weeks -Maternal serum AFP -Fetal echocardiogram at 20 weeks -NST -Kick counts -Can cause BPP in 3rd trimester

assessments and goals for cardiomyopathy

-VS (BP, O2, HR- S1, S2 only), Cardiac, Respiratory (Fluids→ Crackles, SOB, difficulty breathing, difficulty breathing upon exertion), Activity and Lifestyle, Fetal Surveillance -Goal: Maintain perfusion and oxygenation, optimize functional cardiac status, deliver healthy baby without undue risk to mother's health *when intrauterine environment no longer healthiest for mother or baby→ deliver

How often would you do a NST on a diabetic mom?

-Weekly after 28 weeks -Twice weekly after 34 weeks (since diabetes can affect placenta)

eclampsia

-Worsening Preeclampsia with onset of grand mal seizures -Seizure precautions -Prevention of injury -Monitoring of condition -Assisting with facilitating a safe delivery -Cure= delivery

foley bulb

-a specialized foley catheter -two balls that inflate with sterile water/saline -The provider will insert the foley through the cervical os until they get the end where the balloon is going to blow up past the internal os, then they fill the balloon up with about 30mL of solution and then pull on the foley itself and tape it down the mother's leg. -there's a constant tension and the balloon puts pressure on the cervix which allows for a release of natural prostaglandins. -It also allows for that pressure to help that cervix soften out. -If the mother starts to dilate, the ball just falls out. Then in the morning when you are ready to start the oxytocin, you just pull the fluid out of the balloon and pull the catheter out.

PROM

-after 37 weeks gestation, before labor begins -We watch mom -By textbook standards you can wait up to 24 hours before you do anything and that's not what you'll see in practice -The barrier for infection is gone so we may need to intervene to get mom moving

When and why would we do a Fetal echocardiogram?

-at 20 weeks -pre gestational diabetes have an increase risk for fetal heart defects

Oxytocin for PPH

-can be released naturally from breast, given to almost all women whether they are in a high risk category or not, usually given to vastus lateralis -IM IV drip or rapid IV with hemmorage -10-40 units in 1,000ml IV fluid -side effect: h20 intoxication

gestational hypertension

-diagnosed after 20 weeks gestation, no proteinuria -Risk that may develop Preeclampsia

Chronic/pregestational hypertension

-diagnosed prior to 20 weeks -Risk: obesity, smoking, diabetes, family history -monitor BP and treatment based on those readings -predisposes for preeclampsia

What are some classic signs of preeclampsia (not diagnositc, just signs)?

-edema -proteinuria -high bp -headache -blurred vision -epigastric pain

symptoms of chorioamnionitis

-elevated maternal temp -painful uterus to palpate -odor in amniotic fluid -fetal tachycardia and possible distress -fetal odor after delivery

So you do an ultrasound at 16-18 weeks...but then again when and why?

-in 3rd trimester -for estimated fetal weight and AFI (amniotic fluid volume)

Hygroscopic Dilators

-laminaria. -There's a thin one that gets put into the opening of the cervical os and then the natural fluids in the vagina and the cervix start to go into the laminaria and expand it and while it's expanding, it's helping to dilate the cervix

Oligohydramnios (shallow end of pool)

-less than 500 ml at 32-36 weeks -Can mean fetal kidney perfusion issues (fetal oxygenation) -Associated with Renal malfunctioN, IUGR, & Post-maturity -Contributes to: skin and skeletal abnormalities, underdeveloped pulmonary system, cord compression

Therapeutic management for a woman with severe preeclampsia during labor

-limit visitors, calm, lights and TV off -Maternal medications -Hypertensive meds as ordered -Anticonvulsive: magnesium sulfate

What kind of vital signs will you see when monitoring a mother with a partial or complete previa and her baby?

-maternal VS: hypotension, high pulse -FHR: Fetal Tachycardia, runs up to 150 but monitor tracing to make sure baby can handle stress of labor

Antidiruetics

-monitor for decreased urine flow, leading to water intoxication (monitor for headache and vomiting); Strict I&O -Encourage mother to empty bladder every 2 hours during labor

PP psychosis

-most severe of the postpartum affective disorders and is considered a psychiatric emergency (increased risk for suicide and infanticide) -Symptoms: mood lability, delusional beliefs, hallucinations, persecution complex (everyone is out to get them) and disorganized thinking pEarly symptoms resemble those of depression but may escalate to delirium, hallucinations, extreme disorganization of thought, anger towards herself and her infant, bizarre behavior, delusions, disorientation, depersonalization, delirium-like appearance, manifestations of mania, and thoughts of hurting herself or her infant. -Usually surfaces within 3 months of giving birth and is manifested by sleep disturbances, fatigue, depression, and hypomania. The mother will be tearful, confused, and preoccupied with feelings of guilt and worthlessness. -Risk factors: Hx bipolar disorder or other psychiatric disorders -DO NOT LEAVE WOMEN WITH POSTPARTUM PSYCHOSIS ALONE WITH THEIR INFANTS -treatment may require hospitalization for several months, drug therapy- including psychotropic drugs, psychotherapy, and supportive group therapy

meds for pp hemmroage

-oxytocin -carbopost -methylergonovine -misoprotel

How do we test for amniotic fluid?

-pooling -damp perineum with oder -fern test (microscope) -Nitrazine (pH checker, some women do have alkaline urine so it's not a definitive test but just highly suggests) -amnisure (q-tip, pretty definite)

fFN - fetal fibronectin test

-predicts preterm birth -Do this BEFORE you check cervix & keep it there for 60 seconds -Negative results - 99% sure that she is not in labor -Positive results - we don't know anything, we are not sure she is not in labor -How can you get a false positive? sex within 24 hours, having cervix checked before check

PPROM

-prior to 37 weeks gestation and before labor begins -Depends on gestational age (if mom is 26/27 weeks, we do not want to delivery the baby) -Rule of thumb= the intrauterine environment is the most healthy place for a baby to grow until it becomes unhealthy so as long as the baby and mom are doing well, if she ruptures her membranes and she is very premature, we will just watch her

risks for chorioamnionitis

-prolonged ROM -excessive vaginal exams -preexisting STD -preexisting unknown GBS

Magnesium Sulfate

-used as neuro protection for baby -anticonvulsant -Relaxes uterine muscle -Affects nervous system and brain -IV in bed & don't get out of bed, nurse should stay with her & do hourly assessments during initial and maintenance dose -Load 4-6 mg then 2mg/hr -"Flu in a bag" nauseous, hot, makes them quiet because it affects the muscles -Monitor for Toxicity -Foley catheter -Side effect of lowering BP -6 is a good level

When do most women get tested with the 1 hour glucola?

26-28 weeks

When is the placenta supposed to come out?

3rd stage of delivery after delivery of baby

When can you do a BPP on a diabetic pregnant women?

3rd trimester

cervix measuring ____ = cervical insufficiency needing a cerclage

< 2.2 cm

Cervix measuring ____ is concern for preterm labor and delivery

< 2.5 cm

Venous Thromboembolic

A leading cause of maternal morbidity and mortality. Occurs 1 per 1000 or 10 times higher than the general population Greatest risk: first 3 weeks up to 12 weeks Nursing care: CDs, early ambulation, no smoking (diminish risk factors)

a nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following types of medications should the nurse anticipate the provider will prescribe? a. Betamethasone B. indomethacin c. nifedipine d. Methylergonovine

A.

Metritis risk factors

C/S delivery Prolonged ROM or labor Chorioamnionitis if membrane ruptures early Excessive Vaginal exams (introducing bacteria up in there) Active STD Weaken maternal state (does mom have immune deficiency?)

What is needed at bedside when giving a woman magnesium sulfate?

Ca++ gluconate

concealed hemorrhage (hematoma)

Can occur anywhere blood oozes into tissue Retroperitoneal area, vaginal wall area, perineum Symptoms: Vulva and perineal may appear dark, bulging, painful to touch Vaginal and retroperitoneal may not be visible Deep, severe, unrelieved pain and pressure No outward blood noted

PreOp C-Section

Consents IV Foley catheter Clip surgical area Prophylactic antibiotic

What drug should you be careful about giving to a patient with diabetes?

Corticosteroid Betamethasone (will cause BG to rise)

a nurse in labor and delivery is providing care for a client who isin preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? a. Calcium gluconate b. Indomethacin C. nifedipine D. betamethasone

D.

a nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the following findings is seen with this condition? a. no alteration in menses B. Transvaginal ultrasound indicating a fetus in the uterus c. Serum progesterone greater than the expected reference range d. report of severe shoulder pain

D.

What labs will be decreased in DIC?

H & H Platelets Fibrinogen

What is the difference between preeclampsia and HELLP?

HELLP - multipara, >25 years of age, Caucasion,, Symptoms do not always include hypertension, edema or proteinuria Preeclampsia - Nullipara (hasn't had a baby before, or if baby is by a different father) <25 years of age, Risk factors of hypertension, diabetes, multiple gestation, African American

How is the placenta affected during preeclampsia?

HPTN pts have higher risk for baby being IUGR (b/c not well-perfused due to effects on placental blood flow from HPTN)

hyperemsis gravidarum S/S

Pale, dry skin Weight loss Change in temperature, high or low Rapid pulse CNS effects such as confusion, stupor headache, delirium, lethargy, & coma

Clinical manifestations of a DIC Hemorrhagic

Petechiae (fine vessels that pop) Ecchymosis (bruising) Purpura (blood sitting in tissue) Hematoma (volume of blood sitting in the soft tissue) Gingival Bleeding (gum bleeding) Hematuria Oozing from invasive lines Oozing from puncture sites and incision sites

Suprapupic pressure for shoulder dystocia

Place fist on the other side of pubic bone and push to facilitate rolling of fetal shoulder to come in and under the pubic bone

Placenta gives off more and more of what hormone as pregnancy progresses → causing more insulin resistance

Placental Lactogen

Why would pregnancy present a risk for glucose intolerance?

Placental factors (Lactogen), dietary changes, exercise changes, excessive weight gain

abrupto placentae

Premature separation of the placenta from the Uterine wall before delivery of the infant

perinatal loss before delivery

Prepare the mother for the delivery because they will be in a different state of decomposition once the baby is born. Depending on the time of death of the baby (weeks/months before) the baby's skin will start to slough and bones will be softer, so there may be some breakdown. If the baby's death was recent (a few days before delivery) the baby will most likely come out looking fine without breakdown. Turn the warmer on because babies get cold quickly.

nursing care for cardiomyopathy

Preserve and promote adequate O2; bedrest→ Risk for blood clots (increased fibrinogen), monitor I&O, cardiac meds, assess VS/O2 sats, assess perfusion, pt. And family support

How do we facilitate contractions with Amniotomy?

Providers go in and intentionally artificially rupture the amniotic sac. By doing this, it irritates the uterus and it causes the mother to start going into labor. The amniotomy is not done to ripen the cervix. The cervix needs to be ripe and the mother needs to be committed to delivery so that it isn't something that's done when a mom is only one centimeter, then we have prolonged rupture of the membranes with increased risk of infection.

perinatal loss during delivery

Providing support to the mother and family members. Offer your presence Therapeutic touch, listening Let them cry if they want to

risks for inverted uterus

Pulling on umbilical cord during 3rd stage Fundal pressure during or after birth An abnormally adherent placenta

Venous Thromboembolic embolism

Pulmonary-PE S/S: SOB Chest pain Apprehension Decreased O2 stat Hypotension

possible outcomes of pp hemmorage

Renal Failure Sheehan's Syndrome (damage to pituitary gland), endocrine symptoms Cerebral hypoxia

what is Oligohydramnios associated with?

Renal malfunction, IUGR, & Post-maturity

hyperemsis gravidarum nursing diagnosis

Risk for dehydration, electrolyte imbalance, imbalanced nutrition

wound infection s/s

Serosanguineous or purulent drainage Edema Erythema Tenderness Discomfort at site Maternal fever Elevated WBC

Metritis complications

Spread of infection (fallopian tubes, pelvic cavity) Development of pelvic abscess Development of septic thrombophlebitis

Candida infection

Starts on skin, secondary to excessive iv antibiotic uses like moms who are GBS positive & have a lot of antibiotics are at increased risk for overgrowth of yeast on their nipples because the baby has yeast in their mouth and they've transferred it to the mother Unilateral, uncommon for it to be bilateral but not impossible Do you have to be breastfeeding to get it? No Treated with increased fluids, rest, antibiotics po, Ibuprofen, continue to breastfeed (infection is in breast tissue not breast milk), keep the milk flowing so tissue has time to heal, warm compresses, support bra, breastfeed on breast that is infected since babies suck is strongest on the breast used first Breasts hurt, feels like the flu

causes of late pp hemorrhage after 24 hours after delivery

Subinvolution Chorioamnionitis: uterus is not contracting down like it should Retained placental material

Venous Thromboembolic thrombus

Superficial Deep Vein S/S: History risk factors Pain/tenderness in lower extremities - calf - girth Edema and warmth on affected leg Positive Homans

What kind of nursing considerations should you have for a pt with Oligohydramnios?

Teach about kick counts, setting up appts for every week or 2, non stress tests twice a week, get mom to lay on side

cardiomyopathy

enlargement of Ventricles

how often should you obtain maternal vital signs and FHR during 1st (active) stage of labor?

every 15 min

How often should you obtain maternal vital signs and FHR during 2nd stage of labor?

every 5 min

What does it mean if there is Meconium in amniotic fluid?

fetal distress R/T hypoxia

Meconium present in amniotic fluid indicates what?

fetal distress related to hypoxia baby could be breathing it in in utero...resuscitation!

If a hydatidiform mole forms into what, it requires chemo?

gestational trophoblastic neoplasia

Will a mom have higher or lower HCG levels with a molar pregnancy?

higher! -mother & baby grow very quickly (this could be a sign of multiparity but molar pregnancy will be detected on Ultrasound)

When would interventions be necessary giving magnesium sulfate?

if UO drops less than 30 ml/hr, RR less than 12/min, if deep tendon reflexes are absent

when should you discontinue oxytocin and notify the provider?

if uterine hyperstimulation or FHR category II or III patterns occur

ectopic pregnancy

implantation occurs outside uterus, normally in fallopian tubes but can also occur in external ovaries, wall of uterus down to cervix and even abdomen

Insulin requirements _____ as pregnancy progresses

increase

Shoulder Dystocia with Brachial Plexus injury

injury to the entire nerve root of the shoulder and arm

a nurse is administering magnesium sulfate iV to a client who hassevere preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (select all that apply.) a. Respirations less than 12/min B. Urinary output less than 30 ml/hr c. Hyperreflexic deep-tendon reflexes d. decreased level of consciousness e. Flushing and sweating

a, b, d

a nurse is caring for a client who reports indications of preterm labor. Which of the following findings are risk factors of this condition? (select all that apply). a. Urinary tract infection b. Multifetal pregnancy C. Oligohydramnios D. Diabetes mellitus E. Uterine abnormalities

a, b, d, e

a nurse is caring for a client who has a prescription for magnesium sulfate. the nurse should recognize that which of the following are contraindications for use of this medication? (select all that apply.) a. fetal distress b. Preterm labor C. Vaginal bleeding D. Cervical dilation greater than 6 cm E. severe gestational hypertension

a, c, d

a nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly hired nurses. which of the following statements by a nurse indicates understanding of the teaching? a. "They are administered in an oral form." b. "They act by absorbing fluid from tissues." c."They promote dilation of the os." d."They include an amniotomy."

a.

wound infection sites

abdomen, perineum, or vagina

If a patient with abrupto placenta is in tachysystole (lots of contractions back to back), what are they at risk for?

abruption

risk factors for peripartum cardiomyopathy

advanced maternal age, Hypertensive disorders induced by pregnancy (PIH), multiparity, multiple gestations, African AMericans, HX of cardiac disease

Blood glucose is harder to control during the 2nd half of pregnancy until when?

after delivery = cured (Placenta is insulin antagonistic and causes insulin resistance and placenta is growing and giving off hormones which cause more insulin resistance)

What will a diabetic women have during labor?

an IV insulin pump/highly titrated, must be run through a 2nd line (with no other meds in it) so mother will have 2 IVs in (one exclusively for IV infusion)

PostOp C-section

assess Fundus, Lochia, LOC, Feeling/movement in extremities get EKG, O2, Suction

a nurse is providing care for a client who is diagnosed with a marginal abruptio placentae. The nurse is aware that which of the following findings are risk factors for developing the condition? (Select all that apply.) a. Fetal position B. Blunt abdominal trauma c. cocaine use d. Maternal age e. cigarette smoking

b, c, e

a client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. Which of the following actions should the nurse take first? a. check the amniotic fluid for meconium. b. Monitor FHr for distress. c. dry the client and make her comfortable. d. Monitor uterine contractions.

b.

a nurse in labor and delivery unit is completing an admission assessment for a client who is at 39 weeks of gestation. The client reports that she has been leaking fluid from her vagina for 2 days. Which of the following conditions is the client at risk for developing?a. cord prolapse b. infection c. Postpartum hemorrhage d. Hydramnios

b.

How is the liver affected during preeclampsia?

blood flow compromised to liver→ swelling and bleeding of capsule around liver & liver fxn→ assess for epigastric pain

What kind of delivery would a mom with abrupto placenta have if fetus or maternal health is at risk?

c-section

a nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect? a. Hyperemesis gravidarum B. Threatened abortion c. Hydatidiform mole d. Preterm labor

c.

a nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus is at risk for developing? a. intrauterine growth restriction b. hyperglycemia C. meconium aspiration d. polyhydramnios

c.

How does a diabetic pregnancy cause RDS in a baby?

can develop if moms blood glucose is high and there is a surfactant delay

If it is a complete previa which means it covers the entire os, The mother will require a what? ALSO what if it is a partial previa?

complete= c-section partial= may have a vaginal birth depending on the amount of coverage and the fetal head position

partial placenta abruption

concealed hemorrhage which means some of the placenta is still adherence to the wall and we are still getting some perfusion to the baby, won't see any bleeding because it's all concealed behind the placenta

Edinburgh Postnatal Depression Scale

consists of 10 questions with 4 possible responses. Has a maximum score of 30 with a cut off score of 9 or 10. The couple is asked to fill out this tool according to their symptoms over the last 7 days.

a nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care? a. inspect the introitus for a prolapsed cord. b. Perform a test to identify the ferning pattern. C. Monitor station of the presenting part. D. Defer vaginal examinations.

d.

a nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? a. Use a condom with sexual intercourse. b. avoid bubble bath solution when taking a tub bath. C. Wipe from the back to front when performing perineal hygiene. D. Keep a daily record of fetal kick counts

d.

a nursing is caring for a client who is receiving iV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? a. nifedipine B. Pyridoxine c. Ferrous sulfate d. calcium gluconate

d.

In the first 20 weeks of pregnancy with a mom who is diabetic, will insulin requirements be increased or decreased and why?

decreased- expending energy requires more glucose= less insulin

what could a decreased amount of amniotic fluid lead to?

decreased→ decreases cushion effect→risk for cord compression

decreased amniotic fluid =?

decreases cushion effect→risk for cord compression

Maternal risk factors for IUGR

diabetes, HTN, smoking, nutritional status, cocaine, any illicit substances

Therepeutic abortion

done for medically necessary reasons so the mother and family have to make choices due to a therapeutic reason

early signs of hypovolemic shock

tachycardia and fetal tachycardia slight decrease in BP baseline pale skin and mucous membranes

stripping the membranes

the provider checks the patient while they're in the provider's office and they put their finger between the cervix and where the membranes attached to the cervix if they can get their finger up into the internal os, and they try to strip the membranes away from the cervix and that causes the uterus to become irritable and contract.

If a mom had diabetes during pregnancy, what does that put her at risk for developing later?

type 2 DM

How do you know if preeclampsia is getting worse and what should you as the nurse do?

*Increasing symptoms* -Platelets dropping -liver enzymes and uric acid elevated -Do urinalysis and a coagulation study -Order a CBC pit count and CMP liver enzyme -Magnesium sulfate therapy

How often will you check blood glucose and when? Also, what level is best?

-4 times a day -Before meals and at bedtime -Under 120 for sure -optimal is 60-90

TOLAC

-60-80% success rate -Best success if previous C/S was non-recurring reason -If in the first pregnancy the baby was breech and in the second pregnancy the baby wasn't breech, you could try a TOLAC. -Risk: Ruptured Uterus -Monitor contractions, FHR, contractions -Decrease induction medications to decrease chances of uterine rupture

Molar pregnancy aka Hydatidiform Mole

-A noncancerous tumor that develops in the uterus as a result of a nonviable pregnancy. -Grape cluster appearance -Can be complete or partial -Usually treated with D & C -Requires careful F/U

Oxytocin (Pitocin)

-Acts on uterine myofibrils to contract or initiate reinforce labor -Administer as an IV infusion via pump, increasing dose based on protocol until adequate labor progress is achieved -CLOSEST TO IV SITE -Assess baseline vital signs and FHR frequently after initiating oxytocin -Assess and determine uterine contractions -Notify provider for uterine hypertonicity or abnormal FHR -Strict I&O - water toxicity -Monitor for possible adverse events such as Hyperstimulation of the uterus, Impaired uterine blood flow leading to fetal hypoxia, Rapid labor leading to cervical lacerations or uterine rupture

what should a nurse know about oxytocin during labor?

-Administered IV infusion pump piggybacked into main IV line at port most proximal to insertion site -Titrated according to protocol to achieve contractions every 2-3 mins, lasting 40-60 seconds. (3 good contractions in 10 minutes) -Once you have the mother titrated, you stop increasing the dose of oxytocin. -Uterus should relax between contractions -consent and bishop score before -monitoring of maternal and fetal health status is essential -External electronic fetal monitor or internal monitoring device -Periodic vaginal exams to determine cervical dilation and fetal descent -Cervical dilation 1 cm. Per hour indicates Oxytocin therapeutic level -Evaluate contractions, resting tone, FHR; adjust oxytocin infusion rate accordingly

postpartum depression

-Affects 12-15% of new moms -Cause unknown but biggest risk factor = being postpartum -We need to take it seriously and screen patients and educate them on signs -Diagnosis is made if feelings of depression is persistent past 2 weeks PP -Can occur and last up to 1 year PP -Risks: hormone changes, Hx of depression, low self esteem, chronic stressors -High risks for impaired maternal infant bonding -progressively gets worse over time and changes in mood and behavior do not go away on their own -Symptoms: restlessness, worthlessness, guilt, hopelessness, change in mood, sadness, feeling overwhelmed, loss of enjoyment, low energy, loss of libido, obsessive thoughts, panic attacks, thoughts of suicide -The levels of estrogen, progesterone, serotonin, and thyroid hormone decrease sharply and return to normal during the immediate postpartum period→ This can trigger depression and lead to changes in mood and behavior -Other triggers: unresolved feelings about the pregnancy, fatigue after delivery due to lack of sleep/ broken sleep, feelings of being less attractive, inadequate assistance from partner, lack of social support network, history of sexual or physical abuse, unemployment/ lack of financial security, doubts about the ability to be a good mother, stress from changes in work and home routines, loss of freedom and their old identity -It is important to remember to check on the patient's significant other or partner during this time as their mental health may be affected as well.

postpartum blues

-Affects 60-80% of PP women -Symptoms: let down, see a puppy commercial and cries, mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, despondency, feelings of being overwhelmed, difficulty thinking clearly, and fatigue. -Can get worse with each pregnancy -Self limiting: temporary, moms usually get into a routine in a few weeks and it goes away -Typically peak on postpartum days 4 and 5 and resolve by day 10 -Usually does not affect the mother's ability to care for her infant -Requires no treatment other than reassurance and validation of the woman's experience -NEEDS TO BE FOLLOWED UP ON- 20% of these patients develop postpartum depression

complete pregnancy

-All products of conception are passed & have come out by mom generally before she comes in -mom will be cramping and bleeding (make sure its minimal, no hemorrhage) -make sure she is stable

severe preeclampsia

-BP 160/110 on 2 occasions 4-6 hours apart -Worsening symptoms -Hyper-reflexia, headache, blurred vision, epigastric pain

mild preeclampsia

-BP ^ +30/+15 on 2 occasions 4-6 hours apart -Weight gain 1lb/week -Edema beyond dependent edema- it is NOT DIAGNOSTIC but it is a classical sign -Proteinuria

what happens during labor with a diabetic mom?

-Blood glucose drops because BMR is increased, uterine muscle is huge and requires a lot of glucose to function properly, glucose load is being used for labor itself -BG checks every 1-2 hours

symptoms of abrupto placentae?

-Board like abdomen there is no relaxation of the abdomen between uterine contractions -Hypertonic, tight uterus/tacky systole -Fetal distress -PAINFUL vagina bleeding

What kind of delivery would a mom with abrupto placenta have if labor progresses and placenta is perfusing fetus?

vaginal delivery (it will at least be attempted)

PROM assessment

vaginal exam to assess cervical status

complete placenta abruption

100% abruption and is concealed, there can be bleeding if it breaks out of the bleeding if it comes around the amnion and that is a bad situation both for mother and for baby

What would you do for a low bishop score?

1st Prostaglandins (Dinoprostone & Misoprostol) administered to ripen the cervix→ then Oxytocin administered for induction

If a patient gets __ abnormal results on their 2 or 3 hour GTT, they are diagnosed

2

What kind of results in a glucose challenge test would be reason to perform further testing and what would that further testing be?

Abnormal results (above 135-145) leads to diagnostic test of 3 hour GTT or 2 hour GTT

What is the patho behind HELLP?

Abnormal vascular tone fragmenting of RBCs Fibrin deposits obstruction of liver blood flow Aggregation of platelets at site of vasospasms systemic thrombocytopenia

Clinical manifestations of a DIC Thrombosis

Acrocyanosius Pain in area of necrosis Ischemic tissue necrosis Gangrene

a nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states she missed one menstrual cycle and cannot be pregnant because she has an intrauterine device. The nurse should suspect which of the following?a. Missed abortion B. ectopic pregnancy c. Severe preeclampsia d. Hydatidiform mole

B.

a nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. the nurse should monitor the client for which ofthe following manifestations? a. blood-tinged sputum b. Dizziness C. Pallor D. somnolence

B.

Does placenta previa cause painful or painless bleeding and why?

vascularization of the cervix is very high and the placenta would be right over the cervix and it is a vascular organ full of vessels that are ready to bleed if disturbed so as the cervix changes even a little bit, it tears at those placental vessels but a placenta doesn't hurt when it bleeds so there's no pain but it's a lot of blood

changes you'll see in labs for a pp hemorrhage pt

DECREASE: H & H: really important to have pre admission H & H readily available (labs mean nothing unless you know pre-admission labs were) Platelets Fibrinogen INCREASE: FSP/FDP: as a clot occurs, these breakdown, increased because mom is going into DIC D-dimer APTT/PTT

signs and symptoms of an inverted uterus

Depression of fundal area Uterus visible in vagina Massive hemorrhage Severe pelvic pain

Gestational diabetes

Diabetes that develops during the SECOND half of pregnancy, AFTER 20 weeks.

shoulder dystocia

Difficulty in birth when the shoulder becomes wedged behind the pubis synthesis due to the way the fetus is coming down in the pelvis or fetal/maternal size. Shoulder dystocias are a bony dystocia

cervical ripening drugs

Dinoprostone Misoprostol oxytocin

McRoberts for shoulder dystocia

Drop the head of the bed down to a straight position and bring the mothers knees as far back as you can, all the way to her chest or as far to the chest as possible, so that the baby's position shifts and the shoulder drops

How is the brain affected during preeclampsia?

Elevated BP and Edema get worse→ edema in brain and HPTN leads to microvascular bleeds→ Assess for severe features showing brain is affected (headache blurred vision and reflexes)

mastitis nursing teaching

Encourage pt to continue to breastfeed and drain the milk Change feeding positions (begin feed with the infected breast first) Cabbage leaves only if she is in over production Rest and drink fluids Teach that the infx is in the tissue not milk, so it will not pass to the baby Soak a cloth in warm water and place it on the breast to help relieve pain

What labs will be increased in DIC?

FSP/FDP D-dimer APTT/PTT

what is Polyhydramnios associated with?

Fetal GI defects and Maternal diabetes (mothers BS is high and goes through placenta, baby's placenta secretes it and utilities it and has high BP so the baby will pee alot which leads to poly)

Metritis s/s

Fever > 100.4, chills, malaise Abd pain and uterine tenderness Anorexia Foul smelling lochia Subinvolution (also at risk for PPH) Elevated WBC usually >25,000

mastitis s/s

Flu like symptoms Tender, hot, red, painful breasts Inflammation of breasts (engorgement) Cracking of skin around nipples or areola Breast distention with milk

UTI nursing care

Fluids Acidify the urine by taking large doses of Vit C or cranberry juice Antibiotics if ordered

Metritis nursing care

Fluids Encouraged fowlers rest (head of bed elevated above 35/45 degrees) to help drain uterus Antibiotics (finish entire course) IV and then on PO at discharge Restore fluid and electrolyte balance Rest (Fowler's position helps drain the uterus) Antipyretics (tylenol or ibuprofen) Provide emotional support Oxytocin or Methergine (if Subinvolution results in bleeding)

mastitis nursing care

Fluids, antibiotics, rest Assess for s/s

HELLP

Hemolysis Elevated Liver Enzymes Low Platelets -Life threatening disorder occurs in 2-10% of pregnancies. -About ½ of patients with HELLP have severe Preeclampsia -Diagnosis is LAB VALUES ONLY -You will always need to monitor your patients with severe preeclampsia for HELLP syndrome -50% of patients with hellp do not have preeclampsia

How does diabetes during pregnancy affect the mom?

Hypertension Polyhydramnios Preterm labor/PROM Hypoglycemia Infections - UTI, Yeast Difficult birth

nursing care for amniotic fluid embolism

If pregnant: Give emergency care to the mother. CPR in a mother is fairly ineffective. Stabilize and deliver the baby ASAP. If Postpartum: Supportive depending on symptoms Remember DIC -- occurs in majority of survivors (50%) Critical Care Support IV steroids may be used during and after the code situation.

nursing management for pp hemmorage

Immediate fundal massage, IV fluid resuscitation, administer uterotonic medications (if these all fail to control bleeding, use more aggressive interventions such as bimanual compression, internal uterine packing, balloon tamponade techniques) Lab tests: CBC (H&H and platelets) Cross-match Coagulation studies Monitor Bp, pulse rates Lower the head of bed Put oxygen on if they are bleeding Start a 2nd IV

mastitis

Infection of the breast tissue; unilateral (can be bilateral), baby has not been feeding well or baby missed a feed, clogged milk ducts and cause static milk and caused moms tissue to inflame

Metritis

Infection of the uterus and possibly the surrounding tissues

chorioamnionitis

Inflammation of the Amnion Related to infection by bacterial or viral source

chorioamnionitis nursing considerations

Limit vaginal exams Antibiotic therapy - per rectum Antipyretics (fever reducing medications) - tylenol PR Fetal monitoring - Increased FHR Maintain clean technique

What would you see in a mom AND baby with PROM?

MOM: elevated Temp., elevated pulse, increased WBC's (indicate infxn) BABY: FHR monitoring for tachycardia or variable decelerations

PP hemorrhage risk factors

Maternal issue (multi-party, hx of PP bleed, clotting disorders) Chorioamnionitis (Inflammation of the Amnion Related to infection by bacterial or viral source) Placental issues (retained placenta, previa accreta) Medications (overuse of oxytocin, magnesium sulfate, general anesthesia) Birth trauma (forceps, vacuum) Prolonged Labor Over-distended uterus (polyhydramnios, macrosomia, multiple gestations)

Nursing management for a prolapsed cord

Minimize pressure to the cord Maternal positioning - mom on hands and knees, drops baby to pelvis and releases pressure on cord SVE to release presenting part from the cord if needed Do not manipulate cord Maintain fetal oxygenation Prepare for emergency delivery C/S - in most cases

what should you NEVER do with oxytocin?

NEVER give oxytocin IV push and NEVER give oxytocin via the IM route when the patient is still pregnant. You can give oxytocin IM post-delivery to prevent PP bleeding but not while she has a baby in her uterus.

Should you check a mothers cervix with a complete or partial previa?

NO! more bleeding and more pain

Fetal risk factors for IUGR

NOT being oxygenated and nourished well

management and nursing care for an inverted uterus

Nursing care supports emergency situation IV access, maybe two lines Replacement of fluid and correcting shock

What are some risk factors for gestational diabetes?

Obesity/Chronic hypertension Age > 35 Hispanic, Native American, African American Family history Previous birth of 9 lb infant, hydramnios or unexplained congenital anomalies of fetal death Gestational diabetes in previous pregnancy Signs of glucose intolerance

How is preterm labor diagnosed?

when documented regular uterine contractions accompanied by cervical effacement and documented cervical changes

What happens during the C-section of a mom with a partial or complete previa?

To get to the baby the physician may need to cut through the placenta... Increasing the risk of hemorrhage

Causes of PP hemorrhage (4 Ts)

Tone (abnormalities of uterine contractions): uterine atony, distended bladder Tissue: (retained in the uterus) retained placenta and clots; uterine subinvolution Trauma: (of the genital tract) Lacerations, hematoma, inversion, rupture Thrombin: Coagulopathy (pre-existing or acquired)

UTI s/s

Urgency and frequency Dysuria Flank pain Low-grade fever Urinary retention Hematuria Cloudy urine w/ strong odor Urine positive for nitrates

hyperemsis gravidarum nursing intervention

Use of IVF as needed Monitor and record inputs and outputs and labs Calm environment Monitor weight Monitor fetal well-being

Causes for PP hemorrhage within the first 24 hours after delivery

Uterine atony (boggy uterus, not contracting); When the uterus contracts down, the vessels inside the uterine wall, get constricted and don't bleed as much OR if uterus relaxes, the vessels are open and flowing, increasing the risk MASSAGE THE FUNDUS Assess bladder whether it is causing the bleeding or not, may want to put in foley catheter Birth trauma Surgical lacerations, lots of bleeding Clotting disorders and surgical complications

What is the patho behind preeclampsia?

Vasospasms......vascular restriction...elevated BP.....decreased perfusion to body organs.

amniotic fluid embolism

We don't really understand the underlying pathophysiology to an AFE. Generally occurs in labor but can occur prior to labor or at delivery. The mother is exposed to amniotic fluid but it's not an amniotic fluid embolism. There is debris in the amniotic fluid (fetal cells, vernix, lanugo, etc.) and exposure leads to an overwhelming immune response in the mother. The mother goes into respiratory and cardiac failure and collapse. This is an emergency obstetrical situation for mother and baby It is an event that cannot be predicted. It is a fairly uncommon occurrence Usually seen in C/S.

perinatal loss after delivery

When the baby is born, give the mother the option to keep the baby in the room. The mother may want to have the baby wrapped up and given back to her to hold. Don't say anything like "oh you'll have another baby" Avoid telling your personal story or feelings Ask the parents to name the baby! Call the baby by name, give some identity to the baby Do footprints, handprints, take pictures.

elective abortion

when the mom has the choice to terminate the pregnancy and does so not necessarily for medical reasons

Will blood glucose levels go up or down in labor?

will go down since she is using a lot of energy

If a mom has PROM and the fetal lungs are mature, can you induce labor?

yes

Why is Indomethacin not given past 33 weeks?

it can prematurely close the ductus arteriosus in the developing fetus

What are some goals for a diabetic mom as labor is apporaching?

maintain good glycemic control, avoid complications of disorder, & give birth to a healthy baby

abrupto placenta mild grade 1

mild bleeding, less than 500 mL of blood, some tenderness to the uterus but the mother generally is doing very well, there's no signs of shock and the baby isn't really having too much distress

what med is used for induction of labor (smaller dose) and pp hemmorage (bigger dose)

misoprotel

Why don't we do 1 hour glucola tests at 20 weeks?

mom might not have elevated blood glucose that early

prognosis for cardiomyopathy

mortality depends on severity of dysfunction; 10-50% mortality rate most within 3 months after delivery, echocardiogram and ejection fraction status; diet, exercise, and medications for minimal heart damage; heart transplant if severe

attachment disorder

occurs when a child does not develop a meaningful attachment to a primary caregiver. The child may exhibit a number of social, chronic health, and emotional problems, and learning disabilities

abrupto placenta moderate grade 2

of the placenta is affected with the abruption, there can be 1000 to 1500 mL of blood loss, mom has constant abdominal pain, starting to show some signs of shock, becoming tachycardic, mom may be normatensive due to blood pressure rising from pain and dropping from bleeding

what is contraindicated until the uterus is replaced in a inverted uterus situation?

oxytocin

apparent placenta abruption

partially abrupt, the placenta is coming off the wall and they're bleeding a lot, the mother is bleeding from the maternal side and the placenta side is bleeding also as it rips away and all the vessels are now exposed in the placenta and on the uterus

How are the kidneys affected during preeclampsia?

proteinuria

treatment for PP depression

psychotherapy, support, anti-anxiety meds, antidepressants, and ECT

If resting uterine tone remains above 20 mmHg while receiving oxytocin, what does this mean?

risk for uteroplacental insufficiency and fetal hypoxia

abrupto placenta severe grade 3

severe bleeding, more than 1500 mL of blood, placenta is separating greater than 50%, losing a lot of blood, the baby isn't being perfused so she can be in profound shock, agonizing abdominal pain, strong risk for developing DIC

late signs of hypovolemic shock

severe hypotension urine output less than 33 cc/her restlessness, agitation, decrease LOC skin is cold and clammy

Why should you the nurse keep close tabs on a mother with pregestational diabetes' blood glucose after labor?

she is at a high risk for hypoglycemia, but now since her demand for meds is going to drop dramatically, the provider will decrease her insulin requirements AND during lactation, mom is using alot of energy and burning alot while breastfeeding

Hemodynamic

stabilized from a fluid volume standpoint

PPROM assessment

sterile speculum examination