Maternity Exam 2

Preconception care and diagnostic testing:

Amniocentesis: major test done around 15 weeks, tests for genetic disorders Chorionic villus sampling CVS: 10-12 weeks Pre-conception genetic counseling Biophysical profile: a test done after the 28th week of pregnancy that helps evaluate the fetus. It measures body movement, muscle tone, breathing movement and amniotic fluid volume around the fetus

A young couple are very excited to discover they are pregnant and ask the nurse when to expect the baby. Based on a July 20 LMP, which day will the nurse predict for delivery?

April 27

Admission assessments during FIRST stage of labor:

Assessment 1: maternal health history, physical assessment, fundal height, uterine activity, contraction frequency, duration, intensity, status of membranes, cervical dilation, FHR, degree of effacement, and pain level Assessment 2: fetal assessment, urinalysis, CBC, syphilis screening, HIV screening (with woman's consent), HbsAg, and GBS screening and psychological status -psychological status; during the active phase of labor where the pt is dilated 4-7cm= she might experience high anxiety, and fear from loss of control

Assessment and nursing management of SECOND stage labor:

Assessment: -Contraction frequency, duration, intensity -Maternal vital signs, fetal response to labor (FHR) -Amniotic fluid with rupture of membranes -Coping status of woman and partner Interventions: -cleansing of perineal area and vulva -assisting with birth, suctioning of newborn and umbilical cord clamping, provide immediate care of newborn; drying, Apgar score, identification

Assessment and nursing management of THIRD stage labor:

Assessment: -placental separation; placenta and fetal membranes examination, perineal trauma; episiotomy; lacerations Interventions: -instructing pt to push when separation apparent; giving oxytocin if ordered, providing warmth and comfort, applying ice to perineum if episiotomy, explaining assessments to come, documenting birth, monitoring mothers physical status -SKIN TO SKIN contact immediately after giving birth

Spontaneous abortion:

Cause is unknown and highly variable -First trimester: due to fetal genetic abnormalities (spontaneous) -Second trimester: related to maternal conditions (induced abortion) Nursing assessment: -vaginal bleeding, cramping/contractions, vitals and pain are elevated -keep pad count, provide support (physically and emotionally) to the patient

Placenta Previa:

Cause is unknown but it is PAINLESS -placenta implants over cervical os= placenta is in the way of baby being vaginally delivered--> C-SECTION (** Low placental implantation**) Assessment: -vaginal bleeding: painless, bright red (because it is close to exit), spontaneous cessation then recurrence Management: -NEVER GET VAGINAL EXAM until you've verified placement of placenta through ultrasound (you could rupture the placenta) -pad count (1 pad in 30 minutes=bad) -monitor FHR

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?

Clear to straw-colored fluid

29.) A woman who is 30 weeks of gestation arrives at the hospital with bleeding. Which differential diagnosis would not be applicable for this client? A. Placenta previa B. Abruptio Placentae C. Cord insertion D. Spontaneous abortion

D. Spontaneous abortion

27.) A woman arrives at the emergency department with complaints of bleeding and cramping. The initial nursing history is a significant for a last menstrual period six weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is dilated two centimeters with ruptured membrane. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion? A. Incomplete B. Inevitable C. Complete D. Threatened

D. Threatened

What physiological changes would be noted in a pregnant woman? Select all that apply.

Delayed gastric emptying and decreased peristalsis, enlarged pituitary gland and lordosis

The nurse is caring for a 25-year old primigravida in the first stage of labor. The client and her husband have been holding hands and breathing together through each contraction. Suddenly the client pushes her husband's hand away and shouts "Don't touch me!" This behavior is most likely

Discharged home to await the onset of true labor.

A patient received epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. This patient is at increased risk for which problem during the fourth stage of labor?

Distended bladder

First stage of labor: Phone assessment

Estimated date of birth Fetal movement; frequency in past few days Other premonitory signs of labor experienced Parity, gravida, and previous childbirth experiences Time frame in previous labors Characteristics of contractions Bloody show and membrane status (whether ruptured or intact) Presence of supportive adult in household or if she is alone Ask about childbirth plan Obtain admission history and physical assessment

Assessment of Diabetes Mellitus:

Estrogen, cortisol, and human placental lactogen = contra-insulin effect--> block on insulin Screening: 24-28 weeks confirms if gestational diabetes or not -Glucose challenge test (GCT): give mom glucose to drink and checks results with finger stick after 1 hour...if abnormal you come back to take GTT -Glucose tolerance test (GTT): confirms gestational diabetes, pt. has to be NPO, check for 3 hours (every hour you check the finger stick), 2/3 abnormal= gestational diabetes -Maternal and Fetal surveillance Check BGL 2/3x daily -First trimester: if women is on insulin/diabetic= the need for insulin will decrease because of placental hormones -Second trimester: need for insulin will increase (hormones effect is declining)

According to the ACOG, ICSI, and AWHONN guidelines, how often should the fetal heart rate be assessed for a high-risk laboring woman during the second stage of labor?

Every 5 minutes -every 15 minutes for LOW-risk woman

TRUE OR FALSE A woman who is 24 weeks' pregnant would arrange for a follow-up visit every 2 weeks.

FALSE -every 4 weeks until she reaches 29 weeks' gestation

TRUE OR FALSE If a pregnant woman in labor calls the health care facility, the nurse should strongly advise the woman to come to the facility to be evaluated.

FALSE -if the initial contact is made by phone, the nurse must ask the woman abutter signs and symptoms and based on the woman's response, she will either stay home or go to the facility -the nurse should tell the pregnant woman to go home if she isn't in true labor and walk or engage in sexual intercourse= both help with dilating and inducing labor

TRUE OR FALSE Pain experienced by a woman in labor is fairly intense.

FALSE -pain during labor is a universal experience, but the intensity varies -pain can be controlled through Gate-Controlled theory of pain; uses non-pharmacological ways to deal with pain or distract pt from pain. Examples include; effleurage, music, guided imagery, etc

TRUE OR FALSE The onset of seizures indicates severe preeclampsia

FALSE -seizures denote the onset of ECLAMPSIA

Pregnant woman with substance abuse:

Fetal alcohol syndrome: infant displays low nasal bridge, short palpebral fissures, short nose, flat mid face, minor ear abnormalities, thin upper lip, receding jaw, epicentral folds Heroin: methadone to help withdraw Cocaine: risk factor = placenta abruption

In which manner is the fetal status best assessed during the active and transition stages of labor?

Fetal heart rate at the peak of a contraction

Trimester 1, 2 and 3 discomforts:

First: urinary frequency/incontinence, fatigue, nausea + vomiting, breast tenderness, constipation, nasal stuffiness, bleeding gums, epistaxis, cravings, leukorrhea Second: backache, varicosities of the vulva/legs, hemorrhoids, flatulence with bloating Third: return of first trimester discomforts, SOB, dyspnea, heartburn and indigestion, dependent edema, Braxton hicks contractions

A woman who develops diabetes during pregnancy is said to have ______________.

Gestational diabetes -once pt. hits 20 weeks blood sugar (BS) increases

The nurse is assessing the external fetal monitor and notes the following: FHR of 175 bpm, decrease in variability, and late decelerations. Which action should the nurse prioritize at this time?

Have the client change position. -Fetal tachycardia, decreased variability, and late decelerations are possible indications of cord compression. The first step is to ask the client to change position to see if that will take the pressure off the cord

The primary risk factor for placental abruption is ________.

Hypertension!!!!

Risk factors for adverse pregnancy outcomes:

Isotretinoins- DO NOT TAKE (acne medication) *Alcohol misuse: could cause placental abruption* Anti-epileptic drugs Diabetes (preconception) *Folic acid deficiency: could cause neural tubal defects, such as spina bifada. need 400-600mcg of folic acid* HIV/AIDS Hypothyroidism Maternal phenylketonurea Rubella seronegativity Obesity Oral anticoagulant STI Smoking

First Prenatal visit:

LONGEST VISIT -focuses on developing a trusting relationship with the patient, education for overall wellness, detection/prevention of potential problems, and comprehensive health history, physical exam, and laboratory tests

Classes in preparation for labor, birth and parenthood:

Lamaze (psychoprophylactic) method: focus on breathing and relaxation techniques Bradley (partner-coached childbirth) method: focus on exercises and slow, controlled abdominal breathing Dick-Read (natural childbirth) method: focus on fear reduction via knowledge and abdominal breathing techniques

Management of ectopic pregnancy:

Medical: IM methotrexate, prostaglandin, misoprostol, actinomycin Surgical: Salpingostomy is the creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure, while Salpingectomy is the surgical removal of a fallopian tube. Rh immunoglobulin if woman is Rh(-)--> give RhoGAM to cover her!!!

Multiple Gestation:

More than one fetus inside the uterus (twins, triplets, etc) -management: serial ultrasounds, operative delivery (usually) -assessment: uterus larger than expected for EDB Moms at high risk for hemorrhage

What is hydrotherapy?

Nonpharmacologic measures used during any part of labor, including early labor and active labor, as well as the late ("pushing") phase. Hydrotherapy is offered as a comfort measure, providing relaxation and pain relief by immersion in warm water during labor.

Premature rupture of membranes:

PROM- women breaks water beyond 37 wks gestation - not contracting SROM - spontaneously broke ( got up at the water broke ) AROM- in labor but the membrane is still intact "need to break the water" PPROM- women LESS than 37 wks gestation -discharge home (PPROM) if no labor within 48 hrs ** When it ruptures : 1st thing check the FHR limit vaginal exams Check there temperature every 2 hours @ risk for infection

Cervical insufficiency:

Premature dilation of the cervix--> cervix isn't competent (remember it is supposed to be CLOSED and long) Management: -bed rest, pelvis rest (avoid sexual intercourse), avoidance of heavy lifting -cervical cerclage: (13-15 wks) Assessment: -pink tinged vaginal discharge or pelvic pressure, cervical shortening via transvaginal ultrasound

Infections:

Rubella: we want immune, if non-immune give vaccine AFTER birth > shouldn't be pregnant within 4 weeks of getting the vaccination Group B streptococcus: test done at 35 weeks, if + give penicillin (or vancomycin if allergic), locate bacilli protect vagina but during pregnancy the vagina becomes more alkalinity = increase risk of infection, educate to wipe from front to back Toxoplasmosis: don't remove cat liter, wear gloves when you garden = can cross to placenta More: HIV, HepB, cytomegalovirus, varicella

Hyperemesis Gravidarum:

Severe form of nausea and vomiting in pregnancy that can cause severe dehydration, metabolic acidosis, alkalosis and hypokalemia -symptoms usually resolve by week 20 Management: -IV fluids to replace lost fluid and electrolyte imbalances and possible TPN Assessment: -diet history, weight, onset, duration -liver enzymes, BUN, CBC, electrolytes, ultrasound, urine specific gravity

What are Leopold maneuvers?

Systematic way to determine the position of a fetus inside the woman's uterus 1. The fundal grip 2. Lateral grip 3. Pawlick's grip 4. Pelvic grip

Importance of Rh factor?

The Rh-immune globulin contains antibodies to the Rh D factor. These antibodies will destroy any red blood cells from the baby that have entered mom's blood. -if fetal blood leaked out to the mother--> antibodies--> need RhoGAM -if synthesized: if the baby is Rh (+) next pregnancy the mom's body will fight it= could cause miscarriage -*fetal blood and mother blood= should NEVER mix*

What are the signs of placental seperation?

The uterus rises upward, umbilical cord lengthens, sudden trickle of blood is released from the vaginal opening, and the uterus changes its shape to globular (spherical)

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor?

These contractions help in softening and ripening the cervix.

Types of spontaneous abortion:

Threatened: bleeding can resolve, fetus is okay mom just has vaginal bleeding Inevitable: cervix opens, continued bleeding and cramping, 2-3cm dilated Incomplete: fetus is expelled, placenta/membrane is still INSIDE Complete: everything is expelled (placenta and fetus) Missed: fetus is nonviable (dead) but still inside the uterus, D&C/D&E or the mother will need to be induced to remove fetus Habitual: (recurrent) many abortions, candidates for Cerclage (13-14 wks) -Abortion= ends before 20 weeks !

Magnesium Sulfate

Used for : Magnesium Sulfate- seizure propitious PTL - tocalytic agent - Nero protector for the fetus *IF KIDNEY NOT WORKING DON'T GIVE Magnesium Sulfate* False signs of medication (toxicity) > decrease DTR, decrease urine output, decrease respiratory rate (normal 12-20) , decrease LOC

What is Rh alloimmunization?

When the maternal red blood cells (RBCs) lacking the Rh antigen (RhD negative) are exposed to RhD positive RBCs through the placenta leading to the activation of the maternal immune system

14. This postpartum infection is the most common infection affecting the lining of the uterus; some causes of which are due to multiple vaginal exams, obstetric trauma and prolonged labor preceding cesarean birth a) endometritis b) endometriosis c) episiotomy d) urinary tract infection

a) endometritis c) episiotomy

36. A pregnant woman is being discharged from the hospital after the placement of a cervical cerclage because of a history of recurrent pregnancy loss, secondary to an incompetent cervix. Which information regarding post-procedural care should the nurse emphasize in the discharge teaching? a) the presence of any contractions, rupture of membranes (ROM), or severe perineal pressure should be reported b) any vaginal discharge should be immediately reported to her health care provider c) the client will be scheduled for a cesarean birth d) the client will need to make arrangements for care at home, because her activity level will be restricted

a) the presence of any contractions, rupture of membranes (ROM), or severe perineal pressure should be reported

The nurse discovers a new prescription for Rho(D) immune globulin for a client who is about to undergo a diagnostic procedure. The nurse will administer the Rho(D) immune globulin after which procedure?

amniocentesis

A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is most important in the first 48 hours postpartum?

assessing for cardiac decompensation

10. Women with hyperemesis gravidarum: a) need intravenous (IV) fluid and nutrition for most of their pregnancy b) have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance c) often inspire similar, milder symptoms in their male partners and mothers d) 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, and electrolyte imbalance

In preparing a class for a group of pregnant couples, the nurse includes information about possible newborn complications associated with smoking during pregnancy. Which complications will the nurse include? Select all that apply.

cerebral palsy low birth weight cleft lip and palate sudden infant death syndrome

A nurse notes a pregnant client has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?

encouraging the client to push when they have a strong desire to do so

Why is misoprostol (Cytotec) used? What are the mechanisms of action?

ensures passage of all the products of conception

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?

fetal distress related to hypoxia

The clinic nurse teaches a client with pregestational type 1 diabetes that maintaining a constant insulin level is very important during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use:

insulin pump

A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV?

respiratory rate

A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time?

spontaneous abortion (miscarriage)

A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable spontaneous abortion (miscarriage)?

strong abdominal cramping

A pregnant woman in her second trimester comes to the prenatal clinic for a routine visit. She reports that she has a new kitten. The nurse would have the woman evaluated for which infection?

toxoplasmosis

A nurse is caring for a pregnant client in her second trimester of pregnancy. The nurse educates the client to look for which danger sign of pregnancy needing immediate attention by the primary care provider?

vaginal bleeding

Key Terms Related to Fetal Heart Rate (FHR):

*Accelerations*: abrupt increase of 15 bpm of baseline and comes back in 15 seconds (32 weeks+) -causes: external acoustic stimulation *Decelerations*: abrupt decrease of 15 bpm of baseline and comes back in 15 seconds (32 weeks+) -*for both decelerations and accelerations if fetus is <32 wks and experiences fluctuations, they should be 10bpm and comes back in 10 seconds* Artefact: occurs when the signal input is from a fetus but the output is inaccurate Baseline fetal heart rate Baseline variability: fluctuations in the fetal heart rate of more than 2 cycles per minute 4 categories; -Absent: fluctuation range undetectable, straight line, go to OR, baby has to be delivered immediately!!! -Minimal: range <5 bpm, due to sleep cycle -Moderate: normal, range from 6-25 bpm -Marked: range >25 bpm Electronic fetal monitoring Periodic baseline changes

Passenger (fetus and placenta):

*Fetal skull*: largest and least compressible structure, has sutures to allow for overlapping and changes in shape (molding), anterior (diamond shape) and posterior (triangular shape) fontanelles *Fetal attitude*: "position", cephalic/vertex position= enhances successful vaginal delivery *Fetal lie*: Longitudinal lie (best), Transverse lie (breech, abnormal, will need c-section) *Fetal presentation*: Cephalic/vertex= head is DOWN, Breech= frank (buttocks of baby is sitting on mom's vagina), full/complete (buttocks and foot on mom's vagina), footling/incomplete (foot on moms vagina, c-section) *Fetal position*: landmarks (OMSA); Occipital bone (O), Chin (mentum, M), Buttocks (sacrum, S), Scapula (acromion process, A) *Fetal station*: looking to see where baby's head is related to ischial spine -0= at level of maternal ischial spine -Positive= below spine -Negative= above spine -crowning= baby is about to make appearance *Fetal engagement*: presenting part reaching 0 station, floating= no engagement of fetal head, it isn't in pelvis yet, freely moveable

Obstetric history:

*G (gravida)*: current pregnancy, # of pregnancies, be sure to include any miscarriages/abortions -gravida I, primigravida -gravida II, secundigravida *T (term births)*: the # of pregnancies ending >37 wks gestation, at term *P (preterm births)*: the # of pregnancies ending > 20 wks or viability but before competition of 37 wks *A (abortions)*: ending before 20 wks *L (living children)*: this factor could change if a child passes away at any point in their life -don't forget twins= ONE pregnancy -Para: a woman who has produced one or more viable offspring carrying a pregnancy 20 wks or more (viable) -Primipara: first pregnancy -Multipara: 2+ -Nullipara: NO viable offspring, 0

Gestational hypertension management:

*Mild preeclampsia management* - Bed rest, daily BP monitoring, and fetal movement counts -Hospitalization; IV magnesium sulfate during labor -Toxicity of Mg sulfate; respiratory distress; decrease urine output, RR, DTR's and LOC (STOP and give antidote CALCIUM GLUCONATE) *Severe preeclampsia management* -Hospitalization; oxytocin and magnesium sulfate; preparation for birth *Eclampsia management* -Seizure management, magnesium sulfate, antihypertensive agents; birth once seizures controlled Nursing assessment: risk factors= smoking, Polyhydramnios, cocaine > buy a BP cuff for @ home and make a log Prevention-- reduce the amount of sodium your patient takes (2 grams a day thats it)

Laboratory tests:

*Urinalysis- hCG, protein (dangerous sign for pre-eclampsia)* Complete blood count *Blood typing- RHOGAM* *Rh factor* *Rubella titer- NO, give POST-delivery and educate to not get pregnant in those 4 weeks after getting vaccine* Hepatitis B surface antigen HIV, VDRL, and RPR testing Cervical smears Ultrasound

HELLP:

*hemolysis, elevated liver enzymes, low platelets* Nursing assessment: similar to that for severe preeclampsia Management: same as for severe preeclampsia

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?

+4

The Five P's affecting labor and birth:

- Passageway (birth canal; pelvis and soft tissues) - Passenger (fetus and placenta) - Powers (contractions) - Position (maternal) - Psychological response 5 additional factors affecting the labor process: philosophy, partners, patience, patient preparation, pain control

Factors influencing the onset of labor:

- Uterine stretch - Progesterone withdrawal ( causes increase of prostaglandin- causes labor) - Increased oxytocin sensitivity (uterine contractions initiated) - Increased release of prostaglandins (ripens pt's cervix) **** GOOD SATA ****

Blood incompatibility:

-ABO incompatibility: type O mothers and fetuses with type A or B blood (less severe than Rh incompatibility) > At risk for jaundice -Rh incompatibility: exposure of Rh-negative mother to Rh-positive fetal blood; sensitization; antibody production; risk increases with each subsequent pregnancy and fetus with Rh-positive blood. SEVERE -Nursing assessment: maternal blood type and Rh status -Nursing management: RhoGAM at 28 weeks ( to prevent sensation iso-immunization if baby is rH + cover with RhoGAM within 72 hours )

Fetal assessment during labor and birth:

-Amniotic fluid analysis -Fetal heart rate monitoring (EFM); handheld versus electronic; intermittent versus *continuous*; external versus internal (normal fetal bpm 110-160) -Fetal heart rate patterns; Baseline (determined by knowing where the FHR settles in 10 minutes), baseline variability (fluctuations in FHR), periodic changes -Other assessment methods; fetal scalp sampling, pulse oximetry, stimulation

Foods high in folate:

-Dark green leafy vegetables (turnip greens, spinach, romaine lettuce, asparagus, Brussels sprouts, broccoli) -Liver, whole grains, peanuts, beans

Physical examination of pregnant women:

-First BP reading is important=baseline -Elevate feet: know signs and symptoms of Pre-eclampsia -Pelvic shape: *gynecoid* (BEST because greater diameter), *android* (narrow, c-section is better option, women with PCOS have this shape, and men have this), anthropoid, and platypelloid -Pelvic measurements: diagonal conjugate, true (obstetric) conjugate and ischial tuberosity

Physiologic responses to labor: MATERNAL

-Increased HR, cardiac output, blood pressure (during contractions)= pain increases vitals -Increased white blood cell count -Increased RR and oxygen consumption -Decreased gastric motility and food absorption -Decreased gastric emptying and gastric pH -Slight temperature elevation -Muscle aches/cramps -Increased BMR -Decreased blood glucose levels

Guidelines for assessing fetal heart rate:

-Initial 10 to 20 minute continuous FHR assessment on entry into labor/birth area -Completion of a prenatal and labor risk assessment on all clients -Intermittent auscultation every 30 minutes during active labor for low-risk women and every 15 minutes for high-risk women -During second stage of labor intermittent auscultation every 15 minutes for low-risk women and every 5 minutes for high-risk women

Passageway: bony pelvis

-Linea terminalis: division of false and true pelvis -*True pelvis: BELOW linea terminalis, inlet, mid-pelvis and outlet * -False pelvis: ABOVE linea terminalis -Pelvis shape: > Gynecoid is most favorable for vaginal delivery > Android: male shaped, not favorable > Anthropoid: usually adequate > Platypelloid: not favorable -Soft tissues: *cervix= THINS through effacement to allow presenting part to descend into vagina*, pelvic floor muscles, vagina -100% effacement when in labor

Preconception care:

-Live vaccines canNOT be given to pregnant women; MMR and varicella -Nutrition -Quit smoking/drinking alcohol -Psychological issues (depression) -Support system: lack of support system could lead to postpartum depression

Maternal assessment during labor and birth:

-Maternal status (vital signs, pain, prenatal record review) -Vaginal examination: cervical dilation (needs to be 10cm to have a baby), effacement (thinning of cervix, we need it to be 100%), membrane status, fetal descent, and presentation) -*Rupture of membranes: supposed to be CLEAR, if it is yellowish/greenish= meconium aspiration*, there is SROM (spontaneous rupture of membranes), and AROM (artificial rupture of membranes) -Uterine contractions -Leopold maneuvers

Physiologic responses to labor: FETAL

-Periodic FHR accelerations and slight decelerations -Decrease in circulation and perfusion -Increase in arterial carbon dioxide pressure -Decrease in fetal breathing movements -Decrease in fetal oxygen pressure; decrease in partial pressure of oxygen

What does the comprehensive health history consists of?

-Suspicion of pregnancy, date of last menstrual period (LMP) which helps calculates the patients due date, signs and symptoms of pregnancy, urine/blood test for hCG -*Past surgical history: if pt. has had a myomectomy they shouldn't be allowed to give vaginal birth, they are candidates for c-sections, and these pt's are at risk for uterine rupture (very important to gather any past medical, surgical, and personal history)* -Ask about the woman's reproductive history; menstrual, obstetric, and gynecologic (how heavy their menstrual cycle is, when did they start their cycle, how many days does it last, etc)

Assessment of fetal well-being:

-Ultrasonography -Doppler flow studies: see placental blood flow -*Alpha-fetoprotein analysis (15-22 wks, normal is 15) to r/o Down syndrome (low level) & neural tube defects (high level)* -Marker screening -Nuchal translucency screening ultrasound (11-14 wks) -Amniocentesis -Chorionic villus sampling (CVS): tissue sample of placenta -*Nonstress test*: 20 minutes, tests how fetus is doing -*Contraction stress test*: mom stimulates the nipple-->oxytocin is then stimulated--> causes contractions--> we want to see (-) test, abnormal (positive) results means fetal HR drops each time mother contracts -Biophysical profile

Continuous electronic fetal monitoring:

-Use a machine to produce a continuous tracing of the FHR -Primary objective: to provide information about fetal oxygenation and prevent fetal injury from impaired oxygenation, and to detect fetal heart rate changes early before they are prolonged and profound -*Prolonged and profound FHR could indicate baby with sever hypoxia* -*criteria for using continuous internal monitoring of the FHR*; ruptured membranes, cervical dilation of at least 2cm, present fetal part low enough to allow placement of the scalp electrode, skilled practitioner to insert spiral electrode -The electrode scalp is applied to the crown of the fetal head, contraindications include; HIV+, placenta previa, intact membrane, HepB and C, and syphilis -Intrauterine pressure catheter (IPC): better view, depicts intensity of contractions

Management of diabetes mellitus during pregnancy:

-blood glucose level control (HbA1c < 7%) -need to perform *"fetal kick counts"*: every hour while awake should have 4 movements --> if not drink something cold and sweet and lay on side (helps increase blood flow to the fetus) --> if fetal movement still has NOT occurred GO TO HOSPITAL

A pregnant client with type 1 diabetes is in labor. The client's blood glucose levels are being monitored every hour and she has a prescription for an infusion of regular insulin as needed based on the client's blood glucose levels. Her levels are as follows: 1300: 105 mg/dL (5.83 mmol/L) 1400: 100 mg/dL (5.55 mmol/L) 1500: 120 mg/dL (6.66 mmol/L) 1600: 106 mg/dl (5.88 mmol/L) Based on the recorded blood glucose levels, at which time would the nurse likely administer the regular insulin infusion?

1500 -Glucose levels are maintained below 110 mg/dL (6.11 mmol/L) throughout labor to reduce the likelihood of neonatal hypoglycemia.

A pregnant woman with diabetes is having a glycosylated hemoglobin (HgbA1C) level drawn. Which result would require the nurse to revise the client's plan of care?

8.5% -A glycosylated hemoglobin level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention.

28.) A woman at 28 weeks of gestation experiences blunt abdominal trauma as a result of a fall. The nurse most closely observe the client for what? A. Placental abruption B. Alteration in maternal vital signs, especially blood pressure C. Complains of abdominal pain D. Hemorrhage

A. Placental abruption

Gestational Trophoblastic Disease (GTD):

Abnormal proliferation of trophoblastic tissue. The disorder is classified into two types; benign (hydatidiform mole) and Choriocarcinoma (pre-cancerous, cluster grape-like) Management: prophylactic chemotherapy= Abstain from pregnancy 1 year after chemotherapy!!! Assessment: manifestations similar to spontaneous abortion at 12 weeks, high hCG levels, ultrasound visualization

Menstrual history:

Age at menarche, days in cycle, flow characteristics, discomforts, use of contraception *Date of last menstrual period LMP* Calculation of estimated or expected date of birth (EDB) or delivery (EDD) -*Nagele's rule: use first day of LNMP, subtract 3 months, add 7 days and then add 1 year*

A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective?

"Purse-string sutures are placed in the cervix to prevent it from dilating."

The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is:

1 cm above the ischial spines.

How long does fundal height correlate with gestational age for?

36 weeks

Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant. This is her 4th pregnancy. She gave birth to one baby vaginally at 26 weeks who died, experienced a miscarriage, and has one living child who was delivered at 38 weeks gestation.

4, 1, 1, 1, 1

32. A fetal heart classification that shows absent variability with recurrent late decelerations or recurrent variable decelerations . sometimes the appearance of sinusoidal pattern. A. Category I B. Category III C. Category II D. Category IV

B. Category III

During pregnancy the cervix is supposed to be:

CLOSED and LONG

7.) A woman in her third trimester is suffering from heartburn, what should the nurse advise to her do?A. Consume tomato products and citrus juices regularlyB. Sleep on the back with the feet elevated C. Lie down immediately after eating D. Eat small meals frequently rather than large meals

D. Eat small meals frequently rather than large meals

A pregnant woman comes to the clinic for a prenatal visit for her third pregnancy. She reveals she had a previous miscarriage at 12 weeks and her 3-year-old son was born at 32 weeks. How should the nurse document this woman's obstetric history?

G3, T0, P1, A1, L1

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Help the woman change positions.

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?

Radiates from the back to the front

11.The nurse recognizes that a nonstress test (NST) in which two or more fetal heart rate (FHR) accelerations of 15 beats/min or more occur with fetal movement in a 20-minute period is:

Reactive

TRUE OR FALSE Cephalic presentation refers to a fetus whose head enters the pelvic inlet first.

TRUE

Importance of RhoGAM:

The incompatibility only occurs if mom is Rh negative and baby is Rh positive, through fetal screening. If this is the case, mom receives a IM shot of RhoGAM at about 28 weeks of pregnancy to prevent Rh alloimmunization -RhoGAM is good for 30 days -when pt is undergoing amniocentesis before she goes home (within 72 hrs of procedure) she needs RhoGAM!!

28. Fetal well-being during labor is assessed by:

The response of FHR to uterine contractions

Which maternal condition always necessitates delivery by cesarean section?

Total placenta previa

A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation (dilatation) to occur?

cervical ripening and softening

Tetralogy of Fallot

congenital malformation involving four distinct heart defects; ventricular septal defect (VSD), pulmonary stenosis, a misplaced aorta and a thickened right ventricular wall (right ventricular hypertrophy). They usually result in a lack of oxygen-rich blood reaching the body.

Iron- Deficiency Anemia

due to inadequate dietary intake - eliminate symptoms, correct deficiency, replenish iron stores. Fetal sulfate (causes constipation- eat foods high in fiber and whole grains) s/s: fatigue, weakness, anorexia, susceptibility to infection (frequent cold)

The nurse is assessing a pregnant client with a known history of congestive heart failure who is in her third trimester. Which assessment findings should the nurse prioritize?

dyspnea, crackles, and irregular weak pulse -The nurse should be alert for signs of cardiac decompensation due to congestive heart failure

The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme iron-rich foods should the nurse encourage her to add to her diet?

meats

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?

meperidine

What symptoms is observed in a client if rupture or hemorrhaging occurs before the ectopic pregnancy is successfully treated?

phrenic nerve irritation

What could sudden weight gain during pregnancy indicate?

pre-eclampsia

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?

prolonged decelerations

Which finding would the nurse expect to assess in a woman with placenta previa?

relaxed uterus -placenta previa exhibits a soft relaxed uterus accompanied by painless bright-red vaginal bleeding that stops spontaneously only to recur

A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?

"The injection is given in the space outside the spinal cord."

ectopic pregnancy

"tubal pregnancy" -Ovum implantation outside the uterus, obstruction to or slowing passage of ovulation through tube to uterus Assessment: -Hallmark sign: abdominal pain (unilateral) with spotting within 6-8 weeks after missed menses - Abdominal ultrasound to confirm Commonly caused by a history of endometriosis present

A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor. (Select all that apply)

ANS: Extension, restitution, external rotation and expulsion.

A client is in active labor. The nurse determines that the fetus's position is occiput posterior. Which of the following nursing diagnoses would be appropriate for the laboring clients?

Acute pain

Assessment and nursing management of FOURTH stage labor:

Assessment: -vitals, fundus, perineal area, comfort level, lochia (postpartum bleeding), bladder status Interventions: -support/info -fundal checks; perineal care and hygiene -*bladder status and voiding (they NEED TO VOID), full bladder will cause fetal head to NOT descend and this will impede delivery* -teaching, comfort and parent-newborn attachment

Which method of pain management is safest for a gravida 3 para 2 admitted at 8 cm cervical dilation?

Breathing and relaxation techniques

A pregnant client with sickle cell anemia is admitted in crisis. Which nursing intervention should the nurse prioritize?

IV fluids

A pregnant woman has been admitted to the hospital due to preeclampsia with severe features. Which measure will be important for the nurse to include in the care plan?

Institute and maintain seizure precautions.

Cardinal Movements of labor:

MUST KNOW FOR EXAM : need to know order 1. Engagement, descent, flexion 2. Internal Rotation 3. Extension beginning (rotation complete) 4. Extension complete 5. External Rotation (restitution) 6. External rotation (shoulder rotation) 7. Expulsion

A woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption (abruptio placentae)?

Onset of vaginal bleeding was sudden and painful

21. With regard to the turns and other adjustments of the fetus during the birth process, known as the mechanism of labor, nurses should be aware that:

The effects of the forces determining descent are modified by the shape of the woman's pelvis and the size of the fetal head.

What is episiotomy?

a surgical cut made at the opening of the vagina during childbirth, to aid a difficult delivery and prevent rupture of tissues

9. A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system?

3-1-0-1-0

53. Spontaneous termination of a pregnancy is considered to be an abortion if: A. the products of conception are passed intact B. The pregnancy is less than 20 weeks. C. The fetus weighs less than 1000g D. no evidence exists of intrauterine infection

B. The pregnancy is less than 20 weeks.

Which drugs are safe for pregnancy women?

Class A drugs Tylenol

Asthma:

Drug therapy: budesonide, albuterol, salmeterol -assess triggers, lung auscultation (wheezing- give albuterol, budesonide, salmeterol treatment ) - monitor oxygen saturation during labor

A client in her 29th week of gestation reports dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's blood pressure. Which intervention should the nurse implement to help alleviate this client's condition?

Place the client in the left lateral position.

What is cervical cerclage?

Stitches placed at the mouth of the cervix to keep baby in place to prevent pre-term labor/spontaneous abortions -if pt's water breaks the cerclage HAS to come out to prevent infection!!! -removal of cerclage is around 35-36 wks -placed 13-15 wks prophylactically

While assessing a woman at 18 week's gestation, which of the following would the nurse report as unusual?

Urinary frequency -during second trimester, urinary frequency typically improves

Interpreting FHR patterns:

• Category I: normal (Predictive of normal fetal acid-base status) -baseline 110-160 bpm, present/absent accelerations/decelerations • Category II: indeterminate (Not predictive of abnormal fetal acid-base status) -fetal tachycardia present, *prolonged decelerations* • Category III: abnormal (Predictive of abnormal fetus acid-base status) -fetal bradycardia, *recurrent late decelerations* -*Interventions: discontinue oxytocin, turn the client on left/right lateral side or knee-chest OR hands to knees to increase placental perfusion/relieve cord compression, administer nonrebreather mask for oxygen, increase IV fluids*

A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia?

Have her blood pressure checked at every prenatal visit.

Premonitory signs of labor:

- Cervical changes (cervical softening--> due to increase prostaglandin) - Lightening: "dropped", indication of labor - Increased energy level - "Bloody show" - Braxton Hicks contractions - Spontaneous rupture of membranes

Powers (contractions):

-Primary: uterine contractions -Secondary: intra-abdominal pressure from mother pushing and BEARING DOWN -Contractions: involuntary, thin and dilate cervix Three parameters; -Frequency: beginning of 1 contraction to beginning of the next, measured in minutes -Duration: beginning of 1 contraction to the end of that same contraction, measured in seconds -Intensity: how strong? mild (nose, 30-40 seconds), moderate (chin, 40-60 seconds), strong (forehead, 70-120 seconds)

HIV:

-if undetected= CAN deliver vaginally -if viral load is high (CD4 <200)= c-section -spread through body fluids (blood, breastmilk) -HIV+: meds= acyclovir (2x daily from 14 wks-birth, oral syrup for newborn in first 6 weeks of life), NO breast feeding if HIV+ I (acute): flu like symptoms II (latent, asymptomatic) III (persistent generalized lymphadenopathy) IV (AIDS): high viral load and low CD4 counts

A urinalysis is done on a client in her third trimester. Which result would be considered abnormal?

2+ Protein in urine

19. The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment to involve:

:IV therapy to correct fluid and electrolyte imbalances.

What is Effleurage?

A type of self-massage that focuses on your abdomen. During effleurage, you use circular, rhythmic stroking movements with the palm of your hand to lightly massage your abdomen

50. A placenta previa in which the placental edge just reaches the internal os is more commonly known as: A. marginal B. total C. partial D. complete

A. marginal

During pregnancy the vagina becomes more ________.

Alkaline!! -the vagina looses acidity--> risk for infection

A laboring client presents to the evaluation unit of L&D and reports that her water has just broken. The nurse's first action would be to A. Encourage the mother to go for a walk B. Check fetal heart tones. C. Ask the client how far apart are the contractions D. Call the provider

B. Check fetal heart tones.

Functional classification system of cardiac conditions in pregnancy:

Class I: asymptomatic; no limitation of physical activity Class II: symptomatic (dyspnea, chest pain) with INCREASED activity =candidate for early epidural and assisted vaginal delivery (vacuum extractor or forceps) Class III: symptomatic (fatigue, palpitation) with NORMAL activity (walking) = need c-section (34-36 wks delivery) Class IV: symptomatic at rest or with any activity= ex:pulmonary HTN= need c-section (32-34 wks delivery) ---shouldn't even get pregnant at all---

During the second stage of labor, assessment would include which of the following?

Complaints of rectal/perineal pressure

Placenta Abruption (abruptio placentae)

EMERGENCY + PAINFUL + C-SECTION needed -(premature) separation of placenta leading to compromised fetal blood supply, etiology is unknown Assessment: -elevated BP -bleeding; DARK red (coming from up high) -uterine tenderness, contractions, bordline abdomen - firm, rigid uterus on palpation -monitor FHR, activity and movement (decreased) Management: -place in LEFT LATERAL position for tissue perfusion (more blood to fetus), strict bed rest, oxygen therapy, continuous fetal monitoring

A type 1 diabetic who is at 33 weeks gestation is having a nonstress test for fetal well-being since she has been having problems with glucose control. Which of the following meets the criteria for her test to test to be considered reactive?

Fetal heart baseline of 140 with two accelerations to 155 for 15 seconds within 20 minutes

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

Fetal heart rate in relation to contractions

Thalassemia

Find out if dad has this -alpha (minor): little effect on pregnancy except for mild persistent anemia -beta (major): usually no pregnancy due to lifelong, sever hemolysis, anemia and premature death

Sickle cell anemia:

Give epidural right away --> tend to have high tolerance to pain -defect in hemoglobin S -postpartum care: antiembolism stockings (DVT prevention) , sequential compression devices = prevent DVT

Chronic HTN (before pregnancy):

HTN before pregnancy or before 20th week -medications: lebitolol, hydrolozine -management: DASH diet (2g sodium thats it!), monitor for placental abruption (rigidity of abdomen, dark red vaginal bleeding), preeclampsia (pulmonary edema, proteinuria, super-imposed preeclampsia)

Compared with contraction stress test (CST), nonstress test (NST) for antepartum fetal assessment:

Has no known contraindications.

Hydramnios (MORE) vs Oligohydramnios (LESS) :

Hydramnios: amniotic fluid > 2,000mL (2liters ) -removal of fluid (amniocentesis), indomethacin (decreases fluid by decreasing fetal urinary output) Mom's @ risk > Diabetes is a cause, multiple gestations (triples/ twins) >> access the fundal height, abdominal discomfort, difficulty palpating fetal parts or obtaining FHR Oligohydramnios: amniotic fluid < 500mL -amnioinfusion (catheter and it allows fluid to go into the uterus) and birth for fetal compromise -assessment: fluid leaking from vagina >> fetal urine problem

What is the estimated date of birth/delivery for a woman who's last period (LMP) was on July 10, 2022?

It would be APRIL 17, 2023 -first you subtract 3 months= April 10 -then add 7 days= April 17 2022 -lastly, add one year= April 17, 2023

What is the estimated date of birth/delivery for a woman who's last period (LMP) was on May 27, 2022?

It would be MARCH 6, 2023!! -subtract 3 months= February 27 -add 1= February 28 --> LEAP YEAR -add year and then the remaining 6 days= March 6, 2023

Types of autoimmune diseases:

Localized - Targets specific organs - For example, Hashimoto's thyroiditis and Graves' disease: targets thyroid gland Systemic - Targets multiple organs - For example, lupus erythematosus: targets lung, heart, joints, kidneys, brain, and red blood cells

Tuberculosis (TB):

Meds: combination of isoniazid, rifampin (orange body secretions) , ethambutol (not god for people with contacts) -chest x-ray contraindicated when pregnant -S+S: night sweats, dry cough -need to take meds for 6-9 months. Pregnant client with tb: maintain adequate hydration

Follow up visits:

Moms with no complications: Every 4 weeks up to 28 weeks Every 2 weeks from 29 to 36 weeks Every week from 37 weeks to birth -Midwife= care for low risk pregnancies Moms with complications (ex:diabetes) Every 2 weeks up to 28 days Every week from 29-36 weeks Twice a week from 37-birth

Who are the health care providers for high risk pregnant women?

Obstetrician

The nurse is caring for an Rh-negative nonimmunized client at 14 weeks' gestation. What information would the nurse provide to the client?

Obtain Rho(D) immune globulin at 28 weeks' gestation.

A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?

Premature separation of the placenta

2. A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath TID, and a stool softener. What information is most closely correlated with these orders? a) the woman has an episiotomy b) the woman had a vacuum-assisted birth c) the woman received epidural anesthesia d) the woman is a gravida 2, para 2

a) the woman has an episiotomy

33.) The nurse who is caring for a woman hospitalized for hyperesnesis gravidarum would expect the initial treatment to involve one? A. Corticosteroids to reduce inflammation B. Enternal nutrition to correct nutritional deficits C. Intravenous IV therapy to correct fluid and electrolyte in balance

C. Intravenous IV therapy to correct fluid and electrolyte in balance

What do you immediately check if a woman's water breaks?

Check the FHR!!!!

What are the contraindications of Magnesium Sulfate?

End stage renal disease, pulmonary edema, myasthenia graves, hypocalcemia

Describe the 4 stages of labor

First stage: longest, cervical dilation of 10 cm Consists of three phases; -latent(early phase) : 0-3 cm, offer epidural at this time, if they want -active (admission: ask if they want epidermal) : 4-7 cm, stronger contractions -transition: 8-10 cm > > longest stage of labor < < Second stage: cervix 10 cm dilated to birth of baby -when baby's head is out, doctors tell mother to stop pushing and check around the baby's neck to make sure there is no cord Third stage: birth of infant to placental separation/expulsion -if you leave a fragment of the placenta--> they could bleed to death--> become SEPTIC Fourth stage: 1-4 hours following delivery

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position?

Long axis of fetus is perpendicular to that of client.

Gestational disorders: Preeclampsia vs Eclampsia

Preeclampsia: high BP during pregnancy, never had HTN before, could have proteinuria and edema. Considered "pre-seizure"--> absence -ultimate cure= DELIVERY Eclampsia: seizure activity--> presence - magnesium sulfate, antihypertensive agents

Pharmacologic measures:

Systemic analgesia: *CAN CROSS PLACENTAL BARRIER* -Route: parenterally thru IV -*opioids: butorphanol (for pain), nalbuphine (do NOT give to heroin addict), meperidine, fentanyl= be aware of respiratory distress!!!!* -ataractics: hydroxyzine, promethazine -benzodiazepines: diazepam, midazolam Regional analgesia/anesthesia: -if you give morphine sulfate you must have *naloxone* in case of respiratory distress!! the half life of morphine sulfate is 3 hours and it peaks around 30-60 minutes -epidural block= continues infusion/intermittent injection when dilation is >5cm, *side effect: maternal hypotension= could lead to decline of FHR, give 500-1000cc fluid IV bolus* -combined spinal epidural block= "walking epidural" -patient controlled epidural -local infiltration= for episiotomy/laceration repair -pudendal block= usually for 2nd stage, episiotomy, or operative vaginal birth -intrathecal (spinal)= during labor and c-section, could cause itching =give Benadryl, *"wet tap"= accidentally punctured the CSF--> result in headache--> give IV fluids, furoate, caffeine--> if that doesn't help= BLOOD PATCH* General anesthesia: less than 2/3 min to deliver baby= because risk of fetal respiratory depression -*emergency c-section/woman with contraindication (thrombocytopenia or scoliosis with the rod in place) to use of regional anesthesia* -IV injection, inhalation or both -commonly first thiopental IV= unconsciousness--> muscle relaxant--> intubation followed by nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesia